Too many young children—particularly those in low-income households—have developmental delays that go undetected until they begin school. By that time, treatment and therapy become more problematic. The Commonwealth Fund's Assuring Better Child Health and Development (ABCD) program is working to address this missed opportunity by helping states improve early child development services for low-income children and their families. Administered by the National Academy for State Health Policy (NASHP), ABCD has partnered with nine state Medicaid agencies to improve policies and services for parents and children. Now, through the ABCD Screening Academy, the program is sharing its considerable know-how with an additional 17 states, Puerto Rico, and the District of Columbia. We spoke with Neva Kaye, NASHP senior program director, about ABCD's accomplishments over the past seven years, the challenge of changing providers' behavior, and how the ABCD model could be used to promote other facets of high-performance health care.
Since 2000, the ABCD team has been collaborating with states to improve the delivery of early childhood development services to poor children. What do you consider to be the greatest accomplishment so far?
Neva Kaye: The policy improvements made by states have been a great accomplishment. States have built on existing federal and state Medicaid regulations, especially those governing the delivery of EPSDT [Early and Periodic Screening, Diagnosis, and Treatment program] services and Medicaid managed care to improve the effectiveness of development services. They've been enormously creative in finding different ways to support the delivery of these services. Taken as a whole, that has been our greatest accomplishment: the variety of models the states have developed and tested.
Another big accomplishment has been the way ABCD has expanded. When we started, we had four states interested in improving development services. The next time we sent out a request for proposals, almost half the states submitted a letter of intent. Now, with the Screening Academy, we're at 17 states, Puerto Rico, and the District of Columbia. And I think that really speaks to the fact that we, in collaboration with the states, have produced tools that others can use. They look at it and think, 'This is something I can do. This is something I want to do.' It gives them a pathway for moving forward.
Although NASHP has played a big role bringing the states together, I cannot emphasize enough that what has made this successful is the work of the states. They're the ones who developed the models and made the improvements. We helped them.
What obstacles stand in the way of screening children for developmental problems?
Kaye: The biggest remaining challenge is around follow-up services, like assessment and treatment. There are really two different problems. One has to do with the connection—making sure pediatric practices know that resources exist and helping families connect with them. The other is: Are there enough resources?
In some cases, there is resistance from providers as well. Providers are concerned that screening will take time away from very busy schedules. In many ways, the states can address these issues. They may have a way to code the services for payment, or they may be able to share the experiences of physicians, like Marian Earls, M.D., in North Carolina, who have been successful. Also, if they have tested the implementation of development screening, they can confirm that it doesn't really take longer and can, in fact, make the practice more efficient.
What has to happen to get states to improve their policies so that they promote children's healthy development?
Kaye: What really seems to resonate with states is to have evidence of effective practices, so they can make policy improvements based on experience. That's one reason we work with states to develop just a few demonstration sites. Then, as those sites work to implement screening, they'll surface the policy issues in the state. That also helps to build real support and buy-in from a range of stakeholders.
States also need data to show it can be done. You need numbers, but also the stories that say, 'Yes, I did this. As a physician, I was able to implement developmental screening. It didn't really take a lot of extra time, and it made things more efficient.'
The second phase of the ABCD collaborative concluded this year. Do you have any early results you can share?
Kaye: The ABCD II collaborative really shows that the demonstration sites were able to increase screening rates. It also showed, in a very real way, the difficulty of determining whether follow-up services were delivered. Yes, the practices made referrals, but then they had difficulty finding out what was done as a result and producing measures of referral and treatment. Follow-up remains the biggest challenge.
In the past year, ABCD has gone national in its quest to encourage states to do more to promote developmental screening in pediatric practices. How have states responded?
Kaye: We've gotten really good applications from states that had clearly thought through an initial approach, and more people than I even expected—well over 100—came to our July learning session in Houston. The evaluations from that meeting were very, very positive. Not only did participants learn important information, but they were able to go back with action steps for what to do next. Since then, we've held our first conference call with states to share lessons learned. Based on the results of that, we know that all of the states are moving forward. They're using tools built by the ABCD collaborative states, but they're also developing new ideas. In the end, when the Screening Academy concludes, there will be even more models.
Is there potential for adapting the strategies and processes developed by ABCD for other applications—such as improving care coordination, reducing racial disparities, or improving health care efficiency?
Kaye: Oh, definitely. There's no question in my mind that the model would work. However, it's not a short-term commitment, and it does require resources. So, if I wanted to apply the model to reducing disparities or creating medical homes, I would start by spending time developing some reasonably concrete ideas to give to the states—not as a directive, but guidance for what they might want to do. And then I'd want to have collaboratives, much like ABCD I and II, to help a few states develop and test models and policy options. Then, you could go more broadly, as we've done with the Screening Academy. You could go to a larger group of states and say, for example, 'We've worked with five states and based on their experiences, here is a host of tools and strategies that you can apply and tweak to make them work within your own state.'