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Improving the Delivery of Health Care that Supports Young Children's Healthy Mental Development

Early Accomplishments and Lessons Learned from a Five-State Consortium


Services that support young children's healthy mental development can reduce the prevalence of developmental and behavioral disorders that have high costs and long-term consequences for health, education, child welfare, and juvenile justice systems—and for children's futures. States are interested in improving their support of young children's healthy mental development and want to learn about ways to do so.

In January 2004 the ABCD II Consortium was formed to provide five states with an opportunity to develop and test strategies for improving the care of young children at risk for or with social or emotional development delays, especially those in need of preventive or early intervention services. Each state is working toward the common goal of improving care, but each of their projects has different objectives and approaches.

  • Develop a service matrix that will be used to create a "roadmap to care."
  • Identify policy and service delivery changes needed to improve access to infant mental health and developmental services.
  • Develop and implement a quality improvement project in primary care practices in two managed care organizations (MCOs).
  • Increase the number of young children who receive comprehensive primary care that addresses social and emotional development, by
    • increasing the use of formal screening tools and referrals for intervention services, and
    • improving pediatric providers' access to materials on early childhood and perinatal mental health.
  • Develop mental health and developmental screening and referral guidelines and test them in four pilot communities before implementing them statewide.
  • Iowa
    • Establish minimum clinical care standards for preventive and developmental mental health services.
    • Establish links to community resources to improve access to appropriate follow-up care.
    • Establish two pilot projects to test the standards and identify policy changes needed to support statewide implementation of the standards
    • Support primary care provider efforts to meet the needs of children who are at risk for delays in social or emotional development but do not meet the criteria for receiving services from the children's mental health system by, among other things,
      • conducting CME trainings on early childhood mental health;
      • increasing the likelihood that children who qualify for care from the children's mental health system are indentified and referred to that system; and
      • conducting two pilots to test strategies to improve care.
    • Modify state policies to increase the identification and referral of children with delays.
    • Increase screening for infant mental health concerns as part of EPSDT/well child visits.
    • Increase interactions between and among Medicaid providers to ensure that providers direct children and their families to appropriate services.
    • Increase screening by pediatric practices for maternal depression during the postpartum period.
    • Conduct three learning collaboratives with pediatric practices to achieve these objectives
    *Unlike the other four states in the ABCD II Collaborative, Illinois's individual project is not funded by The Commonwealth Fund but, rather, by a local funder, the Michael Reese Health Trust.

    The five states have not yet completed their projects, but they have accomplished key tasks and learned valuable lessons. The purpose of this paper is to provide an opportunity for other states interested in improving child development services to benefit from the experiences of these five states.

    Key Accomplishments

    Promoted pediatric provider use of validated screening tools. All five states have identified, with stakeholder participation, a set of tools that they recommend clinicians use and are promoting the tools' use through activities, such as modifying Medicaid provider handbooks and holding training sessions.

    Helped primary care providers integrate these tools into their practices. The five states have supported primary care providers in a variety of ways that have included establishing learning collaboratives of practice-based teams, developing training modules for individual pilots and practices; identifying "physician experts" to serve as mentors to primary care providers, and partnering with provider organizations that provide direct support to practices.

    Identified and facilitated appropriate referral to follow-up services. The five states have identified resources through activities such as surveys, stakeholder interviews, and review of materials, including state regulations. Further, these states have facilitated referrals to resources through activities such as creating a database of local and statewide resources, providing practices with training including information about local resources, designating a local individual or agency that is familiar with resources for follow-up services to facilitate referrals, and working with primary care practices and representatives of local resource agencies to develop referral pathways. Finally, these states have used the information collected about local resources to identify gaps in the system and begin developing ways to fill those gaps, such as facilitating use of a diagnostic classification system specifically designed for young children.

    Identified and addressed policy barriers. All five states have developed a process for identifying and addressing policy barriers based on their ABCD project experience and stakeholder input. These include: establishing statewide policy workgroups, producing documents identifying and describing the barriers, presenting the results of the work to state leaders who can act on the information, and developing guiding principles for addressing changes. This work has already enabled the five states to implement policies that better support young children's healthy development—not only in those governing Medicaid, but also in those that govern other programs such as early intervention.

    Formed partnerships to achieve project goals. The five states have all established key partnerships that they believe will enable them to meet their project goals. These states have partnered with other state agencies, clinicians, provider organizations, and others. These partnerships have been key not only to developing and implementing the project but to identifying and addressing policy barriers, communicating with clinicians, and improving the quality of care delivered.

    Used quality improvement to make progress. Most of the efforts of the ABCD II states are designed to produce and sustain improvement in the delivery of care within existing federal guidelines and funding. These states are fostering change through such mechanisms as better defining Medicaid expectations of clinicians and supporting clinicians in their efforts to improve the quality of care they provide. Also, California, Illinois, and Utah are all working through their Medicaid managed care systems to improve care. These states are undertaking performance improvement projects, working with their external quality review organizations (EQROs) to plan and promote improvements, and developing model quality improvement projects.

    Lessons Learned

    Screening with a standardized tool for potential social and emotional development delays is an important step in ensuring young children's healthy mental development. There is a clear consensus in the field that pediatric clinicians have both the opportunity and expertise to identify children who are in need of care to support their mental development. There are also indications that physicians often fail to diagnose children with a clearly defined developmental problem. In response, the five ABCD II projects have focused their improvement efforts on encouraging and supporting primary pediatric practices to make periodic use of a validated, standardized screening tool a regular part of the way they deliver care to all children.

    Screening does little good without access to follow-up services. All five states have found that efforts to identify and help families and clinicians access resources for assessment and treatment are critical to project success. These follow-up efforts are necessary to ensure that children who are identified with potential needs receive appropriate care. In addition, the ABCD II states have found that pediatric clinicians are often reluctant to adopt (or continue) using a screening tool unless they are confident that the children they identify as potentially needing further care will receive it. As a result, the five ABCD II states have undertaken efforts to identify existing assessment and treatment resources, remove policy barriers to accessing those services, and facilitate referrals to these resources.

    States can facilitate access to follow-up care for young children who are identified by pediatric providers as experiencing or being at risk for delays in social or emotional development. States pay for assessment and treatment not only through their Medicaid programs but also through early intervention and children's mental health programs. They have resources available not only to pay for treatment but also to facilitate access to treatment by:

    • providing direct assistance,
    • improving coordination among programs, and
    • helping practitioners to develop links with local resources.

    Demonstrations can inspire and test policy change. Each of the ABCD II states has established pilot sites (demonstrations) to test new ideas and delivery mechanisms, test new policies, and/or identify policy barriers. They have found that the pilot sites have proven to be an effective method of not only testing whether new ideas work but of also ensuring that policy changes are grounded in real life experience—an important aspect of making policy work relevant and tangible.

    Partnering with pediatric clinicians is critical to improving the care delivered to children. Active partnerships with clinicians have proved critical to obtaining provider acceptance and support for the projects. Specifically, in all five states, clinicians have played key roles in:

    • Developing state recommendations for screening tools and effectively communicating those recommendations to clinicians;
    • Identifying policy changes needed to promote improvement; and
    • Providing training and assistance to the pilot practices and spreading improvements in practice throughout the state.

    Developing successful partnerships with providers takes effort and a willingness to follow as well as lead. Each of the ABCD II states has developed successful partnerships with medical providers. These partnerships have been forged even in states where the Medicaid agency and clinicians have not always worked well together. These partnerships have been built over time as partners recognize what each has to contribute to improving care. The ABCD II states have also found that joining partnerships led and administered by others can be very beneficial.

    States can improve care without new funding or legislation. All five ABCD II states have improved (or are on track to improve) the delivery of care to young children. For the most part they have done this without seeking new appropriations, changing state law, or obtaining federal approval. They have accomplished their work by leveraging existing resources and partnering with other stakeholders including their sister agencies, private organizations, and providers.

    Publication Details



    N. Kaye, Improving the Delivery of Health Care that Supports Young Children's Healthy Mental Development: Early Accomplishments and Lessons Learned from a Five-State Consortium, National Academy for State Health Policy and The Commonwealth Fund, April 2006