Tuesday, December 11, 2007

Finding Rosie D.: Setting up a Screening Program

So now the rubber meets the road. Pediatric practices all over Massachusetts have to institute screening programs that identify children with serious emotional disturbances at all well child visits by December 31st. At our staff meeting today, we hashed out the nitty gritty of how this is going to happen, trying to keep it as simple as possible. Fortunately, the staff at South County Pediatrics are really good at this sort of thing, at least in part because they have had to put up with me doing screening of one sort or another a lot over the last 17 years.
1) We've been screening adolescents for substance abuse through the RAFFT and later the CRAFFT questions for 15 years; using standardize screening questions is pretty routine for us. In fact, the Department of Public Health is having all of their adolescent primary care sites (of which we are one) use the CRAFFT as a screener.
2) We've been passing out M-CHATs to the parents of 18 month olds for the past 2 years, and have a longstanding relationship with our local Early Intervention Center.
3) We participated in a trial of using the PEDS as a developmental screener last year; we actually decided not to use it routinely last year because we weren't convinced that it was worth the extra paperwork. But at least we know the instrument.

So, how are we going to do this?
Well, first we wanted to cast a broad net using as few instruments as possible. The M-CHAT and the CRAFFT, sadly, are focused screeners aimed at autism and substance abuse respectively. So we picked (from the list) the PEDS for kids under 5 years of age, and the PSC/PSC-Y for the older kids. Both are one-pagers, well normed and easy to score (pluses to keeping the flow going). And this way, it is just one more piece of paper (not 4 or 5 more pieces of paper). Something to be said for that.
Next, we want to minimize steps. The screener will be handed to the parents or the youth by one our our nursing staff to complete while they are waiting to be seen. The provider scores the form, discusses the results with the parent and files the form in the chart. The provider also codes for the extra procedure (in our office, I suspect that coding will be the weak link.
Finally, we wanted the protocol to be useful. The PEDS will pick up not only behavioral issues, but developmental ones as well. The PSC/PSC-Y should also help us detect school dysfunction and family stress, which are real problems, but not necessarily serious emotional disturbances. Knowing these things about our patients will help us guide them to resources.

Potential problems:
  • Lack of parent: We get lots of kids who come in without a custodial parent; they come with a friend, an aunt; if there is no parent, we can't do a proper assessment.
  • Low reading level: May take some folks a long time to complete the form, slowing down flow in the office.
  • Billing by third party payers: Families on Medicaid won't get a bill from our practice if MassHealth won't pay for it. But our families with old fashioned commercial insurance might, if thier insurance won't pay the "screening" code.
  • Too much screening: We will still do the CRAFFT and M-CHAT in addition to the other screenings, and then there is the MASQ (Medical-legal Advocacy Screening Questionnaire) that we do on behalf of Family Advocates of Central Massachusetts. It all might be too much.
  • We'll swamp our available resources: More on that later.
  • Other stuff we can't predict: We can predict that these will happen. We just can't predict what they will be.
So, here we are. Pediatricians on the verge of a nervous breakdown, finally implementing the systems of care of which we have spoken for so long. In the middle of flu season, yet. It will be interesting, for sure. And, we hope, beneficial to the children like Rosie D.

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