In a recently released issue of Pediatrics (10.1542/peds.2017-4017), Dr. Kathleen Conroy and a team of colleagues share results of a quality improvement (QI) project whose goal was to ensure that at least 70% of patients referred to Early Intervention (EI) from an academic primary care clinic serving a low-income population were evaluated within 120 days of referral. The authors identified a clear need, in that prior to the intervention just half of children referred to EI were actually evaluated. Barriers to change included multiple referral paths to EI, a non-centralized EI system with overlapping geographic catchments areas, limited tracking and no ability for practices to access the state EI Registry. Strengths that the team could rely on included frequent standardized developmental screening in the practice with an excellent rate of >95% completion: thus risk for developmental delay was largely being well identified.
The primary care clinic included attending physicians, nurse practitioners and 66 resident physicians, so there was no lack of challenge in designing and implementing an intervention. A multidisciplinary team of stakeholders collaborated to design and carry through the intervention, which was very successful. Among the changes, two features stood out to me: 1- the active discussions with the local EI staff, which led to education and best practices to facilitate referrals, and 2- the benefit of instituting an electronic referral process, which made overall tracking possible, including tracking of those who might have previously been lost to follow up.
EI is an amazing service and has great potential to benefit children who are either at risk for delay or who have documented developmental delay, as well as their families. Early intervention services are provided under the Individuals with Disabilities Education Act (IDEA). States receive grants from the federal government and provide free (or low cost) screening, assessment and therapies. Current state law (in my state) requires the state to serve infants and toddlers who have been diagnosed with developmental delay or who have a condition putting them at risk for delay. So, in a busy clinic setting, ongoing education is needed to make sure everyone, including new trainees, are aware of the need to refer to EI. And on one hand, it can be frustrating to realize that families have the right to decline EI, and some families may strongly prefer not to have a home visitor; however, EI staff will go to the child’s daycare or any other setting to provide services, and sharing this information with the family up front can make the difference between acceptance and being “lost to follow up.” Conversely EI is not a medical diagnostic service, and does not substitute for a medical evaluation that may include referral to neurology or genetics specialists, in addition to other testing.
Dr. Kathleen Conroy and her co-authors and team members deserve great credit for their work. By sharing this quality improvement effort, others will be able to replicate the project or adapt elements to their own setting, so that EI can do what it is intended to do: benefit our youngest and most vulnerable patients.