Closing the loop: Improving quality of screening, identification, referral and outcomes related to developmental screening through a multi-directional collaboration

Background :Assuring Better Child Development (ABCD) is a statewide program to facilitate the consistent developmental screening, identification, and referral of children in the pediatric primary care setting using the Ages and Stages Questionnaire (ASQ). ABCD initiated collaboration among three health organizations when all identified numerous and similar system and practice-level gaps and barriers. The collaborative has been actively developing a shared, consistent, and comprehensive methodology to gather data and report outcomes. Methods: Quality improvement (QI) efforts were implemented across the organizations: a community safety-net organization, a large managed care organization (MCO), and a children's hospital. Systems data included information about screening, eligibility, and types of services received. Manual record reviews, electronic data pulls, and phone follow-ups were used to gather the information. At the children's hospital, electronic medical record data resulted in a comprehensive database including all children who were eligible for developmental screening beginning in January, 2009. The dataset currently contains over 3,500 cases. At the community safety net organization, 108 charts were reviewed to determine status of children following abnormal ASQ score. Results: Prior to the ABCD program, data on developmental screening, identification, and referral were not tracked. QI efforts at all 3 organizations identified significant gaps in the communication of information about referral results from the community referral agencies back to the providers. As a result, the children's hospital implemented a question set in the electronic record resulting in tracking 70% of developmental screens and a phone follow-up protocol for families with abnormal screening results, effectively “closing the loop” at this organization. The safety net organization was able to “close the loop” through extensive manual chart review and follow-up with families and the community agencies in 91 cases. The MCO adapted processes of tracking and follow-up from the community safety net organization and the children's hospital for pilot testing. Conclusions: Ongoing statewide efforts to implement developmental screening, identification, and referral in pediatric primary care settings identified numerous system and practice-level gaps and barriers including: review and documentation of screening results, family understanding of referral process and services, lack of follow-up post-referral, lack of communication between early intervention programs and providers, and challenges tracking and managing data. Using implementation science and data from quality improvement efforts, collaborations among the 3 institutions and the state program have facilitated bidirectional translation of ideas. This collaboration has resulted in alignment of data collection efforts and outcomes evaluation.