The goal of Enhanced-Early Intervention Service Coordination (E-EISC) is to ensure that all children referred through our screening program and found eligible for Early Intervention receive appropriate services in a timely manner.
1. Identify the process of obtaining early intervention services and points of failure in that process
2. Identify a role for the E-EISC to provide intensive case coordination
3. Revise the Early Intervention Program process to reduce these points of failureâ€ barriers to service
Formulating the goal and objectives began with data analysis of case outcomes of children of low socio economic status (SES) referred to the Early Intervention Program (EIP) from 2011-2015 through Screen for Success at WIC. A flow chart and diagrams were developed for presentation purposes to demonstrate timeline, points of failure, and make recommendations to address the disparity in children getting to actual therapeutic services. This information was used to form the basic conceptual framework for Enhanced-Early Intervention Service Coordination (E-EISC).
With the problem identified, the Early Intervention Supervisor, Program Director and the Director of Maternal Child Health (MCH) conducted several meetings as the proposed project needed administrative support to reassign staff and increase the schedule of outreach dates per month. Discussions centered around data that supported the need for and specific process changes that could improve outcomes. Maintaining data to use for future program evaluation was a lesson learned from a previous Model Practice submission. Staff who had been conducting developmental screenings at WIC were consulted for their valuable feedback and suggestions. This information along with our data defined the process of consolidating steps and further refined the role and responsibilities of Enhanced â€“ Early Intervention Service Coordination (E-EISC). Our hypothesis was that establishing an E-EISC team on site to conduct the screening outreach could move the clients through the first few phases of the Early Intervention process in one initial contact and provide intensive ongoing support thereby increasing the likelihood of getting eligible children to service.
For the project to move forward, it was also important to have buy in from the general staff whose caseloads would increase once a service coordinator was pulled out of the rotation to focus specifically on the target population. The findings of our outcome review were presented to the general staff at a department staff meeting. A PowerPoint presentation including timelines and charts clearly demonstrated where gaps existed and where the program was losing families before receiving services. A lively and interactive discussion ensued. Initially, the meeting had the opposite effect of the buy in we were seeking. There was unanticipated resentment expressed by some staff who felt their current work practice was being criticized. The staff meeting forum provided a venue for staff to verbalize their feelings and for the project launch team to clarify the mission and need. Staff dedication was acknowledged but the data showed that despite their best efforts children were being lost. The Power Point graphics provided a strong visual representation of where the drop offs were occurring and clarified the need for change. The research we provided validated the specific difficulties they encounter in day to day practice. Creating an environment where staff feel comfortable sharing honest feelings opens up an avenue for ideas and change. Staff began to share personal stories of frustration involving cases they lost to follow up and the difficult circumstance they encounter when working with families in poverty. This was followed by a productive conversation about measures that could be implemented to reduce attrition.
Once staff and administration were committed to addressing the issues in Early Intervention process, the ensuing steps were implemented to launch the Enhanced-Early Intervention Service Coordination(E-EISC) program. An enhanced core team was assembled comprised of the Child Find Nurse who had been conducting the developmental outreach partnered with a Bilingual Spanish Service Coordinator identified as the Enhanced-Early Intervention Coordinator (E-EISC). The project supervisor met with the identified team multiple times to devise the team concept, work flow, and provide orientation. The Child Find Nurse had extensive experience using the Ages and Stages Questionnaire -3 and provided on - site support for conducting developmental screenings and outreach. Both staff screened and provided education. There was is a soft hand off to the E-EISC of any children being referred to Early Intervention. The E-EISC attempted to conduct the Initial Visit and contact the evaluator all at that first encounter. If possible, the evaluation to determine eligibility was also scheduled at that point. The system was designed that the case load would be limited to the cases referred through SFS outreach for the duration of a child's time in the Early Intervention Program. Outreach was increased from biweekly to once a week to reach as many families at WIC as possible. Space was negotiated with WIC staff to work with families and stocked with necessary supplies. Having a set team provided consistency for smoother execution as well as a familiar presence at WIC.
The E-EISC maintained contact with the family and provider agencies on an increased basis to ensure the family remained connected to the process without interruption. It was agreed that no cases would be closed as lost to follow upâ€ without heightened attempts to reach families and supervisory review. The E-EISC often had to make multiple visits and an increased number of phone contacts to the family and providers as compared to typical cases referred to Early Intervention. When necessary, the E-EISC accompanied the evaluator to the actual evaluation in order to write an Individualized Family Services Plan in conjunction with the evaluation when there was heightened concern regarding either the child's disability or risk for the family's disengagement from Early Intervention. All of this required the flexibility in schedule that a lower case load permitted.
As an additional safety-net in in the Enhanced -Early Intervention Service Coordination model, children evaluated and not found eligible for Early Intervention but who exhibit risk factors (borderline delays) were encouraged to enroll in ongoing developmental surveillance through the At-Risk track of Early Intervention. The case remained with E-EISC team but at this point the Child Find nurse took over to conduct periodic surveillance. In some of these cases, children were subsequently re-referred to the Early Intervention track and determined eligible for service.
In order to ensure that contact with families was maintained, the intake form was redesigned to include multiple contact sources. A consent to contact by text was an idea suggested by the team based on their experience at WIC to improve communications with younger families. An Excel spreadsheet was set up for selected data points in order to track case outcomes. This was entered into a shared drive accessible by the E-EISC team and select health department administrators. Maintaining the ongoing case outcome data is a shared responsibility between the E-EISC and the Project Supervisor. This format simplified the process of extracting the information needed to evaluate case outcomes. The E-EISC supervisor functions as a liaison between the E-EISC team, LHD administration (specifically the Director of Division of Maternal Child Health), and the Director of the Office of Children with Special Needs. Data on the results of Enhanced -Early Intervention Service Coordination were reported monthly to the Board of Health.
The cases targeted for this practice were children at Hempstead WIC who were between the ages of birth to three years, who received a developmental screening at WIC and were referred to the Early Intervention Program (EIP) due to a suspected developmental delay. Beginning in April of 2016, all children referred to EIP through the screening outreach were assigned to Enhanced-Early Intervention Service Coordination (E-EISC). The exciting results realized through this practice are based on the period studied from its inception in April 2016 through May 2017 and provide the basis for this submission of Enhance-Early Intervention Service Coordination for consideration as a Model Practice.
The primary stakeholders involved in the development, implementation and success of Enhanced -Early Intervention Service Coordination include the Office of Children with Special Needs/Early Intervention staff, Nassau County Department of Health Administration, in particular the Division of Maternal Child Health, families at WIC and WIC staff. Community and related stakeholders included: early intervention provider agencies, New York State Bureau of Early Intervention, Local Early Intervention Coordinating Council, Stony Brook University Hospital Preventive Medicine Residents, Docs for Tots, local police precinct Community Liaison Officer, and the Housing Supervisor of a large apartment complex in the target community.
It was important to have the cooperation of service provider agencies as they also assume some of the inherent costs in time and staff incurred working with difficult to reach cases. Nassau County's Local Early Intervention Coordinating Council holds a biannual meeting for Early Intervention stakeholders which is open to the public. Attendees include partners from provider agencies, Early Childhood Direction Center, Child Care Council, Child Protective Services, Foster Care, NuHealth (a local safety-net hospital), Nassau County residents, and the medical community. This event provided a forum to reach out to these entities asking for their support in working with families in at-risk communities. The E-EISC Supervisor shared the case outcome findings, introduced the new initiative, and encouraged providers to use increased resourcefulness and dedication to bring children to needed services. As an example of a process change, the Multidisciplinary Evaluation required to determine eligibility for early intervention services requires a minimum of two evaluations from different disciplines. Typically, the evaluators make individual appointments based on their schedule to conduct their respective assessments. We requested that to the extent possible, evaluations be conducted arena style to reduce the number of appointments a family has to keep to determine eligibility.
Concerns expressed by stakeholders included the fact that these cases were more time intensive, often required repeated attempts to evaluate making them cost prohibitive. Two agencies in particular worked closely with the E-EISC team to ensure children were successfully evaluated and services placed. They absorbed the costs associated with difficult to serve populations and engaged staff that had a dedication to reaching underserved children. Providing support for staff both within the health department and for outside providers was imperative to prevent frustration and burnout. While there are typically no tangible rewards available for recognizing extra effort in public health, some personnel involved with the project appreciated having their efforts acknowledged and were excited at being part of a project they supported.
Another issue raised by providers was a concern for therapists' safety as these cases are located in neighborhoods associated with high incidence of crime. To mitigate this issue, the local police precinct community liaison officer was contacted and put us in touch with the building supervisor at one large apartment complex that providers were especially reluctant to enter. This community partner worked out a plan for parking and space in the community rooms for services. The Housing Supervisor invited Early Intervention to do outreach in the building lobby to bring awareness of the program to its residents. This particular community effort was shared at a Community Engagement Committee that was working on projects included in Nassau County Department of Health's Public Health Accreditation Application. It inspired an offshoot committee specifically targeting minority outreach with plans to invite other community stakeholders to the LHD to trouble shoot access to care and community health issues. It was suggested that the committee to reach out to other building owners in the community.
Nassau County Department of Health provides a Public Health rotation for Stony Brook University Hospital's Preventive Medicine Residency Program. Residents observed the Early Intervention process, our developmental screening outreach and assisted with the data analysis and literature review. Residents had opportunities to put their training into actual practice analyzing health needs, assessing best use of resources, making recommendations, presenting proposals to staff and administration and engaging a variety of stakeholder in a common goal. This has been a helpful partnership for Nassau County as it assisted staff with time consuming projects and saved potential overtime costs that would have ensued if our staff had to complete the data analysis.
The Director of Maternal Child Health negotiated funding of $2000.00 between the New York State Bureau of Early Intervention and the Nassau County Early Intervention Program for the purchase of gift cards to a local store as incentives to encourage families to complete the Initial Visit a developmental screening and/or Initial Visit at their initial encounter at WIC. Engaging the State Bureau as a stakeholder was also necessary to change the practice permitting texting as a means of communication with families. This took considerable campaigning to achieve as it required review by the Bureau and their legal department to address the impact testing would have in relation to the confidentiality laws in Early Intervention. Sharing the data on Nassau County's Early Intervention attrition rates and disparities in access to services for children of lower socio economic status at WIC was the most impactful tool in gaining the Bureau's permission for both the incentives and texting. Health Departments across New York share their challenges and strategies in reaching the underserviced Early Intervention age population during state conference calls and meetings. When the Bureau approved Nassau's consent to text, the change benefited all New York municipalities giving them another method to use in reaching families.
There have been some tangential benefits realized from this project in developing E-EISC. Docs for Tots received a grant to work with Nassau County's pediatric medical community to increase the practice of providing developmental screening at well child visits. The Program Director and Coordinator reached out to the Early Intervention Program to learn about our role and seek partnership in their endeavor. Docs for Tots program director and coordinator visited our screening program and provided some suggestions to improve engagement with families. In turn, they set up a screening model in the Federally Qualified Health Centers that are run through NuHealth. This increased the number of children of low socio economic status that were reached with developmental screening and referred to Early Intervention when there were suspected delays. A significant benefit that came out of this collaboration was developing contacts among the Health Centers, the local safety net hospital and the Early Intervention Program. Nassau County Medical Center and the Health Center's Patient Coordinators worked with our staff to locate and follow up with families that formerly would have been lost to Early Intervention. We have coordinated a strategy for some especially challenging cases to coordinate the Early Intervention contact with a child's well visit. Nassau County recognizes the benefits of sharing ideas and practices that address common public health issues. As it has for past model practice awards, Nassau County is concurrently submitting an abstract proposal to present Enhance-Early Intervention Service Coordination at the 2018 New York State Public Health Conference as another avenue to share our program's effectiveness in addressing engagement disparities in Early Intervention.
Other than the $2000.00 purchase for incentives, no additional costs ensued as the project is staffed with existing personnel that is in the existing program budget. Enhanced-Early Intervention Service Coordination (E-EISC) involves redistributing resources of personnel, time and process. The impact of the incentives had mixed reviews on how helpful it was in engaging people. Anecdotal feedback from the E-EISC team observed that if a parent was concerned they stayed to complete the initial appointment regardless of receiving an incentive.