Enhanced-Early Intervention Service Coordination:  A Health Equity Initiative for Early Intervention

State: NY Type: Model Practice Year: 2018

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Nassau County Department of Health
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Enhanced-Early Intervention Service Coordination:  A Health Equity Initiative for Early Intervention

Nassau County, New York has a population of 1,360,000, making it the 27th largest county in the nation. The County is undergoing a rapid demographic shift; it is aging and it is becoming far more ethnically, racially and economically diverse. Although Nassau County is generally considered as economically prosperous, several areas of extreme poverty can be identified and health disparities are a major concern. The Nassau County Department of Health (NCDOH) administers several programs specifically targeting at-risk populations. Each year, the Office of Children with Special Needs Early Intervention Program has contact with approximately 7,000 children, provides developmental evaluations for over 4,500 children and has an active caseload of approximately 3,000 children ages birth to three. The NCDOH WIC program serves low income women, infants and children of whom 63% are Hispanic, 24% African American, and 13 % classified as other.

In 2013, a NACCHO Model Practice was awarded to the Nassau County Department of Health (NCDOH) for the Screen for Success: Early Intervention - WIC Developmental Screening Collaborative (http://archived.naccho.org/topics/modelpractices/displaymp.cfm?id=778).

This program leveraged the resources of their two major Maternal Child Health programs; the Early Intervention Program (EIP) and WIC to provide parent education and individualized developmental screenings at a busy WIC site for children under age three years. When indicated, children were directly referred into Early Intervention for tracking, multi-disciplinary evaluations and services. Streamlining the referral eliminates some of the barriers that exist in providing early intervention services to children in an at-risk community.

In early 2016, an evaluation of four years of Screen for Success program data was completed. Of the 61 children who were referred to Early Intervention, 40 children received an Initial Visit, 31 children received a multi-disciplinary evaluation, 20 children were found eligible for early intervention services, and 16 children received at least a single therapeutic service. Over 30% of the WIC children referred to Early Intervention were never seen for the Initial Visit, 30% of children who had an Initial Visit never followed with an evaluation. Finally, only 16 of the 20 children eligible for services received a service. This data drove an in-depth assessment of the observed points of failure” in access to early intervention services for WIC families. Enhanced-Early Intervention Service Coordination (E-EISC): A Health Equity Initiative for Early Intervention was implemented in response to these findings.

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 the Early Intervention Program receive appropriate services in a timely manner.

Objectives:
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 failure” barriers to service

Enhanced-Early Intervention Service Coordination (E-EISC) Model was implemented to meet the need for close coordination of the types of early intervention cases identified through the internal review of Screen for Success. Enhanced-Early Intervention Service Coordination (E-EISC) is both a program and a specific role which act to combat the barriers to health associated with poverty. This program streamlines the steps completed at the initial contact, improves timelines and reduces the possibility of losing families to follow up. The E-EISC closely followed families over the entirety of the early intervention process to ensure that eligible children receive service.

The outcome measure for the Enhanced-Early Intervention Service Coordination Program is that 100% of children found eligible for services through the Early Intervention Program following their multidisciplinary evaluation successfully receive those services within 90 days. During the fourteen-month period since the inception of the program, 94% of eligible children received service within 83 days. All of our objectives were successfully met. We attribute the success of this practice to our continual effort to utilize an evidence-based approach (data analysis and internal review of service). This enabled us to correctly identify areas of weakness and barriers to service which aided in implementing an appropriate program specifically designed for the population that we serve.

Enhanced Early Intervention Service Coordination has had a significant impact on our ability to get children to service. While the developmental screening at WIC continues to be successful in identifying and referring children, our team learned that the process steps needed to be delivered differently to help at-risk families negotiate the barriers of poverty and remain engaged in Early Intervention.

Nassau County Department of Health Early Intervention Program Website https://www.nassaucountyny.gov/3898/Child-and-Family

Nassau County, New York is situated on Long Island and has a population of 1,350,000, making it more populated than ten US states. Nassau County is undergoing a rapid demographic shift; it is aging and it is becoming far more ethnically, racially and economically diverse. Twenty-three percent of Nassau's population speaks a primary language other than English in the home. Although the Nassau County average household income is quite high, many pockets of extreme poverty and subsequent health disparities are a major concern. With an annual birth rate of 14,000, Nassau County has a population of over 40,000 children under the age of three years. These children live with their families in approximately 467,000 households, where 4.5%, or 21,000 households have incomes below the federal poverty level.

Research indicates that disparities in access to Early Intervention exits in minority and low socio economic populations. Poverty is also closely linked to decreased Early Intervention (EI) participation rate. (Grant & Isakson, 2013). It is crucial to implement evidence based programs such as Enhanced – Early Intervention Service Coordination (E-EISC) and Screen for Success that produce synergistic effects in reaching and retaining this vulnerable population in our effort to reduce disparities. In 2013, the Nassau County Department of Health (NCDOH) was awarded a NACCHO Model Practice for the Screen for Success (SFS) program which provided education, identification and referral of children and families from lower socio economic at-risk communities to Early Intervention for either evaluation or developmental tracking. Despite the significant achievements of Screen for Success, ongoing data analysis identified a significant gap between the children who were screened at WIC and found eligible for services and the number of those children who actually received services. Out of a total of 61 WIC children assessed, only 16 of those children actually received at least one therapeutic service, which was the outcome measure for the program.

Prior to 2016, the Screen for Success team screened children on site at WIC and submitted a referral for indicated cases to the main office of Children with Special Needs (OCSN) which administers the Early Intervention Program in Nassau County. The case was then assigned, as with any other Early Intervention referral, to an Initial Service Coordinator who worked with the family through the early intervention process steps in accordance with New York State Bureau of Early Intervention (NYS BEI) Regulations. This system works seamlessly for a majority of the thousands of children seen by NCDOH in any given year. Nassau County's Early Intervention Program consistently meets state and federal regulatory timeliness requirements for the development of an Individualized Family Service Plan and initiation of services.

As detailed in the evaluation section, outcomes were different for the children referred through our outreach at WIC. From the point of the referral from WIC to Early Intervention, there were significantly higher numbers of families lost to follow up. WIC families referred to Early Intervention became disengaged, most frequently between the initial visit and the evaluation. This resulted in the loss of potentially eligible children who then did not receive therapeutic services. Providers often recused themselves from cases due to frustration stemming from family delays in responding, frequently missed appointments, the inability to locate the family and reluctance to provide services in communities associated with high crime rates.

While Screen for Success remains Nassau County's primary means of successful outreach to identified communities, program evaluation also demonstrated that additional support was needed for families to maintain engagement in order to complete program requirements and actually receive therapeutic services. The challenges associated with poverty that families face include inconsistent modes of communication, transient living situations, decreased health literacy, transportation limitations, and decreased English proficiency. It became clear that the same barriers that impede families in at-risk communities' awareness of and access to programs continue to impact their ability to follow through with the oftentimes burdensome regulatory processes required to determine eligibility, implement a services plan and finally receive the therapeutic services. Many actions must be completed in order to enroll a child in EI services, and missing anyone of these steps can halt the process. The following were identified by the evaluation team as Points of Failure” in Early Intervention enrollment, engagement, and enabled program managers to map opportunities for interventions as follows:

Point of FailureIntervention
Initial Screening during WIC VisitEngage more families for screening, as the WIC referral rate is 2-3 times greater than community referrals
Referral to Early Intervention and assignment of the Initial Service Coordinator A single ICS is assigned to this project
Initial Home VisitEvery effort, including the use of incentives, is made to complete the IHV at the time of the Initial Screening at WIC, thus eliminating the need for a separate visit
Multi-Disciplinary Evaluation by contracted Provider AgencyAgency is encouraged to complete the multidisciplinary evaluation in one session
Individualized Family Services Plan Meeting (IFSP)IFSP can be conducted at the time of the evaluation if indicated
Initiation/Provision of Services by contracted Provider AgenciesContracted provider agencies receive additional supports from the DOH including leveraging community relationships to ensure safe places to provide services

Enhanced Early Intervention Service Coordination (E-EISC), is a carefully designed, evidence-based practice developed to integrate additional strategies that reduce the identified points of failure” in this complex system in order to reach our goal of delivering therapeutic services to at-risk children. This creative addition to the existing practice is tailored specifically to meet the ongoing and challenging needs of the population of families found at WIC. The implementation of Enhanced Early Intervention Service Coordination (E-EISC) has resulted in significant improvement in the outcome measure of getting children to needed early intervention services. Recommendations that have come out of program evaluation of the practices are now being used in our general practice to decrease attrition in other challenging cases.

Since inception of Enhanced-Early Intervention Service Coordination (E-EISC), almost 100% of eligible children in this program have received services. This is a significant improvement over 61 children referred through the screening program from 2011- 2015 where only 16 of those children actually received services. It is also significant to note that the initial developmental screening at WIC results in a 20-30% rate of referral to Early Intervention, as compared to the expected 10% referral rate to Early Intervention in non-targeted, general community settings.

The target population for both initiatives has remained unchanged; children of low income families between birth and three years of age. The WIC program, by federal guidelines, serves families who have incomes below 185% of the poverty level, thus providing an ideal opportunity to reach underserved families already enrolled in a Health Department program. Each year, the Early Intervention Program serves approximately 6,000 children; provides developmental evaluations for over 4,000 children and has an active caseload of approximately 3,000 children ages birth to three. Nassau County Department of Health's (NCDOH) WIC program site in Hempstead, NY was selected for both its demographic profile and large caseload, with an average of 5,000 mothers and children visiting the site four times each year.

The Enhanced – Early Intervention Service Coordination (E-EISC) model dedicates staff to work with WIC families from the initial point of contact through the Early Intervention experience. The relationship begins at the screening and education and continues to build a connection that has reduced attrition. The E-EISC was teamed up with a Child Find Nurse at WIC, providing a consistent team to conduct the education and screenings. When a child is suspected of developmental delay there is now an on-site soft hand off from screener to the E-EISC who completes the Early Intervention referral, initial visit and assignment to the evaluating agency. This compresses the first four steps of the process into one initial encounter. In certain cases, the E-EISC may attend the evaluation so an Individualized Family Services Plan (IFSP) can be developed at the time of the evaluation, further consolidating the steps to services. A lower caseload, allows time for a more intense effort to engage clients who often require repeated contacts and follow up activities to ensure compliance with the requirements of Early Intervention.

As the population served at Hempstead WIC is 68% Spanish speaking, the assignment of a bilingual E-EISC was critical. Many of the young parents at WIC use texting as their primary means of communication. The E-EISC team submitted a consent to text” proposal and justification to the New York State Bureau of Early Intervention (NYSBEI) and gained approval permitting texting as a means of communicating with families. These were small yet important changes, as frequent obstacles identified from our record reviews was an inability to communicate or locate families once initial contact had been made. The Division of Maternal Child Health secured funding for $10.00 store cards as incentives to encourage families to stay on site and complete the Initial Visit at that first encounter. A lower E-EISC caseload has been the critical factor in the success the program has experienced allowing for the time intensive follow up required to maintain contact with families and provider agency staff.

In a hospital setting, the intensive care model decreases the patient to nurse ratio to meet the patients increased needs. Applying this model to Early Intervention Service Coordination has made a big impact. The overwhelming majority of cases assigned to Enhanced- Early Intervention Service Coordination (E-EISC) had their initial visit on same date that they were referred. The percentage of eligible children from this population receiving services has increased. Among those who benefited from the Enhanced – Early Intervention Service Coordination (E-EISC) program are children with extensive cognitive and communicative delays; newly diagnosed with Autism; and unaddressed hearing loss that missed existing mainstream efforts to identify developmental delays. Aspects from E-EISC have been generalized to regular early intervention practice with other difficult to engage families to improve retention. The number of cases lost to follow up in Nassau's At- Risk developmental surveillance track has also been decreasing since incorporating some of these strategies. The Enhanced -Early Intervention Service Coordination (E-EISC) methodology has resulted in a significant improvement in the program goal of increasing the number of eligible, at-risk children receiving needed early intervention services.

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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.

Objectives:

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 failure” 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 – 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 up” 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.

All initial primary data was collected by the Enhanced -Early Intervention Service Coordination (E-EISC) team who is responsible for providing education and screening at WIC. Included in the data are the number of families that received education, children that received screening at WIC, and families referred to Early Intervention along with identifying information (name and DOB) and dates of encounter. The E-EISC recorded the date of each step of the Early Intervention process in an Excel spread sheet with the specific data points to be evaluated: First Contact, Initial Visit, Multidisciplinary Evaluation, Initial Family Service Plan Meeting, Initial Service, and Six Month Review Meeting. In evaluating program performance, missing information was retrieved from either the electronic case record or the New York State Early Intervention System (NYEIS). Eligibility status and reasons for case closure (parental request, relocation, etc.) were recorded. This data was submitted to the project supervisor who monitored case progress.

Objective 1:

Identify the process of obtaining early intervention services and points of failure in that process.

Process and performance measures for evaluation:

  • Internal review using the data from 2011-2015.
  • Identified steps and timeline for Early Intervention
  • Data analysis to identify:
    • Numbers of cases being closed
    • Point of Early Intervention process cases where closing was occurring
  • Identified most common reasons for case closure
  • Calculated timeline between steps along the Early Intervention process

Results:
The Nassau County Early Intervention Program's recommendations for time between referral to first contact with parents is 7 days and from referral to Individualized Family Service Plan (IFSP) for an eligible child is 45 days. The mean number of days at each point during this period were 2 days longer for referral to first contact (with 66% meeting the requirement) and 7 extra days for referral to IFSP (with 60% meeting the requirement). Other steps (IFSP to Service, Referral to Initial Visit, Initial Visit to evaluation date) met the time requirement. Outliers were excluded in the calculation of mean when applicable.

In the cases studied prior to the implementation of E-EISC, the most common reasons for case closure were parental declination of services (n=13) or being lost to follow up (n=11). 85% of parental declination and 100% of lost to follow up took place during the initial stage between referral to multidisciplinary evaluation.

Modifications:
Parental declination of services was thought to be due in part to lack of parental understanding of developmental milestones and language barrier/cultural differences between Early Intervention screening staff and families. In order to mitigate this issue, a bilingual (English/Spanish) staff was designated as the E-EISC. Also, in order to prevent loss of client to contact, another major reason for case closure, contacting parents via texting was implemented. The intake/referral form was redesigned to include space for multiple contact information fields. As for improving the timeline, Enhanced -Early Intervention Service Coordination (E-EISC) was implemented to intensive case coordination as detailed under Objectives 2 and 3.

Objectives 2 & 3:
Identify a role for the E-EISC to provide intensive case coordination
Revise the Early Intervention Program process to reduce these points of failure” barriers to service

Process:
The E-EISC was present during each WIC outreach session to streamline the steps completed at the initial contact, thereby improving the timeline and reducing the chance of losing families to follow up during the hand-off process. To ensure targeted case coordination and consistent follow up to help families complete the Early Intervention process and to ensure that eligible children do receive service, a smaller case load was assigned to E-EISC so that the same E-EISC would closely follow families throughout the whole process.

The performance measured for this study:

  • Timeline at each step of Early Intervention (EI)
  • Proportion of children moving on to the next step of the EI process
  • Timeline between referral to Individualized Family Service Plan,
  • Timeline between referral to service
  • Proportion of referred children receiving service
  • Proportion of families lost to follow up
  • Proportion of parents declining services
  • Number of children that were transferred to Child Find that later received re-evaluation and service

Results:
The number of children referred to Early Intervention through Screen for Success during this study period (82 in 14 months) was significantly greater compared to previous years (61 children over 4 years: 2011-2015). This may be due to the increase in frequency of WIC outreach from biweekly to weekly during the study period (April 2016 May 2017) to reach more families.

During the study period of April 2016 to May 2017, the families of 2,603 children received education on developmental milestones through the WIC outreach effort. Out of these 2,603 children, 20% received developmental screening on site. Of children screened, 14% were referred to Early Intervention for multidisciplinary evaluation and 90 % actually completed the evaluation.

During the Screen for Success program for the period between 2011-2015, only 51% of the referred children were evaluated. Among those not receiving evaluation, approximately half declined service and half were lost to follow up. During the Enhanced-Early Intervention Service Coordination study period from April 2016 - May 2017, 90% of referred children were evaluated. Parent declination prior to evaluation was only 6% and only 1 child was lost to follow up.

Of the evaluated children, 66% were found to be eligible for service and 96% of them received service, which is a significant improvement from 80% in the previous 4 years (2011-2015). It was validating to see that the service continuation rate at the Six Month Service Review also increased significantly from 60% to 90% (excluding 2 children that had not yet reached the 6-month mark during the study period).

In addition, there was a significant improvement in the timeline of initial steps of the Early Intervention process. In 2011-2015, the referral to Initial Contact/ Initial Visit took a mean of 9 days but during the current study period, it was reduced to a mean of 1.8 days (mean excluding 1 outlier=0.58) for Initial Contact and 4.84 days (mean excluding 2 outliers=1.2) for Initial Visit. As for referral to IFSP, the mean was 52 days in 2011-2015 and 53 during this study period. However, the mean excluding 4 outliers was 47 days and this number more appropriately reflects improvement on the part of Enhanced -Early Intervention Service Coordination. Most delays were due to complications associated with at - risk families. Parental delay was the reason for going over the recommended 45-day timeframe in 2 out of the 4 outliers and one was due to evaluator delay. 1 outlier had an inconclusive reason due to insufficient information recorded in the case record.

Lastly, the goal timeline of this practice study was previously determined to be 90 days from date of referral to service initiation. Program evaluation demonstrated that the timeline was reduced to a mean of 83 days and a mean of 72 days excluding 3 outliers.

Over the course of fourteen months since its inception, the Enhance-Early Intervention Service Coordination program achieved a significant reduction in attrition rate and improvement in timeline of the initial steps and of the entire process compared to the previous four years.

Of note, 2 children who were initially reached at WIC and were transferred to Child Find (1 in 2016 due to ineligibility and 1 in 2017 due to parental service declination) were re-evaluated and eventually received service. Such success may also be attributed to improved coordination and consistent follow up by Enhanced -Early Intervention Service Coordination.

Modifications:
In order to continue providing improved service coordination, we have ensured a consistent presence of E-EISC during WIC outreach. Also, in cases of parental declination of Early Intervention service, 2- month follow up phone calls were made to parents to address any new concerns and to re-enforce the importance of recognizing developmental delay and providing timely early intervention. Tracking children who were Not Eligible and transferred to Child Find/At-Risk was implemented as a safety net measure. For improved data collection, easy identification of reasons for parental declination, and determination of barriers to timely service provision, a coding chart was created. A written guideline for entering data was also provided to Early Intervention staff responsible for data collection to prevent discrepancy between collected data and electronic records.

The results of this practice is that Enhanced-Early Intervention Service Coordination actually realized a success rate of 96% of eligible children receiving services. This dramatic improvement in achieving our goal supports the need and benefits for Nassau County to continue this highly valued and sustainable practice.

Enhanced-Early Intervention Service Coordination(E-EISC) clearly demonstrates that with the added support of thoughtfully designed intensive case coordination, families of low socio economic status could overcome many of the barriers associated with poverty that interfere with their long-term engagement in early intervention services. As demonstrated in the evaluation section, the impact of E-EISC on the case outcomes of children is dramatic. Nassau County's Office of Children with Special Needs is committed to continuing E-EISC as our research demonstrates that without the specific supports in place many of these at-risk children will be lost to services.

An additional lesson learned is that program evaluation is essential to measure outcome success, provide information for ongoing quality improvement, and to gain administrative support for continuation of practice. Identifying our clear data points to measure outcome data and employing a simple system to record information made an easier process for ongoing and long-term evaluation. Sharing this information with Nassau County Department of Health administration through the monthly Board of Health report has brought recognition to our work and staff. For municipal entities, there are limited opportunities for tangible rewards or compensation, but having one's work validated and acknowledged can be a motivating force for staff.

Staff was initially reluctant to volunteer and change responsibilities for this new initiative. Educating the general staff concerning our data helped them recognize the need to develop creative strategies to reach our target families. The E-EISC supervisor and EIP Director canvased the staff to identify the person with the right skill set and desire to be part of this newly developing practice. Regular meetings between the E-EISC supervisor and the team provided feedback on the practical aspects of the program in order to make needed adjustments in process and provide staff support.

It is important to understand the needs of the population that is being served. For the population in our targeted area, a bilingual Spanish speaking, culturally competent staff member was the best fit. Allocating resources to this program is critical. The success of the E-EISC Program is directly associated with the ability of this specific caseworker to have a lower caseload assignment. Direct supervisory involvement to provide support, education and encouragement was needed to sustain commitment to this program.

Inviting other programs to see your work can open up new access and ideas with positive results for your program. Nassau County Department of Health's'(NCDOH) relationship with Stony Brook University Hospital's Preventive Medicine Residency Program (PMR) has been an effective way to support our research projects, program development and proposal campaigns. PMR's have global views of public health, access to research materials and have been eager to be involved with our data analysis and program review projects as it is something that aligns with their required deliverables. These are time intensive activities are difficult to address within departmental budget constraints. Academic partnerships are valuable and in fact essential to the developmental of new practices.

A second strong partnership was developed between our Early Intervention Program and Docs for Tots (http://docsfortots.org/ ). Initially there was reluctance about meeting with another agency that would most likely be looking for a time commitment, taxing our already overloaded schedules. Both programs have benefited as the partnership helped us refine our screening program and established a complimentary screening model in the County's Federally Qualified Health Centers. This expands the number of at-risk low socio economic status children receiving developmental screening. In turn, NCDOH is partnering in Doc for Tots' endeavor to establish a Long Island chapter of Help Me Grow (https://helpmegrownational.org/) which will be another program to support the work of Early Intervention.

Ultimately, services to children are provided by contracted agencies who work in the community. Many of the providers are reluctant to provide services in targeted communities in Nassau County. Providing support and identifying community based areas for children to be served helped to gain the cooperation of the Early Intervention provider community. There is increased stress associated with working with a high concentration of challenging cases. Taking proactive measures to address this concern may prevent burnout. Reaching out to our staff and stakeholders to thank them for their time and dedication was appreciated and solidified our relationships. Sharing the results and successes with partners is a strategy to foster these necessary partnerships. Using a public forum such as the Local Early Intervention Coordinating Council meeting to enlist partners appears to have had the benefit of positive peer pressure. Forging one to one personal relationships and providing program updates are keys to keeping partners engaged. Public acknowledgement of a stakeholder's contribution engenders goodwill and it is hoped will encourage others to take a serious role in providing services for children in at-risk communities.

It was helpful to interact in the community to gain an understanding of the populations needs. This also provides visual presence that can serve to familiarize the community with the LHD as a resource. Connecting with the housing supervisor gave us another viable option for providing the services to children in a high crime neighborhood. It is hoped that NCDOH's Minority Engagement Committee will be helpful in reaching other landlords in the community.

A formal cost/benefit analysis was not done as the associated costs for Enhanced -Early Intervention Service Coordination (E-EISC) are absorbed into the existing Early Intervention Programs' budget. Enhanced -Early Intervention Service Coordination (E-EISC) is a more effective, although expensive, use of staff time to meet the extraordinary needs of these families. General staff have higher caseloads in order to maintain the E-EISC caseload at a manageable number. The demands of increased caseloads are offset by several improved efficiencies in the routine processes of general program operations. Future sustainability plans for E-EISC include:

  • Rotate the assignment of the E-EISC annually
  • Continued staff training and education
  • Offer continued support and recognition to staff and other stakeholders
    • i.e.: availability of free online conferences that offer a low cost intervention
  • Expand this program to include other low socio economic populations
  • Investigate use of incentives for provider agencies servicing certain zip codes
  • Meet with other apartment building owners/management in the community to secure safe location for providing services
  • Public LHD acknowledgement of stakeholder for their service
    • i.e.: The Local Early Intervention Coordinating Council Meeting

Research indicates the long term negative health and financial impacts on delayed recognition and treatment of developmental delays in children. The theme of The Early Care & Learning Council’s (http://www.earlycareandlearning.org/) 2017 Annual Meeting, Early Care & Education: An Economic Investment sums up the issue. The question is not if we can afford to continue the program, but instead, can we afford not to invest additional resources in the future of at-risk children. The Nassau County Department of Health remains committed to ensuring that all children have access to our services. Enhanced - Early Intervention Service Coordination has proven to be an effective tool to reach this goal and remains a priority for Nassau County.

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