Ongoing Services

- Cavity-Free at Three Statewide Training
- How to refer children with developmental delays
- Provider Resource Helpline Helps Your Special Needs Children: Identify & Access All Resources and Care Coordination
- Medical Home Certification
- Post-partum Depression Screening
- Practice Manager's Meeting
   HEATHCARE INFORMATION TECHNOLOGY (HIT) INCENTIVE PROGRAM
   Is your practice eligible for federal stimulus dollars?
   Presented by: Robyn Leone, Director of the Colorado Regional Extension Center
   Wednesday, July 21st from Noon to 1PM @ TCH, RSVP carter.joyce@tchden.org
- Announcing an Interactive Cross- Cultural Communications Website Designed Especially for Healthcare Professionals
- Introducing the CCHAP Quick Reference Link
- Child Psychiatry Telephone Consultation on Medicaid Children
- Integrating Developmental Screening In a Pediatric Practice
- Medical Spanish Training For Your Office Staff
- Child Psychiatrist Available to Provide Conferences for You In your Office
- Language as a Communication Barrier in Medical Care for Hispanic Patients Plus A Spanish Course For Providers

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Screening for Adolescent Depression

 
Colorado has one of the highest rates of teen depression and teen suicide in the country.   Mental health screening is recommended the American Academy of Pediatrics, the American Academy of Family physicians, the National Association of Pediatric Nurse Practitioners, the U.S. Preventive Services Task Force and the Institute of Medicine on all of our teenage patients each year.  It is a required component of routine care for new plans under the 2010 health reform legislation. 
 
The Patient Health Questionnaire Modified for Teens (PHQ-9 Modified) is a well-accepted questionnaire, used by many providers and health plans across the country.  It can be used with patients between the ages of 12 and 18 and takes less than five minutes for them to complete.  The PHQ-9 Modified can be administered and scored by a nurse, medical technician, physician assistant, physician or other office staff.   Teens are more likely to truthfully answer questions about depression on a questionnaire than when asked the same question by a provider.
 
The PHQ-9 Modified was developed by the Division of Child and Adolescent Psychiatry at Columbia and is available for free.  You can download the questionnaire and a guide for implementation in your practice at teenscreen.org. There is a guide for implementing depression screening in your practice (http://www.teenscreen.org/library/implementation-materials-fact-sheets#PC).   It also has a guide for when to refer and how to get reimbursed (http://www.teenscreen.org/library/implementation-materials-fact-sheets#PC).  There are training tools for office staff also at (http://www.teenscreen.org/library/implementation-materials-fact-sheets#PC).

Cherry Creek Pediatrics (private practice) and Community Health Services (a school-linked clinic in Commerce City) have been using this tool at each adolescent well child visit and recommend it.  Also, they are billing a 96110 and receiving reimbursement from Medicaid.  This screening tool is being used by John Genrich at Cherry Creek Pediatrics.  If you have questions, contact him at johnhgenrich@comcast.net.

Where to refer a teen at risk for suicide

Of course, what we all worry about is identifying a teen who is at risk for suicide, then not being able to find a mental health provider to see the teen.  For teens covered by Medicaid or CHP+, figure out the county the teen’s Medicaid or CHP+ card was issued in and go to the CCHAP on-line manual or “quick link” to determine who to call to make the referral.

Uninsured or Under-insured Teens at Risk for Suicide
When a teen at risk for suicide has no insurance or has inadequate mental health coverage, contact Second Wind Fund (SWF). The mission of Second Wind Fund of Metro Denver is to decrease the incidence of teen suicide by removing financial and social barriers to treatment for at-risk youth.  Learn more by visiting http://www.swfmd.org/aboutfund.html or calling 303-988-2645

After you make the referral, SWF will:

1. After ensuring that the student is a suicide risk, lacks financial means to pay for therapy, and is not on Medicaid, SWF assigns the student a referral number. If the student is on Medicaid, he or she is first referred to the county mental health association.
2. The counselor initiates a referral with parental permission. After given a SWF referral number, the school counselor writes the referral number on a program referral form, signs the form, and gives it to the student and/or parents. 
3. The referred student is given the referral form and a list of private therapists who have agreed to see SWF clients. 
4. All therapists in the SWF program are private therapists who are licensed, maintain malpractice insurance, have experience with teens at-risk for suicide, and have agreed to see SWF clients at a drastically reduced hourly rate. 
5. SWF will pay for a student to visit a program therapist up to 20 times. (Eight visits are automatically approved at the time of the initial referral. More visits require additional information.)

To contact someone in your area to make a referral of a teen at risk of suicide:
 
SWF Metro Denver (Adams, Arapahoe, Broomfield, Denver, Jefferson, Park Counties) – call 303-988-2645

SWF Four Corners Colorado – Lillian Ramey – Lillian@riversagecounseling.com (covers La Plata and Montezuma Counties)

SWF Boulder County – Faye Peterson and Kathy Valentine – fayepeterson@comcast.net and vastone2@hotmail.com (covers Boulder County) 720.212.7527

SWF Uncompahgre Plateau – Kimberly Hamilton – Kimberly.hamilton@westernalum.org (covers Montrose, Ouray, and San Miguel Counties)

SWF Weld County – Keith and Shannon Wawrzyniak – kpw@dynamicfamilydesign.com (covers Weld County)

SWF Eagle River Valley – Carrieann Angrisani – page132@hotmail.com (covers Eagle County)

SWF El Paso and Teller Counties – Constance Gelvin – cvgelvin@aol.com (covers El Paso and Teller Counties)

SWF Douglas County – Lynn Pender – secondwinddc@comcast.net (covers Douglas County) 303-895-0434

SWF Northeastern Colorado – Maranda Miller and Jackie Reynolds – maranda.miller@rural-solutions.org and Jackie.reynolds@rural-solutions.org (covers Sedgwick, Phillips, Yuma, Morgan, Lincoln, Washington, Logan, and Kit Carson Counties)

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Modesty in Healthcare: A Cross-cultural Perspective
By Marcia Carteret, M. Ed.
Special thanks to Amy Sass, MD (Adolescent Medicine) and Erlinda DeLuna Elbaum of CCHAP for sharing their experiences, expertise, and ideas that informed the writing of this newsletter.

Studies have shown that obtaining accurate medical histories and diagnosing current symptoms can be adversely affected by a patients’ concerns about modesty. Though these concerns are not exclusive to cross-cultural encounters, the most challenging situations do often arise because of differences in modesty mores between providers and their patients. Though initially our tendency is to think of modesty in fairly simple terms (i.e. covering the intimate body parts), cultural values around modesty can be far more complex.  Therefore, expanding our assumptions about modesty is important to ensure successful cross-cultural interactions.  This includes understanding the impact of acculturation and assimilation. To avoid stereotyping individual patients and family members, we may start by considering normative behaviors for less acculturated individuals first, but then we always expand our view and test our assumptions. We allow for a great diversity among human beings’ values, beliefs, and behaviors.

Defining Modesty: “Modesty is not just about covering up or wearing specific clothing. By definition, modesty is about respect. A provider who takes cultural modesty into account is someone who shows respect and caring in the highest degree.” 1
Though we often associate modesty with the prescriptive doctrines of certain religions, modesty in many cultures often means showing propriety in speech, dress, or behavior and lack of pretentiousness. In many cultures, modesty demonstrates essential goodness in a person and is highly valued. Purity of thought and manners is as important as physical/sexual purity – and in fact the two are inextricably linked. In collectivist cultures where the family is the center of all loyalty, obligation and status, social approval is very important. Shame and honor are highly emphasized because a person’s bad action dishonors their entire family, tribe, village, and so on. In a highly individualistic culture, this is lesser concern because a person’s behavior reflects more on himself or herself.

In societies that place a high value on modesty, it is important for both sexes, but particularly emphasized for women. A woman’s sexual purity and chastity honors her entire family. American women may view this as more discriminatory than protective. It is important not to assume that women in high-modesty cultures are forced to accept the restrictions placed on them by men. In fact, for many women in these cultures modesty is an attribute to be admired and attained. Women often impose modesty on themselves and other women as a way of keeping boundaries of privacy and respect.

In the majority of health care visits, a routine handling of modesty and privacy concerns suffices. However, sensitive interactions do arise for cultural and religious reasons. There are no hard and fast rules for handling these situations, but being prepared to ask culturally sensitive questions is important in reducing anxiety and stress for patients and family members.  Delicate situations require preparedness in the form of appropriate questions: After explaining what is usual in western medicine (drapes, closed doors and knocking before entering) asking “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?” Or, “In your culture, how would a doctor show respect for a female/male patient during the examination.”

Modesty in Traditional Arab Culture: Strict cultural guidelines about modesty are very common in Arab cultures, especially among Muslims. The Islamic world view emphasizes the dependency of humans on God, and fear of God’s punishment tends to direct Arab Muslims to follow Islamic ethics. Modesty is stressed for both sexes, spiritually and physically. However, it is of greatest importance for Muslim women. Although there is considerable variation in the manner of dress and segregation of the sexes in different Arab countries, traditional custom dictates that women cover their hair, body, arms, and legs. This is a concern any time a woman might be seen by men who are not from her immediate family. Thus, special provisions should be made for female providers to examine Muslim women. Similarly, female nurses should be assigned, and a female nurse should always be present if a male doctor is treating a female Muslim patient.  Some Muslim women may resist uncovering parts of the body not being examined. Opposite-sex medical interns, assistants and interpreters should be avoided. Sometimes a husband may ask to be present while his wife is being examined, and all efforts should be made to comply with his request. Muslim patients, both male and female, will appreciate privacy screens and consistency in closing examine room doors. They may be unsure about making direct requests for themselves about privacy measures, so being able to anticipate their needs will demonstrate real cultural awareness and sensitivity.

Finally, many Muslims believe it is forbidden to touch a member of the opposite sex outside their family and will resist shaking hands. However, others will shake hands (unless they have just performed cleansing rituals that precede prayer). The important thing to remember is to mirror the behavior you witness. If you offer your hand and the other person does not respond, do not take this as a personal insult. American women, especially, may feel rejected when an Arab male refuses her hand, especially if she is a doctor. She should not attach her culture’s meaning to this behavior. In general, healthcare professionals should avoid touching opposite-sex Muslim patients except when giving direct care. Such hesitation isn’t as necessary with a patient who is of the same sex.

The above discussion of modesty in Arab culture provides the normative values and behaviors of people who have recently immigrated and are not yet acculturated in the U.S. Many of the Arab American families in our community will not express these same concerns about modesty. It is important to ask questions of each individual patient/family to determine where they are along the assimilation continuum and how strictly they adhere to traditional customs and practices. The extremely modest Arab may be the exception in a provider’s experience, but it is important to be prepared to handle the exceptional case when it appears.

Asian Cultures and Modesty: In general, traditional Asian women place a high value on modesty and may be uncomfortable in health care interactions with male doctors. Even today, modesty is related to the relationship between genders specifically. Any overt display of affection in public between members of the opposite sex is unusual in parts of Asia, and even hand holding between men and women could be considered inappropriate unless they are married. This simple gesture of affection is more common between two women in China, for example, and does not in any way suggest a tendency towards homosexuality, which it might in American culture.

In China over 90% of obstetrical or gynecological providers are women which averts the problem of women’s extreme modesty in health care interactions2. In many Asian cultures, sexuality usually gets discussed within the context of marriage and child bearing only. Thus, sex is still a taboo subject in many parts of Asia. Parents and healthcare professionals may be reluctant to provide sexual information to young people in their families.

Traditionally, modesty and chastity are highly valued qualities in young Asian women who are taught to avoid premarital sex because it would tarnish their family honor. As Chinese and other Asians are exposed to western cultural values around modesty and sexuality, these attitudes change. Many highly acculturated Asian women have no objection to being examined by a male physician, are comfortable discussing their bodies, their sexuality, and reproductive health.  The astute health care provider is aware of the spectrum of values, beliefs and attitudes and asks culturally sensitive questions of each patient to avoid stereotyping.

Modesty in Latino Cultures: As is the case in Arab and Asian cultures, acculturation is key to a person’s attitudes and behaviors around modesty and privacy in Latino cultures. More traditional women who have recently immigrated from Mexico and countries in central and South America, for example, may be very modest, whereas the typical second or third generation Americans from the same countries will likely be much more relaxed in health care interactions. Religiosity can also be an important contributor to ideas about modesty; many Latinos are strict Catholics and may feel that modesty is an important part of being faithful to the church. Finally, among many Latinos the concept of modesty is closely connected to respecto and privacy. Latino cultures are collectivist with a strong sense of in-group belonging, interdependency and responsibility. Illness is often considered a very private family matter, and sharing private matters in front of strangers may be regarded as wrong. In more traditional Latino cultures, a doctor might be someone a family has established relationship with over many years. A doctor is thus a trusted member of the community who can be trusted with personal health matters. In American culture, patients expect a formal and detached relationship with health care professionals. We don’t usually have close personal ties to our doctors and, for us, being open and less modest is easier with a professional we are unlikely to encounter outside the exam room.
 
Sources Cited

1. Andrews, C. 2006 Modesty and healthcare for women: understanding cultural sensitivites. Community Oncology. Vol. 3 No. 7 443-445
2. Mo, B. 1992 Modesty, Sexuality, and Breast Health in Chinese-American Women. Cross-cultural Medicine – A Decade Later [Special Issue] West J. Med Sept; 157:260-264

Additional Resources for this Article

1. Galanti, G. 2003 The Hispanic Family and Male-Female Relationships: An Overview. Journal of Transcultural Nursing, Vol. 14 No. 3 180-185
2. Lawrence P., Rozmus, C. 2001. Culturally Sensitive Care of the Muslim Patient.  Journal of Transcultural Nursing, Vol. 12 No. 3 228-233
3. Hammad, A., Kysia, R., Rabah, R, Hassoun, R., Connelly, 1999 M Guide to Arab Culture: Health Care Delivery to the Arab American Community. ACCESS Guide to Arab Cultur.  1-32

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Practice Manager’s Corner

The next Practice Manager’s Meeting:  Everything you need to know about obtaining Federal Stimulus dollars to help fund meaningful use of an electronic medical record in your practice.  The head of Colorado’s program will make a presentation and answer questions.  The next Practice Manager’s Meeting is Wednesday, July 21 at noon at Children’s Hospital and it will also be available by webinar. Watch for details that will be sent by email to you

REMINDER: Billing Medicaid for 96110
Medicaid limits billing of screening code 96110 to ONE per patient per day.  This code can be billed for developmental screening, ADHD screening, depression screening, etc.

New Medicaid Automatic Voice Response System (AVRS)
ACS will implement a new AVRS at the end of July 2010. The new system will still allow providers to retrieve client eligibility, claim status, and warrant information. The local number that is currently used, 303-534-3500, will be disconnected and all providers will be required to use the toll free number 1-800-237-0044. Providers will continue to be able to retrieve client eligibility through Faxback using the toll free number 1-800-493-0920.

Local Medicaid Provider Services Phone Number Will Be Discontinued
Beginning August 1, 2010, the local ACS Provider Services Call Center phone number currently used, 303-534-0146, will no longer be active. All providers will have to access the Call Center through the toll free number 1-800-237-0757.

Option for Submitting Medicaid Prior Authorization Requests (PARs) to the Colorado Foundation for Medical Care (CFMC)
CFMC is the authorizing agent contracted by the Department to process PARs for the following services for Medicaid fee-for-service (FFS) and Primary Care Physician Program (PCPP) clients:

• Durable Medical Equipment (DME) – limited to orthotics, prosthetics, power wheelchairs, power scooters, and miscellaneous DME
• Home Health – limited to EPSDT Extraordinary Home Health 
• Medical/Surgical – as outlined in the monthly Provider Bulletins 
• Out-of-state, non-emergent admissions and surgical services 
• Physical Therapy (PT) and Occupational Therapy (OT) 
• Diagnostic Imaging (effective August 1, 2009) – limited to non-emergent Computed Tomography (CT) Scans, Magnetic Resonance Imaging (MRIs), and all Positron Emission Tomography (PET) Scans 
• Transportation – limited to non-emergent air ambulances, bariatric ground ambulances, commercial flights/trains, meals, and lodging

Beginning August 1, 2009, providers were given the option to submit PARs electronically through CFMC’s Web Portal. Electronic submission allows the provider to view the PAR status through CFMC’s Web Portal. Provider registration is required. Registration and submission instructions are available at  http://www.cfmc.org/copar/. For additional assistance, please contact CFMC’s PAR line at 1-800-333-2362 or 303-695-3300 ext. 3129.
Please note that faxing paper PARs to CFMC at 303-790-4643 remains an option.

New Medicaid Fee Schedule Effective July 1, 2010
http://www.colorado.gov/hcpf > Provider Services

Medicaid Provider Bulletins
Remember to review the monthly Provider Bulletins at:
http://www.colorado.gov/hcpf > Provider Services

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Provider Resource Helpline

Family Voices and CCHAP established a Provider Resource Helpline (PRH) to help you identify services and resources for chronically ill or special needs patients in your practice.  The number to call is 1.877.731.6017. Our goal is to make your time with the patient and family more productive, focused and efficient.

The Provider Resource Helpline provides accurate, comprehensive and timely assistance to healthcare providers throughout the state of Colorado. Whether the family or child has commercial or public insurance, the PRH makes resource information and care coordination services available. The PRH considers physical, mental health, developmental disability, disability specific resources, health care coverage and oral health.  The PRH offers referral and resource information regarding socio-economic, family education, public and private funding, Medicaid waiver, and family and community resources. For example, the Helpline can ensure that your patients gain access to case management, care coordination, education resources and advocacy groups, Medicaid waiver information, medical assistance grant funds and supports services for parents. Feel free to offer the Helpline to families directly and we will make sure we will get back to you to support the partnership between families and professionals. The number is 1.877.731.6017

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Apply Fluoride Varnish
To the Teeth of Young Children ON Medicaid
And Receive Generous Reimbursement

Cavity Free at Three is a statewide effort aimed at improving oral health in children and pregnant women.  We are working with CCHAP to offer our program model to interested practices.  Recent Medicaid and CHP+ guidelines allow primary caregivers to provide oral health counseling along with fluoride varnish application and receive reimbursement for these services.  Medicaid will pay for two applications of fluoride varnish in the primary care office per year and two applications in the dentist’s office.  CHP+ has begun this month to pay for these services.  

In order to participate, the medical provider as well as the staff members who will be involved in this care should complete online training through the Smiles for Life Curriculum.  Simply visit  http://www.smilesforlife2.org, and complete Module 2:Child Oral Health and Module 6: Fluoride Varnish.   After the online process is completed, we can provide a site visit for a “hands on” demonstration and training,  as well as follow up and support of our program.

We are in the process of coordinating training opportunities throughout the state of Colorado. As they are organized around the state, practices within the geographical area will be notified.  This will allow for representatives from your group to attend trainings in your area.  If you have questions about our program, please contact karen.savoie@ucdenver.edu or visit  http://cavityfreeatthree.org. Thank you.

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For those children and their families in our practice with Autism…

Early diagnosis and treatment determines the best outcome for children with autism. A few options exist for your patients to gain access to early treatment.

An autism waiver exists in Colorado to provide Medicaid benefits in the home or community for children with a medical diagnosis of Autism who are most in need due to the severity of their disability. This waiver, specifically called the HCBS Children with Autism Waiver (CWA), exists to serve those children with autism that have intense behavioral needs placing them at risk of institutionalization. As this is a waiver, parental financial resources or income for eligibility is not considered. The waiver uses the child’s income and resources, independent of the parent(s). Parents may access this waiver through the child’s community centered board, the county-specific agency responsible for services for the developmental disabilities population. The autism waiver serves children under the age of six; however, there is a wait list.  The waiver covers Applied Behavioral Analysis (ABA) therapy.  ABA is the only method of treatment supported by the America Academy of Pediatrics for the treatment of autism, including the U. S. Surgeon General.

As of July 1, 2010, SB 244, or HIMAT - Health Insurance Mandated Autism Treatment - becomes in effect for the autism community in Colorado.  While the law takes effect July 1, individual insurance policies and benefits become effective only on their renewal date of the policy. Therefore, if a patient has a policy that renews January 1, 2011, the new benefits under HIMAT would only take effect then, and not July 1, 2010. HIMAT mandates that insurance companies provide coverage for the assessment, diagnosis and treatment of Autism Spectrum Disorder (ASD), no longer classifying ASD as a mental illness or condition. The law defines what type of coverage is required for the treatment of ASD, including ABA therapy; therefore, insurance plans will be able to cover more therapies for Autism. The law allows for unlimited speech, physical and occupational therapy.  As you consider this information, however, please remember that the HIMAT mandate is valid only for fully funded commercial insurance plans, originating in Colorado. Self-funded plans, known as ERISA plans, are not privy to the same rules outlined by the Colorado Division of Insurance - Department of Regulatory agency (DORA).  Additionally, the public insurances of Medicaid (unless on the Autism waiver) and CHP+ will not cover ABA therapies.

For more resources or questions, please call Colette Christen at the Provider Resource Helpline at 877.731.6017 or 303-733-3000x105.

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Cavity-Free at Three

Cavity Free at Three is a statewide effort aimed at improving oral health in children and pregnant women.  We are working with CCHAP to offer our program model to interested participants.  Recent Medicaid guidelines allow primary caregivers to provide oral health counseling along with fluoride varnish application and receive reimbursement for these services.  In order to participate, the medical provider as well as staff members involved in this provision of care should complete online training through the Smiles for Life Curriculum.  

Simply visit  http://www.smilesforlife2.org, and complete Module 2:Child Oral Health and Module 6: Fluoride Varnish.   After the online process is completed, we plan a coordinated effort for site visit based training opportunities offering hands on demonstrations as well as follow up and support of our program.

We are in the process of coordinating training opportunities throughout the state of Colorado beginning early 2010.  This will allow for representatives from your group to attend trainings in your area.  If you are interested in hosting a training, or learning more about Cavity Free at Three opportunities, please contact Anita Rich at rich.anita@tchden.org.  If you have questions specific to our program, please contact karen.savoie@ucdenver.edu or visit  http://cavityfreeatthree.org. Thank you.

Announcements:

Thank you to Pediatric Partners of Glenwood Springs, particularly Brian McGill, for coordinating a Cavity Free Training on February 16th.  15 people attended.  That is a great turnout.  

More training is scheduled for March. March 18th in Durango hosted by Pediatric Partners of the Southwest and on March 26th hosted by Miramont Family Medicine in Ft. Collins.

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How to Refer Infants and Toddlers for Early Intervention Services

Bill Campbell

This is a quick reminder that for children suspected of having developmental delays, the referral resources depend on the age of the child.   Refer  infants and toddlers to Early Intervention Colorado if they are suspected to have significant developmental delays, or if they have any health conditions associated with a high probability of developmental delay.  Refer preschoolers and children not already enrolled in public school to Child Find for similar concerns.  For families whose children are already enrolled in public school, the parents have the right under special education law to request a comprehensive educational evaluation, but it’s best if they start by request a formal meeting with school staff, including the teacher, a special educator, and a school administrator.  At the end of this article you’ll find a link to a referral flow chart that outlines the decision-making process for referring children of different ages for developmental and educational assessments, but the following paragraphs will focus on how to refer infants and toddlers for early intervention services.

Developmental delay is common among infants and toddlers (at least 10 percent of infants and toddlers have delays in one or more areas of development).  Early intervention services have been shown to be effective in helping children with developmental delays, particularly children with autism spectrum disorders and other communication handicaps.  All 50 states have developed early intervention programs in accordance with Part C of the Individuals with Disabilities Education Act.  All 50 states also have special education procedures and services for preschoolers and school-age children.  

Colorado’s early intervention program is called Early Intervention Colorado (formerly Early Childhood Connections), or “EI Colorado” for short.  It’s designed to promote the best possible outcomes for infants and toddlers (birth up to 36 months of age) who have significant developmental delays (or health conditions associated with a high probability of developmental delay).  In order to take advantage of early intervention services during this critical developmental period, families need to know how to access them.  The following paragraphs explain this, and additional information can be found in the “Make a Referral” section at www.eicolorado.org.

While anyone – including the parents -- can refer a family to EI Colorado, primary care providers (PCPs) are the main source of referrals.   And using a standardized screening test is the most reliable way to identify children with delays.   A recent quality improvement initiative in the Denver metro area suggests that infants and toddlers are more likely to proceed through the evaluation phase if the PCP sends a referral form to the local EI Colorado program, in addition to having the family call the referral contact person there.
The PCP should inform the family that further evaluation is recommended to see if the child and family may benefit from early intervention services.  You can give the family an early intervention flier or panel card that briefly explains this, and also tells the family how to contact their local EI Colorado program.  These informational cards can be obtained for free from your local EI Colorado program office (e.g., from Denver Options for those residing in Denver), or you can order panel cards for free on the EI Colorado website (www.eicolorado.org) by clicking the “order public awareness materials” link on the home page or in the “Make a Referral” section.  You’ll find a lot of other information in the “Make a Referral” section, such as explanations of the early intervention assessment process and even links to professional medical society recommendations for the medical evaluation of children with developmental delay.

The process for having the infant or toddler evaluated begins with making a referral to EI Colorado.  The referral form should be completed by the PCP office during the visit, and the parent or legal guardian should be asked to sign the consent to release medical information at the bottom of the referral form.  You can obtain referral forms in English and Spanish for free from the EI Colorado website.  Or you can access the referral forms specific to your local EI Colorado program in the “Make a Referral” section of the website by clicking on the “Make a Referral” link and then scrolling down to the link that says: “To refer to Colorado's early intervention system click here to locate the appropriate Community Centered Board! (includes referral form)”.  You’ll then be taken to a page where you can enter or search for the specific local EI Colorado program, which will then take you to a page with that program’s contact information and links to referral forms with preprinted local program name and fax number.  I’ve found it easiest to keep preprinted referral forms handy rather than printing a form for every referral.

If the child was referred because of concerns on standardized developmental screening, please document the tool you used and fax the screening instrument along with the referral form; this will help the evaluation team understand the screening results and develop an assessment plan without repeating the screening.  I should mention at this point while the evaluations are conducted by Child Find teams from the local school districts or BOCES, the local EI Colorado programs arrange these and provide coordination throughout the process, so please refer infants and toddlers to the local EI Colorado programs directly (a service coordinator will be assigned and contact the local Child Find team within a couple of days).

Provide the family with a copy of the referral/consent form and the contact information for the local EI Colorado program, and arrange a follow-up visit for about 2 months later.  Explain to the family that a service coordinator will be assigned within a couple of days of the referral to help the family through the next steps; the developmental assessment should be completed within 45 calendar days, as well as the Individualized Family Service Plan (IFSP) if the child is found to be eligible for services (both are at no cost to the family).  Ask the family to bring copies of the IFSP and any evaluation reports.  Even though the Early Intervention and Child Find teams do not provide medical diagnoses, their findings can be important to you in helping the family understand the significance of the developmental delays and in guiding further appropriate medical evaluations.

Speaking of medical evaluations, you may have already initiated some when you first became concerned about possible developmental delays.  For example, children with language delay should be referred for formal audiology evaluations.  You don’t need to wait for audiology or other medical evaluations or treatments to be completed before referring to EI Colorado for early intervention evaluations and services.  The link to the referral flow chart at the end of this article illustrates the parallel processes for medical and developmental evaluations.  Professional medical society recommendations during recent years have offered specific recommendations regarding the medical evaluation and follow-up by primary care physicians/clinicians for children with developmental delay, cerebral palsy, and autism spectrum disorders.

And speaking of developmental evaluations, you can usually wait for the results of the early intervention or special education evaluations before referring for diagnostic medical developmental evaluations, such as those done in the Child Development Unit at The Children’s Hospital.  But if an autism spectrum disorder is suspected, then you should refer simultaneously to EI Colorado (for early intervention services) and to a medical center or clinic with special expertise in autism spectrum disorders (for the diagnostic medical evaluation).  The referral flow chart below gives other examples of where to refer children for medical or behavioral evaluations and treatment.

Click here to view the referral flow chart

I hope this information is helpful to you in getting early intervention services for infants and toddlers as soon as possible, and in getting preschoolers and school age children the help they need.

Please feel free to call me with any questions at 720-777-6632, or email me at Campbell.william@tchden.org.

Also see these two web sites for more detailed algorithms

The link for the 0-3 year-old flow diagram: click here
The link for the 3-5 year-old flow diagram: click here

These are the referral forms that are used state wide for Early Intervention.

• English - click here
  
• Spanish - click here

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The Provider Resource Helpline Helps Your Special Needs Children:
Identify and Access All Resources
Assists with Care Coordination

          The American Academy of Pediatrics has promoted the concept of providing a medical home for children with special health care needs for over a decade.  At a recent focus group of family physicians and pediatricians discussing medical home, primary care providers said that finding the available resources and coordinating care for children with multiple problems was the most challenging of the roles of a medical home.  
          The Provider Resource Helpline is a service created to address this need through a collaboration among CCHAP, Family Voices, and the Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid and CHP+.  Family Voices of  Colorado is a chapter of the national, grassroots organization composed of families and friends who care for and about our children with special health care needs.

Provider Resource Helpline
Helping care for our children with special health care needs

Information for families
Valuable community resources
Care coordination

1.877.731.6017

The Colorado Provider Resource Helpline is here:

• To give providers information and access to valuable community resources for children with special health care needs.
• To provide case management and care coordination services to families.
• To identify shortages in services/barriers through the data collected.
• To provide family-centered programs, training and education.

When Calling, Please Have the Following Information:

• The PCP name and office phone and fax information.
• Name and date of birth of patient.
• Medical condition / disability of patient.
• Resource question or service need of patient/family.
• Family Contact information, if the provider wishes us to follow up directly with the family.

If the helpline can answer your question immediately, you can provide the information to the family while they are still in the office.  If we are unable to answer immediately, we will contact you with an answer as soon as possible following the patient’s visit (via phone, fax, or email). 

Download Flyer

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Medical Home Certification

Around 80 of the 190 pediatric and family practices that CCHAP currently works with are in the process of obtaining “medical home certification.”    The Colorado Department of Health Care Policy and Financing (HCPF), which administers Medicaid in Colorado, is directed by  Senate Bills 07-130 and 07-211 to document that children on Medicaid receive care in a quality medical home.  So, HCPF is asking practices that are receiving the enhanced reimbursement (as a CCHAP – affiliated practice) to obtain Medical Home Certification to document the quality of the medical home they provide to children on Medicaid.  Practices that have affiliated with CCHAP in the past 8 months have already begun the certification process.  The remaining CCHAP-affiliated practices will be asked to begin the certification process very soon.  

Medical home certification is a three step process.  The CCHAP orientation is step one.  The following are the two steps needed for medical home certification for practices that were oriented in the past and are already receiving the enhanced reimbursement.  Each CCHAP-affiliated practice will be asked to:

• Conduct a self-assessment survey of practice staff and providers called the Medical Home Index.  This brief survey seeks to determine your perception of how well you are doing in providing a medical home.  The survey also will be given to some parents in your practice.
• After reviewing your survey results, you will be asked to select some aspect of “medical home-ness” to improve using a quality improvement process.  CCHAP staff is available to coach you through the quality improvement process if you wish and we have QI projects already prepared for you to implement easily in your practice if you wish.  You may already have QI projects going, which will likely meet this objective.

Medical Home
The American Academy of Pediatrics and the American Academy of Family Practice have promoted the concept of a medical home for many years now.  A recent combined statement by the two academies reaffirmed their support of the concept.  The Academies believe that all children should have a medical home where care is accessible, family-centered, continuous, comprehensive, coordinated, compassionate and culturally effective.  For a reminder of the American Academy of Pediatrics and the American Academy of Family Medicine description of a medical home for children, click here. 
And if you want someone to come to your office to present a more description of what a medical home is and does, please contact: Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Medical Home Index
Starting in April 2009, recently oriented CCHAP practices began the process of Medical Home Certification.  The Medical Home Index is completed at a group meeting of your practice with as many of the practice staff and providers as possible. During this meeting the group will complete a Medical Home Index self-assessment, discuss how each indicator rated relates to a quality Medical Home.  The facilitator will conduct informal interviews of families coming to your practice that day asking them to assess the practice’s medical “homeness.”  For a look at the medical home index, click here.

Quality Improvement Projects
Within a few weeks after the practice takes the MHI, you will be contacted by a Quality Improvement Coach with CCHAP. At that time, you will receive your Medical Home Index results, as well as guidance as to how to interpret the results. HCPF asks that you select an element of being a medical home that your practice wishes to work on.   The Quality Improvement Coach from CCHAP – at no cost to your practice – is available to help you decide what your practice would like to work on, develop strategies for making the changes you want to make, and measure the effectiveness of the resultant changes.   

The higher reimbursement practices receive for preventive care is the reward for your practice’s commitment to providing a quality Medical Home for children on Medicaid.

AAP and AAFP Board Certification for pediatricians and family physicians
Both the AAP and the AAFP require that all physicians, when they recertify, develop a quality improvement project in their practice as part of their recertification.  So, CCHAP is helping you obtain both professional board certification and Colorado Medicaid medical home certification.

For more information
Shortly, we will be expanding the Medical Home Certification process to all CCHAP practices.  More information will follow. You may also contact Anita Rich (Rich.Anita@tchden.org) or Angie Goodger (angela@cchap.org) for more information.

Quality Improvement Coach
Your CCHAP Quality Improvement Coach is Angie Goodger. Angie holds masters degrees in Public Health and Healthcare Administration.  Angie comes to us from Minnesota where she previously worked as a home healthcare manager. Angie is very excited about working with your practice using Quality Improvement methods to work on those issues you want to address.

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The Colorado Pediatric Postpartum Depression Screening and Referral Toolkit

Developed by Brian Stafford, MD, MPH
Medical Director, Perinatal Mental Health Program, The Children’s Hospital

Click here to download the complete toolkit to enable a primary care practice
to recognize and refer women with post-partum depression.    

Why should every pediatric and family practice implement this toolkit?

•  Postpartum depression is a serious medical and psychiatric illness and a significant health concern.
• Approximately 12% of all new mothers develop symptoms consistent with a major depression in the post-partum period
• If left untreated, half of these mothers, about half will continue to have symptoms that last greater than1 year.
• These symptoms include sadness, lack of energy and pleasure, irritability, guilt, anxiety, as well as thoughts of wanting to harm the infant.
• Several lines of research have shown that post-partum depression has significant risk for the child’s cognitive, social, and emotional development and may impact school readiness.
• In addition, the depressive symptoms lead to difficulties in the mother-infant and parental relationship.
• The depressive symptoms are also associated with excessive urgent care and emergency room visits as well as missed scheduled routine pediatric visits.
• Providing pediatric anticipatory guidance to a depressed caregiver does not change any parental behaviors in regard to safety, sleep, nutrition, reading, and interaction.
• Pediatric care providers of infants are in a strategic position to screen and refer depressed mothers for behavioral health evaluation and support.
• Pediatric provider inquiries about maternal health have been viewed as appropriate by mothers.
• Pediatricians, historically, like other primary care providers, have low rates of detecting maternal depression and few pediatricians have a systematic approach to screening for maternal depression.

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Announcing an Interactive Cross-Cultural Communications Website
Designed Especially for Healthcare Professionals

dimesionsofculture.com

 
Register now! Click the link above and get full access
with your own secure login and password!

A Website to Support On-going Training for Healthcare Professionals in Colorado

Because culture can have important clinical consequences, this website is devoted to supporting the self- development of healthcare professionals in basic cross- cultural communication competencies that impact health outcomes for patients. In place of the typical "diversity training" approach, practical communication strategies are emphasized that can be put to use immediately in private practices, clinics, and hospital settings.

An Interactive Website for Building a Learning Community
 
The content of this cross- cultural communications website focuses on reinforcing key concepts presented in cross-cultural communication trainings by Marcia Carteret. Additionally, this site presents the opportunity for physicians and staffs in multiple healthcare settings to interact with one another through threaded discussions. Because nothing can replace real life experience in the learning process, a virtual learning community will make it possible to share true stories and post useful questions while culture and medical experts facilitate discussions.
 
Website Features
 
Listed here are the pages that currently make up dimensionsofculture.com. Please note that some pages require a login and password because only select groups of healthcare professionals, including all CCHAP pediatric practices, will have full access to the “community” pages.

Public Pages

• Home Page
• Greetings from the Site Editor
• Culture Calendar- Monthly religious and cultural holidays
• Culture Quest – Information about cultural happenings in our community, as well as statewide and nationally.

Healthcare Community Pages (Login/Password Protected)

• Newsletters – Monthly articles addressing key cross-cultural communication topics written by Marcia Carteret and other guest contributors.
• Interactive Forums– an interactive on-line community dialogue between healthcare professionals about communicating with patients from different cultural backgrounds. 
• Provider Profiles– An ongoing series of profiles introducing some of the dynamic and culturally diverse doctors working in the CCHAP network of pediatric practices
• Culture Ambassadors – A panel of representatives from cultures around the globe, with a strong focus on the cultures most heavily represented across out state.

This website is designed to meet the needs of the healthcare community served by Colorado Children’s Healthcare Access Program. If you are a participating CCHAP provider or staff member and have suggestions for the website, please contact Marcia Carteret at mcarteret@gmail.comor 720-777- 3124. Your comments and suggestions will help make dimensionsofculture.com an effective tool for learning and community building.

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INTRODUCING THE CCHAP QUICK REFERENCE LINK!

Do you need to know the one telephone number to call for a Medicaid mental health referral?  Want to reach the CCHAP social worker?  Need help in finding resources for a special needs child?  Having trouble remembering all of the 14 support services CCHAP provides for your practice?    We have a quick reference link for your desk top!  For these things and many more…

Recently, our advisory group of physicians and practice administrators suggested an idea for a quick and easy way to access CCHAP affiliated resources for frequently used contacts and services.  We liked the idea and have developed a web link that will quickly access a single page that contains contact information as well as additional links to documents and web pages.  The goal is to have a computer desktop shortcut that, with just a click or two, will provide CCHAP affiliated providers and staff with the information you need, when you need it.  

Because this new tool is for you, we want it to be pertinent and efficient.  So please, if you have ideas as to how to improve on this, contact Kevin Heckman heckman.kevin@tchden.org or 720.777.6309, our Program Administrator, with your feedback and suggestions.  Thanks!

INSTRUCTIONS:

1. Click on this link http://www.cchap.org/qr/ to open the Quick Reference Link web page (Note: you can also type this address into a web browser manually).
2. In your browser window menu (upper left corner) click File>Send>Shortcut to Desktop. 
3. The Quick Reference Link is available from any computer with internet access.

Kevin C. Heckman
Program Administrator
CCHAP
720.777.6309

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All CCHAP-affiliated Practices Now Can Receive
TELEPHONE CONSULTATION ON MENTAL HEALTH ISSUES
FOR CHILDREN ON MEDICAID

Rick March is a child psychiatrist who has received grant monies to provide phone consultation regarding children and adolescents with mental health problems throughout Colorado.  He has over twenty years experience in child psychiatry and is available weekdays during regular business hours.  If you do not reach him directly, he would be able to speak with you, at the outside, by the next business day.  Dr. March is at the Mental Health Center of Denver which provides services for children who live in Denver County.  However, he may be able to arrange to see other patients outside this catchment area, possibly in your practice in very difficult cases.  He is also available to provide educational presentation for your providers on a wide variety of mental health topics.

His direct line is 303-504-1500

So, telephone consultation from a child psychiatrist for Medicaid children cared for in a CCHAP-affiliated practice is now available in all counties in Colorado.  

For Boulder and Jefferson Counties – Don Bechtold, MD – 303-432-5172
For Adams, Arapahoe and Douglas Counties – Joe Pastor, MD – 303-853- 3888
For all other counties (including Denver) – Rick March, MD – 303-504-1500

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Integrating Developmental Screening
Into a Pediatric Practice

• The Colorado Assuring Better Child Health & Development (ABCD) project has received a three year grant to provide training and technical assistance to providers to implement a “validated” developmental screening tool at well child visits for infants/toddlers birth to five.
• The ABCD project is partnering with CCHAP to provide training and support to pediatric practices to implement developmental screening.
• Medicaid will reimburse $34.00 to providers if you use a standardized, validated developmental screening test at an EPSDT visit.
• The Colorado Chapter of the AAP supports the ABCD project.
• Early detection and intervention improves outcomes.  Many delays in children’s development are missed in the first 4-5 years of life without a standardized, validated screening test. 
• The most time-efficient tool is one in which the parent completes a questionnaire.
• To comply with 2010 recertification guidelines by the American Board of Pediatrics, documentation will be required to show levels of involvement in practice improvement initiatives. By implementing the use of a “validated” developmental screening with a sensitivity and specificity rating of 70% or greater like the ASQ or PEDS, practices are taking steps to integrate quality improvement into their practices.
• What providers are saying about implementing either the ASQ or the PEDS parent questionnaire developmental screening tools:
  •  
    • It takes 1-2 minutes for an MA, LPN or RN to score.
    • It takes less than a minute of the provider’s time if the MA, LPN or RN scores the questionnaire.
    • In many instances, it reduces the length of the visit.
    • It helps providers concentrate on the concerns/priorities of the parents.
    • It reduces the number of concerns that come up as you are walking out the door at a well care visit.
    • It improves patient satisfaction.
    • It promotes positive parenting practices.
    • It increases provider confidence in decision-making for when to refer a child for further developmental evaluation.
• Eileen Auer Bennett, the Colorado State ABCD Coordinator and her team are available to assist providers in getting started. Training and technical assistance will be provided to practices to implement a standardized tool such as the ASQ or PEDS. Support will also be given to office staff on how to incorporate a standardized developmental screening tool into the current office work flow.

For more information, please contact:
            Eileen Auer Bennett
            720-333-1351
            ileanben@yahoo.com

The Ages & Stages Questionnaire (ASQ) is a well respected screening tool.  It has the best sensitivity and specificity.  It is standardized across various common minorities.   Health care providers have identified the following advantages:

• Parent completed—Parents are partners in their child’s
  assessment and intervention activities.
• Serves as a talking guide with parents identifying a
  child’s strengths as well as things the child is not
  doing yet.
• Practical—Scoring takes 1-2 minutes and can be done
  by paraprofessionals.
• Cost-efficient—May be photocopied repeatedly.
• Scoring is simple—Only three responses:
  1. Sometimes, occasional or emerging response from
     child = 5 points
  2. Yes, child performs specified behavior = 10 points
  3. Not Yet = 0 points
• If the child’s total score falls in a shaded area of the bar
  graph for any developmental area, further diagnostic
  assessment is recommended.

• Developed out of four cross-validation studies on a
  nationally representative sample of families.
• Uses parent concerns or judgments about the child’s
  development and behavioral status.
• Easy to score—two minutes to elicit and interpret.
• Enables health care providers to determine the need to
  refer and where.

Visit www.pedstest.comto view and order the PEDS tool online.

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Spanish Interpretation Training for Pediatric Practices

An assessment of each individual’s skill level will be done during a 5-10 minute phone call prior to first telephone conference/class.  Maria will contact you to schedule this initial individual telephone call upon receipt of your registration email.  A certificate of completion will be given after completion of all 6 sessions. The faculty is Maria Soto, a certified Spanish interpreter and trainer with International Language Services.

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Child Psychiatrist Available to Provide Conferences for You In your Office

Rick March, MD is a child psychiatrist at the Mental Health Center of Denver.  He is available to provide teaching on a variety of child Psychiatry topics (below) in your office.  He is also willing to discuss cases with you, as well.  Please contact him to take advantage of this wonderful opportunity.
He can be reached at Rick.March@MHCD.org

Here are some of the topics he can cover for you.

• Diagnosing Depression in Children and Adolescents
• SSRI’s and Black Box warnings
• Suicide and self-abuse
• Diagnosing Bipolar Disorder in Children and Adolescents (including differential diagnosis)
• Atypical Antipsychotics
• Mood Stabilizers and Antidepressants
• Pediatric Psychopharmacology and the FDA
• Kids with ADHD who don't get better on stimulant medication
• Psychosis in Children and Adolescents

And, remember there is a child psychiatrist on call available by phone for your Medicaid children…

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Abe Grinberg MD, FAAP MPH
   

Language as a Communication Barrier in Medical Care for Hispanic Patients

           Communication with patients and their families is essential in providing quality medical care. Cultural and language barriers create a void in the delivery of safe health care, customer satisfaction and quality of care. The public debate on how to bridge cultural and language barriers has a long history. The use of formal interpreters and translators is associated with the ability to eliminate these barriers; however, the ability to communicate directly with health professionals in a common language is associated with an increase level of trust in medical settings.

             There are 7 important points to have in mind when addressing cultural and language barriers with the Hispanic patients and their families:

1. The number of people speaking a language other than English at home and the number of Americans Limited in English Proficiency (LEP) in the United States is significant. It is expected that the total number of people in these two groups will continue to increase at a faster rate than the one of the general population in the USA. About two thirds of them are Spanish speaking individuals (₁) (₂).
2. Multiple studies document that quality of care can be seriously compromised when Spanish LEP patients need but do not get translation and interpretation services (₃) (₄).
3. Studies also document that the quality level of interpretation offered by bilingual providers and professional hospital interpreters is high. However, the quality of interpretations offered by hospital employees who are not professional interpreters, family members, relatives, friends, and ad-hoc translators are many times incorrect and of poor quality (₅).
4. Interpretation errors are common. About 60% of the errors have potential clinical consequences. Even professional interpreters commit significant errors about 50% of the time (₅).
5. Patients, who interact with a bilingual provider, frequently rate them as more friendly, respectful, and concerned when compared to those who interact with a translator or interpreter. Patients and families who are taken care by a provider who speaks their own language frequently have a more accurate recall of critical information about the encounter than those who interact with a provider who uses a translator or an interpreter(₆) (₇).
6. There are data that suggest that the length of hospital visits, the incidence of any testing, the cost per visit and the number of hospital admissions are decreased in those patients who interact with a provider who speaks their own language when compared to those providers who use a translator or interpreter during the course of the medical encounter (₈). 
7. There is evidence that courses in Medical Spanish can help health care professional achieve fluency in Spanish at the functional level and promote cultural awareness that strengthen communication skills. The promotion of such courses is associated with decreased interpreter use and increased patient and family satisfaction (₉).

          Bear in mind that Hispanics embrace people when they make an effort to speak their own language. They tend to be tolerant and have a tendency to develop relationships that are based on friendship and respect. You will make them fill comfortable and help them feel that you are concerned about their medical care.
 
          “Dele a un hombre un pescado y él comerá por un día. Enséñele cómo pescar y comerá por el resto de su vida” (Lao Tzu. Filósofo Chino).

1. 1. Flores Glenn. 2005. The Impact of Medical Interpreter Services and the Quality of Health Care: A Systematic Review. Medical Care Research and Review 62: 255- 299
2. Colorado Alliance for Immigration Reform. U.S Immigration Data, Projections and Graphs. Retrieved: October 2, 2008. http://www.cairco.org/data/data_us.html
3. Flores, Glen., Abreu, Milagros., Schwartz, Ilan., and Schwartz, MD, and Hill, Maria. (2000). The importance of language and culture in pediatric care: Case studies from the Latino community. The Journal of Pediatrics. 137 (6): 842-848
4. Flores G. Language Barriers to Health Care in the United States. NEJM 2006; 355:229-23
5. Flores G., M.B. Laws., S.J. Mayo., B. Zuckerman., M. Abreu., L. Medina and E. J. Hardt. 2003. Errors in clinical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics 111: 6- 14
6. Baker, David W., Hayes, Risa., and Puebla Julia. 1998. Interpreter Use and Satisfaction with Interpersonal Aspects of Care for Spanish- Speaking Patients. Medical Care. 36(10):1461-1470 
7. Seijo, R., H. Gomez and J Frienderber. 1995. Language as a communication barrier in medical care for Hispanic patients. In. Hispanic Psychology_Critical issues in theory and research, edited by A.M. Padilla, 169-181. Thousand Oaks,Ca: Sage.
8. Hampers, L. C and., McNulthy, J.E. 2002. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department. Arch Pediatr Adolesc Med. 156:1108-1113.
9. Suzan S. Mazo., Louis C. Hampers., Vidya T. Chande. Steven E. Krug. (2002).Teaching Spanish to Pediatric Emergency Physicians: Effects on Patient Satisfaction. Arch Pediatr Adolesc Med 156: 693-695

Course in Medical Spanish customized for pediatric care providers. Once a week for 12 weeks (2 hour class), includes also 6 month internet access to “Spanish for health care course”. Flexible schedule to accommodate participants’ preferences; Classes take place at the providers’ office for groups of 8-12 students.
$ 389 dollars per student. Includes 6 month internet access to the on line training course.
          Contact: Abe Grinberg MD (720) 748-7669.
          abe@bilingualmed.com my web-site www.bilingualmed.com

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Copyright 2010 Colorado Children's Healthcare Access Program and other entities as noted.

 CCHAP Home > Newsletter Articles > Newsletter 40, July 2010