Coming Your Way...
Iowa Child Health Care Maintenance Clinical Notes
Facilitating Screening, Anticipatory Guidance, and Referral
Dianne McBrien, MD, and Kay Leeper, Center for Disabilities and Development
University of Iowa Hospitals and Clinics
Kay DeGarmo, Prevention of Disabilities Policy Council
Summer 2004

Developmental and behavioral screening and guidance are integral parts of every well child visit. Since most children under 5 years of age are seen at least occasionally in the primary care provider's office, this is an ideal place for such screening. Yet in the current landscape of crunched time and inadequate reimbursement, many primary care providers find it difficult to use formal developmental screening instruments. Disagreement also exists among practitioners about which children need referral and when they should be referred.

Iowa's Care for Kids program is developing the Iowa Child Health Care Maintenance Clinical Notes to provide an accessible, time-sensitive solution to these dilemmas. Originally designed by University of Iowa Hospitals and Clinics Associate Professor of Pediatrics Mary Larew, the clinical notes were modified by UIHC Assistant Professor of Family Medicine (Clinical) Susan Langbehn and Assistant Professor of Pediatrics (Clinical) Royann Mraz, of the Center for Disabilities and Development, to emphasize developmental screening. This was done as part of the activities of the Iowa Interdisciplinary Developmental Services Work Group.  

Further refinement of the clinical notes and testing of the validity of the tool's screening portion will soon begin through Iowa's new ABCD II Care for Kids Healthy Mental Development Initiative. This initiative has convened a clinical panel to further refine the forms. It will also add key questions to screen for behavioral and psychosocial problems. This panel includes representatives of the: 

• American Academy of Pediatrics, Iowa Chapter  
• Iowa Academy of Family Physicians  
• Iowa Mental Health Consortium  
• Iowa Nurse Practitioner Association  
• Iowa Physician Assistant Association  
• National Association of Social Workers, Iowa Chapter  
• Key early intervention provider groups  

The clinical notes are specific to each standard health maintenance visit for young children, up to and including the 5-year visit. Based on the "Iowa Recommendations for Scheduling Care for Kids Screenings," the notes use a checklist format that can be easily completed by health care providers and nurse teams. In addition to gathering information about such topics as nutrition, medications, immunizations, and lead screening, the checklists make it simple to gather key information about developmental milestones, and to provide anticipatory guidance.  

Developmental milestones. At each visit, the clinical notes prompt you to ask parents if they have concerns related to their child's development or behavior. The notes provide a checklist of developmental milestones that can act as "red flags." If any milestone is not met, or if you or the parents have concerns, the child should receive further screening or assessment using standardized tools. Such screenings may be conducted in the practitioner's office, or the child may be referred to another provider.  

The clinical notes approach developmental screening through parental report of skills, a strategy that several studies have shown is predictive of developmental delay. Practitioners can use the notes as a framework to guide basic screening of development at each visit, and to detect emerging concerns as the child grows. As development is a dynamic process, experts recommend periodic monitoring, rather than a single test at one point in time that only gives a snapshot of the process.  

Behavioral and psychosocial screening. Screening for behavioral and psychosocial concerns in young children poses particular challenges for the health care provider. We are learning more, however, about the mental health development of the young child, and new screening tools are being developed. Key behavioral and environmental screening questions are being incorporated into the clinical notes for use during each well child visit. 

The ABCD II Care for Kids Initiative is developing a list and description of standardized screening tools for developmental, behavioral, and psychosocial problems that will provide you with multiple options and a choice of screening methods. This information will be available later this year. 

Sources for referral
If in your clinical opinion a child is developmentally delayed or is at risk for delay, or if you have concerns about a child's development or behavior, contact Iowa COMPASS at 1-800-779-2001. You don't have to confirm a diagnosis prior to contacting them. COMPASS will link you with referral sources for follow-up screening, assessment, or treatment as needed.  

If the child is younger than three years, COMPASS will connect you with a local Early ACCESS provider.  

For children 3-5 years old, COMPASS will refer you to an appropriate source of care, such as Child Health Specialty Clinics, AEAs, community health centers, or other clinics.

A win-win situation
The clinical notes can help you provide care that is more consistent as well as more comprehensive. It is a win-win situation: Good for you as you try to find enough hours in the day for all you need to do; good for the children - and families - in your care.  

We welcome your input!
Iowa Child Health Care Maintenance Clinical Notes will be tested in selected demonstration sites in Iowa beginning in early 2005. You can preview an example of the clinical notes, those for the six-month clinical exam, on pages 5 and 6. Let us know your thoughts about the clinical notes and their format. Email your comments to the ABCD II Care for Kids Coordinator at cfitzger@idph.state.ia.us.  

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