PUBLIC HEALTH BRIEFS
EPSDT-One Quarter Million Screenings in Michigan THOMAS R. KIRK, MD, MPH, R. GERALD RICE, MD, MPH, AND PAUL M. ALLEN, MS
Introduction Since the spring of 1973, Michigan's EPSDT program has screened more than 300,000 children. This paper is a report on the planning, organization, implementation, and outcomes of this new venture into preventive health care.
Planning In Michigan the Department of Social Services is the state agency responsible for the administration of Medicaid. In early 1972 that Department asked the Department of Public Health to design a screening program for Michigan's approximately 440,000 Medicaid-eligible children from age zero to 21. The program content was established in accord with the federal guidelines. The screening includes parents' completion of a printed health history questionnaire, obtaining height and weight measurements, head circumference of children under two, microhematocrit, sickle cell for blacks, blood lead for children between age one and six, Denver Developmental for children under age six, blood pressure for those over age five, vision and hearing tests, tuberculosis and venereal disease tests, and an unclothed physical inspection. Each team is headed by a nurse and includes two technicians and a clerk. A team can screen 18 children per day or about 4,000 per year. Rescreening is at intervals of six months for children under one year of age, two years for children between ages two and five, and at three year intervals up to the age of 21.
Organization By agreement with the Department of Social Services, the Department of Public Health contracts with all local health departments (which are basically autonomous agencies) to hire one or more teams to screen eligibles under their jurisdiction. The agreement specifies that team training, supervision, interpretation of findings to parents, and referrals are responsibilities of the Health Department. It specifies that the Department of Social Services is responsible for determining eligibility, performing outreach, scheduling apDrs. Kirk and Rice are with the Bureau of Personal Health Services, Michigan Department of Public Health, and Mr. Alien is Deputy Director, Michigan Department of Social Services, Lansing. Address reprint requests to Dr. T. R. Kirk, Bureau of Personal Health Services, Michigan Department of Public Health, 3500 North Logan Street, Lansing, MI 48914. This paper, presented at the 103rd Annual Meeting of the American Public Health Association in Chicago, November 19, 1975, was revised and accepted for publication in the Journal on February 6, 1976.
482
pointments, and assisting in transportation for screening and referral. Jointly the two departments share the responsibility for evaluation.
Implementation Plans were well developed in late 1972, and screening was to begin in July 1973. In January of that year the Welfare Rights Organization brought suit against the Department of Social Services to begin screening immediately. The federal court ordered screening to be started before April 1973. In late March the State Health Department staff screened a few children in Lansing and in April nine county health departments began screening. By July of 1973 all county and multicounty health departments had signed contracts inasmuch as their screening programs were in various stages of development. By the end of 1973 approximately 10,000 children were being screened each month. Training and retraining for team nurses is provided every two months in two-day sessions and for technicians every two months in four-day sessions-in part because of personnel turnover. Full-time state EPSDT staff include one public health nurse, one audiologist (responsible for the performance of the technicians), a coordinator, and an administrative analyst. The Chief of the Division of Child Health (the senior author) has overall responsibility for the program. Referral criteria are built into each step in screening. If a test is failed and the child is not already under care for that problem a referral must be made for diagnosis and treatment. The computer has been programmed to reject screening summary cards that fail to have appropriate referrals. These are returned to the clinics for corrective action.
Outcomes To date over 300,000 children have been screened. There are 72 part-time and full-time teams screening approximately 10,000 clients per month. Forty per cent are children under five years of age, forty per cent are from age six through twelve, and 20 per cent are from 13 to 21. Figure I displays this distribution as well as showing that it differs from the age distribution of those eligible for services. The percentage who fail the screening tests varies from county to county and, as shown in Figure 2, approaches 60 per cent on a statewide basis. The highest percentage of referrals (27 per cent) is for dental caries, although dental screening is not a designed part of the program, and referrals are made only for rampant caries obvious on gross inspection. Lack of complete immunization, the second most AJPH
May, 1976, Vol. 66, No. 5
PUBLIC HEALTH BRIEFS
edAwiAd Efigibie& *500,670 200.000-
Goai 250,235 Number of Prsons Actually
1974
E
155.763
Screud
176.000-
150.000-
12.126
12a,OOO-A 100.000-
75.000-
oI . 0
-
AGES *NOTE.
O dh 3.9 aM ps§h wihV ame
I Ifr eligbe
WIhyVw yam o qd. m eWMefewt hin hftbe. -so t-hAg to source
Oepavtrv"I t of Soee
13%
hi
A*SeiWu
seftiU.
FIGURE 1-Numbers of Children Eligible, Program Goal, and Number Screened, by Age Group
frequent cause of referral, is found in 26 per cent of the cases. In most screening clinics, needed immunizations are begun on site and counted as part of the referral. The reasons for referral for children screened during 1974 are displayed in Figure 3. Referrals are arranged for 85 per cent of those needing them by the clinic team. The families agree to arrange for an appointment with a provider for the remaining 15 per cent. The types of providers to whom the referrals are made are displayed in Figure 4. Pockets of children with low hematocrits, short stature, and low weight have been discovered. In some counties children lacking immunizations is as low as 10 per cent; in other counties the percentage approaches 65 per cent. At the outset we had concerns about several areas of the program. Would county health departments participateagree to hire one or more screening teams, have the teams trained, and work with county social services people? They all did and continue to do so. Would physicians and other providers accept referrals from the screening clincs? As indicated, by and large they did and still continue to do so even with some probable over referral. In some areas dental services are scarce, even for the non-Medicaid population, and this remains a problem. Could the two state departments work well together in the daily problems of the program? The answer is "yes" without exception-perhaps because of AJPH May, 1976, Vol. 66, No. 5
the will to do it and because of previous good working relationships. Day Care centers (including Head Start) and schools accept screening reports for certain admission requirements. A county health department dental project was initiated because of need shown by EPSDT. These are some administrative successes. We also have administrative failures. Figure 5 shows the no-show rate which in some areas reaches 60 per cent. Also we know there are no-shows after referrals are made. A match of children referred against Medicaid billings was made for the first quarter of 1974. Providers bills were found for 38 per cent of the children referred within 120 days of screening. We are now trying local level clinic follow-up in some areas; we find 65 per cent of children referred receive diagnosis and treatment. Total cost for the screening program will be $4,200,000 this fiscal year. The cost per child screened will be $26; the cost per appointment made will be $19. The screening and other administrative costs are minimal compared to all costs incurred for providing identified and expanded services to children referred. These costs, e.g., dental, ophthalmic, medical, etc., have increased by more than an estimated $50 million per year since inception of the program; some of this cost comes from this program. The EPSDT program needs further evaluation in many areas. The costs and benefits of each component test of the screening must be determined. Some tests may need to be added, others may need to be dropped. In addition, we need an evaluation of whether Medicaid screening as performed in
80.000-
70.000
SCREENINGS
60.000
50.000-
40.000-
30.000-
20.000-
M22
10.000 532
Ns
0 20-
40-
60-
30o
REFERRALS
FIGURE 2-Number of Individuals Screened and Per Cent Referred by Ethnic Origin
483
._ r
PUBLIC HEALTH BRIEFS i.n or
DEAL
41X3
!I
OUTPATIENT CLINIC
---
lqw
CRIPPLED CHILDREN CLINIC 1%
41.23
RWKALCOU
31.%2
1110118 lVuff UAEKOU INYB ROOD
3.19 3121
ANEAL NOW66
AIW ML.323
nWI!
NM
4M1
4m1
6.C. CULTUE
4
V.D.i.L.
4
ROOD Pima1811
FIGURE 4-Percentage of Provider Types Receiving Referrals from the EPSDT Clinics
313 No CIoCN9E TOTAL IffAIS 183.41
FIGURE 3-Most Frequent Areas of Health Problems
in'
ums
AVAUAI
Michigan is a valid way of determining which children need health care. This assessment is being planned and hopefully will be underway in the near future.
Summary Since the spring of 1973, Michigan's EPSDT program has screened more than 300,000 children. The Department of Social Services contracted with the Department of Public Health to design the screening and referral parts of the program; in turn, the Department of Public Health contracts with local health departments to do screening with one or more teams composed of a nurse, two technicians, and a clerk. The 72 teams screen 10,000 clients each month. More
484
FIGURE 5-Utilization of Available Screening
Appointments
than one-half of these clients are referred for diagnosis and treatment. The highest percentage (27 per cent) of referrals is for dental care; the second highest (26 per cent) is for immunization. Participation in the program of state and local social services departments, local health departments, and all groups of health providers has been excellent. There continues to be a high no-show for screening and a moderate noshow rate to providers for diagnosis and treatment. Evaluation of the program elements is needed.
A4JPH May, 1976, Vol. 66, No. 5
EPSDT-One Quarter Million Screenings in Michigan THOMAS R. KIRK, MD, MPH, R. GERALD RICE, MD, MPH, AND PAUL M. ALLEN, MS
Introduction Since the spring of 1973, Michigan's EPSDT program has screened more than 300,000 children. This paper is a report on the planning, organization, implementation, and outcomes of this new venture into preventive health care.
Planning In Michigan the Department of Social Services is the state agency responsible for the administration of Medicaid. In early 1972 that Department asked the Department of Public Health to design a screening program for Michigan's approximately 440,000 Medicaid-eligible children from age zero to 21. The program content was established in accord with the federal guidelines. The screening includes parents' completion of a printed health history questionnaire, obtaining height and weight measurements, head circumference of children under two, microhematocrit, sickle cell for blacks, blood lead for children between age one and six, Denver Developmental for children under age six, blood pressure for those over age five, vision and hearing tests, tuberculosis and venereal disease tests, and an unclothed physical inspection. Each team is headed by a nurse and includes two technicians and a clerk. A team can screen 18 children per day or about 4,000 per year. Rescreening is at intervals of six months for children under one year of age, two years for children between ages two and five, and at three year intervals up to the age of 21.
Organization By agreement with the Department of Social Services, the Department of Public Health contracts with all local health departments (which are basically autonomous agencies) to hire one or more teams to screen eligibles under their jurisdiction. The agreement specifies that team training, supervision, interpretation of findings to parents, and referrals are responsibilities of the Health Department. It specifies that the Department of Social Services is responsible for determining eligibility, performing outreach, scheduling apDrs. Kirk and Rice are with the Bureau of Personal Health Services, Michigan Department of Public Health, and Mr. Alien is Deputy Director, Michigan Department of Social Services, Lansing. Address reprint requests to Dr. T. R. Kirk, Bureau of Personal Health Services, Michigan Department of Public Health, 3500 North Logan Street, Lansing, MI 48914. This paper, presented at the 103rd Annual Meeting of the American Public Health Association in Chicago, November 19, 1975, was revised and accepted for publication in the Journal on February 6, 1976.
482
pointments, and assisting in transportation for screening and referral. Jointly the two departments share the responsibility for evaluation.
Implementation Plans were well developed in late 1972, and screening was to begin in July 1973. In January of that year the Welfare Rights Organization brought suit against the Department of Social Services to begin screening immediately. The federal court ordered screening to be started before April 1973. In late March the State Health Department staff screened a few children in Lansing and in April nine county health departments began screening. By July of 1973 all county and multicounty health departments had signed contracts inasmuch as their screening programs were in various stages of development. By the end of 1973 approximately 10,000 children were being screened each month. Training and retraining for team nurses is provided every two months in two-day sessions and for technicians every two months in four-day sessions-in part because of personnel turnover. Full-time state EPSDT staff include one public health nurse, one audiologist (responsible for the performance of the technicians), a coordinator, and an administrative analyst. The Chief of the Division of Child Health (the senior author) has overall responsibility for the program. Referral criteria are built into each step in screening. If a test is failed and the child is not already under care for that problem a referral must be made for diagnosis and treatment. The computer has been programmed to reject screening summary cards that fail to have appropriate referrals. These are returned to the clinics for corrective action.
Outcomes To date over 300,000 children have been screened. There are 72 part-time and full-time teams screening approximately 10,000 clients per month. Forty per cent are children under five years of age, forty per cent are from age six through twelve, and 20 per cent are from 13 to 21. Figure I displays this distribution as well as showing that it differs from the age distribution of those eligible for services. The percentage who fail the screening tests varies from county to county and, as shown in Figure 2, approaches 60 per cent on a statewide basis. The highest percentage of referrals (27 per cent) is for dental caries, although dental screening is not a designed part of the program, and referrals are made only for rampant caries obvious on gross inspection. Lack of complete immunization, the second most AJPH
May, 1976, Vol. 66, No. 5
PUBLIC HEALTH BRIEFS
edAwiAd Efigibie& *500,670 200.000-
Goai 250,235 Number of Prsons Actually
1974
E
155.763
Screud
176.000-
150.000-
12.126
12a,OOO-A 100.000-
75.000-
oI . 0
-
AGES *NOTE.
O dh 3.9 aM ps§h wihV ame
I Ifr eligbe
WIhyVw yam o qd. m eWMefewt hin hftbe. -so t-hAg to source
Oepavtrv"I t of Soee
13%
hi
A*SeiWu
seftiU.
FIGURE 1-Numbers of Children Eligible, Program Goal, and Number Screened, by Age Group
frequent cause of referral, is found in 26 per cent of the cases. In most screening clinics, needed immunizations are begun on site and counted as part of the referral. The reasons for referral for children screened during 1974 are displayed in Figure 3. Referrals are arranged for 85 per cent of those needing them by the clinic team. The families agree to arrange for an appointment with a provider for the remaining 15 per cent. The types of providers to whom the referrals are made are displayed in Figure 4. Pockets of children with low hematocrits, short stature, and low weight have been discovered. In some counties children lacking immunizations is as low as 10 per cent; in other counties the percentage approaches 65 per cent. At the outset we had concerns about several areas of the program. Would county health departments participateagree to hire one or more screening teams, have the teams trained, and work with county social services people? They all did and continue to do so. Would physicians and other providers accept referrals from the screening clincs? As indicated, by and large they did and still continue to do so even with some probable over referral. In some areas dental services are scarce, even for the non-Medicaid population, and this remains a problem. Could the two state departments work well together in the daily problems of the program? The answer is "yes" without exception-perhaps because of AJPH May, 1976, Vol. 66, No. 5
the will to do it and because of previous good working relationships. Day Care centers (including Head Start) and schools accept screening reports for certain admission requirements. A county health department dental project was initiated because of need shown by EPSDT. These are some administrative successes. We also have administrative failures. Figure 5 shows the no-show rate which in some areas reaches 60 per cent. Also we know there are no-shows after referrals are made. A match of children referred against Medicaid billings was made for the first quarter of 1974. Providers bills were found for 38 per cent of the children referred within 120 days of screening. We are now trying local level clinic follow-up in some areas; we find 65 per cent of children referred receive diagnosis and treatment. Total cost for the screening program will be $4,200,000 this fiscal year. The cost per child screened will be $26; the cost per appointment made will be $19. The screening and other administrative costs are minimal compared to all costs incurred for providing identified and expanded services to children referred. These costs, e.g., dental, ophthalmic, medical, etc., have increased by more than an estimated $50 million per year since inception of the program; some of this cost comes from this program. The EPSDT program needs further evaluation in many areas. The costs and benefits of each component test of the screening must be determined. Some tests may need to be added, others may need to be dropped. In addition, we need an evaluation of whether Medicaid screening as performed in
80.000-
70.000
SCREENINGS
60.000
50.000-
40.000-
30.000-
20.000-
M22
10.000 532
Ns
0 20-
40-
60-
30o
REFERRALS
FIGURE 2-Number of Individuals Screened and Per Cent Referred by Ethnic Origin
483
._ r
PUBLIC HEALTH BRIEFS i.n or
DEAL
41X3
!I
OUTPATIENT CLINIC
---
lqw
CRIPPLED CHILDREN CLINIC 1%
41.23
RWKALCOU
31.%2
1110118 lVuff UAEKOU INYB ROOD
3.19 3121
ANEAL NOW66
AIW ML.323
nWI!
NM
4M1
4m1
6.C. CULTUE
4
V.D.i.L.
4
ROOD Pima1811
FIGURE 4-Percentage of Provider Types Receiving Referrals from the EPSDT Clinics
313 No CIoCN9E TOTAL IffAIS 183.41
FIGURE 3-Most Frequent Areas of Health Problems
in'
ums
AVAUAI
Michigan is a valid way of determining which children need health care. This assessment is being planned and hopefully will be underway in the near future.
Summary Since the spring of 1973, Michigan's EPSDT program has screened more than 300,000 children. The Department of Social Services contracted with the Department of Public Health to design the screening and referral parts of the program; in turn, the Department of Public Health contracts with local health departments to do screening with one or more teams composed of a nurse, two technicians, and a clerk. The 72 teams screen 10,000 clients each month. More
484
FIGURE 5-Utilization of Available Screening
Appointments
than one-half of these clients are referred for diagnosis and treatment. The highest percentage (27 per cent) of referrals is for dental care; the second highest (26 per cent) is for immunization. Participation in the program of state and local social services departments, local health departments, and all groups of health providers has been excellent. There continues to be a high no-show for screening and a moderate noshow rate to providers for diagnosis and treatment. Evaluation of the program elements is needed.
A4JPH May, 1976, Vol. 66, No. 5
