Developmental Screenings

Purpose

NICU Developmental Screenings Purpose

Referral Specialists review all potential referrals to PIC to assure appropriate referrals are being made. If Referral specialist have a question about if a child should be screened or go directly to evaluation, they will consult team manager(s), then review and determine if the referrals are initially screened in-house, or go to evaluation. Availability of an appropriate provider determines if there is a screen, otherwise referrals go to eval. Screens are assigned in teams. OT, PT are appropriate provider type due to need for a motor therapist. SLP is appropriate only when there is solely a feeding concern. Providers manage the client scheduling and communication.

Procedure

Billing Procedures

No screenings (NICU, developmental, hearing, or vision) are billed out, so the only necessary billing documentation is to list the screening clock times under the Long Term Therapy Note type “Screening”

How to- Developmental Screenings Data Entry

Trigger to know to look for a screening? Set up an auto-task to group 10?
Once a developmental screening is completed, it needs to be added to the state database under the Ref/Screen tab
1. If there is a reason to pend prior to the screen, the disposition is updated in the referral.
Add the screen in the Screens subheader with the date of service (ex shown below DOS is 10/22/24) by clicking the green square + sign.
1. The “Screened By” will always be EI/ILP
2. The Disposition depends on what the recommendation was in the note, but it generally falls into the following categories:
  1. Declined Further Services: the family doesn’t want to move forward with the PIC process
  2. None- Within Normal Limits: the provider doesn’t recommend a rescreen and the child falls within normal limits at the time of the screening
  3. Refer to team: the provider recommends a full evaluation Disposition --> Schedule multidisciplinary evaluation
  4. Rescreen: the provider recommends rescreening in 1-3 months
    1. If this is the case, then the child will need BOTH the disposition of “Rescreen” AND “Evaluation Pending/Family Reason” with the following reason for pending:
      “The provider recommended that CHILD be re-assessed in # months. The family understands that an evaluation is within their rights, but declines evaluation at this time, preferring to wait # months to rescreen.”
    2. Add the reason for pend, as well as the summary (usually the last paragraph) as a Note with the date as the DOS for the screening.
      
      Example:
      
      LAST PARAGRAPH:
      CHILD is a very young infant with a history of drug exposure which puts her at higher risk for developmental delays. CHILD is demonstrating increased extensor tone throughout her body, along with a head-turning preference. Additionally, CHILD presents with poor repertoire of movement as graded by the General Movements Assessment. It is recommended that CHILD be re-assessed in 1-2 months.
      
      PEND REASON:
      The family understands that an evaluation is within their rights, but declines evaluation at this time, preferring to wait 2 months to rescreen.
      
      **Make sure the RT status matches the SDB status**
Signature forms needed:
1. 1st screening: screening packet, even if 1st screening is WNL, NO PWN is needed.
2. 2nd screening: PWN and consent to screen
Add summary to SDB task
1. Example: entered: 10/22 screening and rescreen pend, screening sigs comp

Process for Screening NICU Referrals

Team managers/PIC NICU point person review with Prov PT all potential referrals to PIC in advance to assure appropriate referral is being made. Referral specialist and team manager then review and determine if the referrals are initially screened in-house, or go to evaluation (availability of appropriate provider determines if there is a screen, otherwise referrals go to eval). Providers manage the client scheduling and communication.

Conducting the Screening

Team	Procedures
Referral Team	Input client to RT and DB Send list to managers who decide if child is goes to eval or screening within 24 hours of email of request from the referral team Processes family information, and places name on the referral list indicating file goes to eval or screen (provider team assigns the screens) Complete a communication log indicating who the assigned provider is after team meeting Referral holds on to any child is in the negative age group (under 0 months) and contact the parent Referral assures that the parent knows that screening is a recommended option and parent can choose eval
Manager Team	Reviews the records at request of the referral team Complete an FSC daily note for having reviewed the medical record and recommendation to screen or eval Global abbrev: recreview Emails referral team indicating send to team with screen or eval Distribute referrals at team At assignment for screening Manager changes “case status” to “on hold” and “on hold until” date three months out: see pics below
Provider	Complete screening packet with family including PWN PWN and Screening consent must be completed at each screening Complete a limited intake and relevant medical history, including but not limited to feeding, sleep patterns, baby’s ability to self-comfort Screen using HINE, ASQ, GMA and head measurement for plagiocephaly, as indicated See actions based on screening results Documentation: RT Screening packet with consent for screening Billing and billing policies Parent rights HIPAA ROIs for providers who are involved Prior Written Notice (if within normal limits and discharging ILP process) Screening note**

Team

Procedures

Referral Team

Input client to RT and DB

Send list to managers who decide if child is goes to eval or screening within 24 hours of email of request from the referral team Processes family information, and places name on the referral list indicating file goes to eval or screen (provider team assigns the screens)

Complete a communication log indicating who the assigned provider is after team meeting

**Referral holds on to any child is in the negative age group (under 0 months) and contact the parent

**Referral assures that the parent knows that screening is a recommended option and parent can choose eval

Manager Team

Reviews the records at request of the referral team

Complete an FSC daily note for having reviewed the medical record and recommendation to screen or eval Global abbrev: recreview

Emails referral team indicating send to team with screen or eval Distribute referrals at team

At assignment for screening Manager changes “case status” to “on hold” and “on hold until” date three months out: see pics below

Provider

Complete screening packet with family including PWN

PWN and Screening consent must be completed at each screening

Complete a limited intake and relevant medical history, including but not limited to feeding, sleep patterns, baby’s ability to self-comfort

Screen using HINE, ASQ, GMA and head measurement for plagiocephaly, as indicated

See actions based on screening results

Documentation:
RT Screening packet with consent for screening
Billing and billing policies
Parent rights
HIPAA
ROIs for providers who are involved
Prior Written Notice (if within normal limits and discharging ILP process) Screening note**

Screening Results

*Whenever possible, the same provider who screened completes the re-screen.

**A screen may be converted to a motor evaluation. Following the motor evaluation, the child is referred to team so that a second discipline can complete the appropriate evaluation of the child. Motor evaluation cannot stand alone—the law requires a child receive a full evaluation prior to being determined ineligible for services.

Picture of how to use the Pediatric Rehab Case to show as a screening on Provider Dashboard

Open a new case on the Child record, select the appropriate case for the provider. Select On Hold in the Case Status dropdown, and set the date approx three months out.

Screenings will appear in blue on the provider’s dashboard:

Global abbreviations:
scrn
“the family understands that an evaluation is within their rights but declines an evaluation at this time, preferring to wait no more than 3 months to rescreen.”

recreview