Streamlining screening across the country’s biggest state

Dog sledding in Alaska
Accessibility is a major challenge in any state with a widespread rural population, but Alaska’s size and terrain make outreach particularly challenging.

On average, 13% of children under age 3 experience developmental delays or disabilities.1 Part C of the Individuals with Disabilities Education Act (IDEA) was created to give these children access to programs and services that can help them successfully transition to preschool and kindergarten. All states are required to have a Child Find program that identifies, screens, and provides early intervention services for eligible infants and toddlers.

Facing the Problem

In 2011, Alaska’s Part C Office took a critical look at its own Child Find efforts and determined that the state could—and wanted to—do better. At that point it was identifying delays or disabilities in only 6% of Alaska’s children ages 0–3, less than half of the average identification rate. And only a third of those identified (2% of all infants and toddlers) were receiving early intervention services.

What was keeping Alaska’s numbers below the national average?

“Geography, expense, and a lack of standardized screening tools,” explains Erin Kinavey Wennerstrom, M.Ed. She is Alaska’s former Part C state coordinator, who led the initiative to enhance Alaska’s Child Find efforts.

Accessibility is a major challenge in any state with a widespread rural population, but Alaska’s size and terrain make thorough outreach both time- and cost-prohibitive. With a square mileage equivalent to that of the entire eastern seaboard, and both islands and mountains in the mix, many areas can be reached only by plane. If screening must be done in person, this presents a problem for both families and professionals.

Consider, too, that the various entities that perform screening—including pediatricians, child care centers and public health agencies—may be using different screening tools. This makes it difficult for the state to measure success, provide ongoing training and support, and decide whether and how to ramp up outreach.

“We knew right away that a universal screening tool could very well address all of these issues,” says Wennerstrom, “but the next challenge was deciding which one.”

Finding a Solution

To determine which screening tool would best meet the state’s needs, Alaska’s Part C Office conducted a comprehensive review of national literature, state workgroup recommendations, and learnings from the Alaska ABCD Screening Academy Project, which had implemented ASQ at several sites to assess the benefits of structured screening.

The result? Ages & Stages Questionnaires®, Third Edition, (ASQ-3™) was the clear choice.

“We made the decision to use ASQ-3 right around the same time ASQ Online went live,” says Wennerstrom. “It was a no-brainer to also incorporate the online system.”

With ASQ Online, any parent with an Internet connection would also be able to complete ASQ questionnaires through ASQ Family Access.

One of the state’s goals was to reach rural families. With ASQ Online, any parent with an Internet connection would also be able to complete ASQ questionnaires through ASQ Family Access. Completed questionnaires are submitted securely, and parents and caregivers receive follow-up from their child care center, physician’s office, or early intervention program.

“This was a really big motivator for our switch to ASQ Online,” says Carol Prentice. Her firm consults for the Alaska Department of Health & Human Services and was hired to implement ASQ Online statewide.

“The expense associated with reaching many Alaskan families is prohibitive,” she adds. “Now that we have a tool that allows families, physicians, rural and public health agencies to go online and enter results, we can provide access in a way that hasn’t been done before in Alaska.”

Getting Started

So how does an organization even begin to implement such widespread change?

The Part C Office worked closely with Prentice to devise an implementation plan that would bring the state’s many screening and referral agencies on board with as little disruption as possible. The goal was to raise the identification rate of children 0–3 with developmental delays or disabilities and increase the number of kids receiving early intervention, from 2% to 2.6%.

It sounds small, but that’s about a 33% increase, an ambitious goal given how many moving parts exist in such a process.

Though adopting ASQ Online is not mandatory, Alaska’s thoughtful rollout approach—along with the screening tool’s proven ease and reliability—made it an attractive and rewarding option for many organizations.

Together, Alaska’s 16 regional Infant Learning Programs (ILPs) have access to, or relationships with, the primary referral sources in their region.

The state decided to take advantage of an existing organizational structure to streamline the implementation process. Alaska has 16 regional Infant Learning Programs (ILPs) that provide early intervention services to children with developmental delays and disabilities. Together these ILPs cover the entire state and have access to, or relationships with, the primary referral sources in their region—including pediatricians, child care centers, Head Start programs, pre-K programs, and public health organizations.

The goal was that the Part C Office would act as the program hub. ILPs would agree to open ASQ Online Enterprise accounts and then provide access to ASQ-3 to the primary referral sources in their respective regions (see diagram). Whether or not to actually use ASQ-3 was up to each screening organization, but just the fact that they were included in the rollout makes Alaska’s program unique.

Implementation was divided into three phases. Each phase would bring ASQ Online to a new set, or cohort, of ILPs while gradually introducing additional tools or features. The pilot cohort included seven ILPs, which had adopted the paper version of ASQ-3 but didn’t yet use the online system.

In January 2012, after concluding the limited pilot and securing funding to expand statewide, Alaska officially launched its universal implementation. Two representatives from Brookes Publishing traveled to Alaska to help promote the statewide rollout.

The second and third cohorts ramped up their use of the online system for ASQ and incorporated access for partner programs, ASQ’s Family Access option, and even started using ASQ:SE, the social-emotional screener.

“What has helped make this such a smooth process overall, is that we opted for a slow timeline to give people a chance to integrate ASQ Online into their programs,” says Prentice.

Overcoming Challenges

No program of this size progresses without hitting a few bumps. Beyond the initial challenge of just picking a tool that stakeholders could agree on, there were technical issues to consider, and reluctance that came in many forms.

A new API allows physician’s offices to integrate ASQ with their electronic health record system, eliminating any need for duplicate data entry.

One of the biggest concerns was how to integrate ASQ with electronic health records in physician’s offices. Initially, there wasn’t a way for the two systems to talk to each other, which meant duplicate data entry. Since most doctors operate within an efficiency model, this was seen as too time-consuming. Based on feedback from the ASQ users in Alaska and other locations, Brookes Publishing has now released an Application Programming Interface (API), which allows users to connect ASQ Online to another data management system, such as an electronic health record system.

Others worried about confidentiality and whether the system is HIPAA compliant. (It is.)

Staff of already-busy offices have expressed a reluctance to invest in the time it takes to learn a new system, as well as a concern that staff turnover will require continual retraining. (These issues are addressed in the training program that was customized for the Alaska implementation, where participants learn that the time commitment is actually minimal given ASQ’s user-friendliness.)

As for parents using ASQ Family Access, it’s always possible that they won’t feel comfortable using the technology or entering data online. Usually this can be handled by the ILPs, who are trained to support families with their technology needs. (Plus, the benefits of reaching more people because of the online tool far outweigh the few exceptions. And those who aren’t comfortable with technology, even after receiving support, can still receive screenings in-person in medical or child care settings.)

Growing and Strengthening

As ASQ became available to the ILPs, Alaska saw that it took some groups longer than others to achieve organizational readiness. Some jumped right in, and others, for various reasons, were either hesitant or unable to start using ASQ right away. Younger generations in particular were quick to embrace ASQ’s technological aspects.

“Even though the system has been voluntary, we’re finding that the response has been overwhelmingly positive,” says Prentice. “As organizations come on board and achieve success, we can demonstrate that the system is working—that it really is reaching those hard-to-reach populations.”

Prentice reports that the robust training program used in Alaska has been one of the forces driving interest and compliance.

The Part C Office worked closely with Brookes Publishing to make use of the company’s many ASQ training offerings. They included:

  • One-on-one orientations for administrators for all new ASQ Enterprise accounts
  • Tutorials and help manuals in the ASQ Online system
  • Topical webinar trainings on ASQ Online, including training for program administrators, ASQ Family Access, and report writing
  • Live Q&A sessions and unlimited access to webinar archives afterward

With 16 agencies, we have a spectrum that includes people who were using [ASQ Online] two years ago and some who are just getting started … it made sense to make use of this continuum of expertise

—Carol Prentice, consultant for the Alaska Department of Health & Human Services

To deliver on its promise of ongoing support, the state also developed its own valuable training efforts. Early adopters from the ILPs are sharing their knowledge with newcomers by participating in open-forum teleconferences and a peer-to-peer network. Having the ability to ask specific questions and receive timely advice strengthens abilities, builds confidence, and prepares ILPs to impart their wisdom to the program accounts within their regions.

“With 16 agencies, we have a spectrum that includes people who were using it two years ago and some who are just getting started,” says Prentice. “It made sense to make use of this continuum of expertise, and we’ve found that people are really willing to do it.”

Realizing Success

Valuable indeed. One success story is Sprout Family Services, a small nonprofit and one of the 16 Infant Learning Programs in Alaska that has an ASQ Enterprise account. Sprout serves children prenatal through kindergarten in a large region that is based in Homer, Alaska. Explains Executive Director Jillian Lush, there’s been a welcome paradigm shift that transfers screening responsibilities to partner programs and parents.

“Thanks to ASQ Online, we can better serve children who need extra developmental support, rather than spending our time screening out ineligible children,” she says. “And due to the extensive training and having a point person in the agency who serves as the ‘ASQ master’, we are seen as a valuable resource to our partners.”

Not to mention the cost benefits. In the past, Sprout would visit 10 communities once a year to conduct screenings, at a cost of $5,214 plus temporary loss of staff resources. This may have only resulted in 52 screenings and 12 referrals for intervention services. ASQ Online has proven to be much more efficient and just as reliable.

Making a Difference

Participants in the statewide adoption of ASQ are experiencing a variety of benefits, from the cost savings due to families conducting first-level screenings themselves, to the unintended benefit of strengthening relationships between Infant Learning Programs and their partners.

“As for concrete numbers, it’s tough to get a clear before-and-after picture due to how decentralized the data was prior to the launch, but it’s obvious from the data we do have that things are going well,” explains Prentice. “We’re seeing a lot of interesting numbers in our online database that hint at big improvements.”

In 2012, 13% of all ASQ screenings in Alaska’s ASQ Online accounts were entered via Family Access. Just one year later, that number more than doubled to 28%.

One hint is how data is being entered. In 2012, 13% of all ASQ screenings in Alaska’s ASQ Online accounts were entered via ASQ Family Access. Just one year later, that number more than doubled to 28%—a strong indicator that online access has proven valuable to a lot of people.

The state expects that these numbers will be reflected in a rise in total screenings over time.

“Most importantly, Alaska now has a clear, comprehensive system that can be evaluated for efficacy,” says Wennerstrom. She’s now an assistant professor of early childhood special education at the University of Alaska, Anchorage, but remains a dedicated supporter who enjoys watching her brainchild succeed.

It’s clear that the State of Alaska and all participants in the universal adoption of ASQ-3 are part of a collective success story that has only just begun.

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Want to learn more about Alaska’s statewide implementation of ASQ-3? View a presentation from the 2014 National Association for Education of Young Children conference. The presenters were current Part C State Coordinator Laurie Thomas, Prentice, and Lush.

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1 Rosenburg, S., Zhang, D., Robinson, C., 2008

 

Originally published: March 2014

  • A boy raises his hand as a girl claps.

    What ASQ Users are Saying

    “What I love about the ASQ is that it allows our staff to catch delays quickly and allows us to get our clients the early intervention programs that they sometimes need. In many cases [ASQ] helps us catch children up before they start kindergarten, therefore providing children with the start that they deserve.

    Sharon Gee, Supervisor, Healthy Families Niagara