An essential element of integrated care is screening. Whether for adults or for children, screening is a form of early intervention and prevention of severe acute outcomes to reduce the high cost of care and high morbidity rates. The need for preventive care to address population health outcomes is a responsibility that goes across systems of care and age groups across the life span. There are three types of prevention: “the classic categories of prevention include primary prevention, controlling modifiable risk factors to avert the occurrence of disease; secondary prevention, the early detection of disease before it manifests clinical symptoms; and tertiary prevention, the control of existing diseases to prevent more serious complications.” Effective preventive care is a must for impactful integrated care.
For children, the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) covers five essential elements. They are:
- comprehensive health and developmental history (including assessments of both physical and mental health development);
- comprehensive physical examination;
- appropriate immunizations;
- appropriate laboratory tests; and
- health education.
States are required to provide Medicaid children with these screenings and the structure for these are clearly defined as provider performance measures. However, as clearly defined as these measures are, there are multiple challenges in special and complex needs populations. Thus, the success rates across the different States vary greatly with nine states not meeting the benchmark at all. Gaps occur across screening components.
For effective integrated care, gaps must be addressed for performance impact. Another key variable is the definition of “medical necessity”, which is defined at the state level. Thus, with the implementation of EPSDT, recognized and reimbursable treatment referrals attuned to the state-approved definitions would further leverage prevention activities. For providers, this means paying attention to national- and state-level changes and practice requirements. For service delivery model change, prevention can be a key driver change — one child at a time.
Loan Mai, PhD, is the Director of Population Based Health Management at SAE & Associates. She is experienced with the clinical mapping of values in IT solutions specific to managed care transition planning and evidence-based care. With direct work in Early Child Development and Prevention Programs, she ties clinical knowledge into operational steps for practice change. Dr. Mai has over 25 years of experience providing clinical and social services in a range of communities throughout the country.