Developmental Services Pathway(Ages 0-3)

Players• Insurance• Regional Center• First 5 services

Interpretation• Basket size correlates with service capacity• Tightness of mesh correlates with strength of role within public

safety net.

Regional Center (RC)

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Regional Center (RC): Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

First 5

Insurance

Case Example: Insured 22 month old male child was referred by PCP. PDD-NOS or related is suspected. Child does not appear to have any other delays but is not vocalizing or imitating sounds/words. Child does not make eye contact and engages in compulsive behaviors/activities.

Insurance approved a full psychological evaluation.

When to Refer to:

Which agency is most likely to approve services?

Insurance

First 5

Regional Center (RC)

Case Example: 24 month old male child is seen for 2 year CHDP visit. PDD-NOS or related is suspected. Child does not have insurance.

Due to the nature of the condition, RC performs full developmental evaluation. Services are offered.

When to Refer to:

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Regional Center (RC): Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

Which agency is most likely to approve services?

Regional Center (RC): Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC & insurance denied.

First 5

Insurance

Regional Center

Case Example: 18 month old female child was referred by PCP due to concerns with speech. Child does not appear to have any other delays but is not vocalizing or imitating sounds/words like other children her age. An assessment indicated a 52% delay in speech. Insurance has denied on account of the child’s age with the assumption that the child will “grow out of it”.

When to Refer to:

INSURANCE: Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Regional Center offers services per: 1)50% + delay in one or more areas; 2)Insurance denial.

Which agency is most likely to approve services?

Regional Center (RC);: Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

Insurance

Regional Center (RC)

When to Refer to:

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Which agency is most likely to approve services?

Case Example: 30 month old male child was referred by daycare due to concerns with behavior. Child has mild delays in speech which are, in part, causing him to act out towards his peers. Child does not appear to have any other concerns with development and no previous medical history that could have precipitated this delay.

First 5offers services per: 1)Mild delay with speech2)Concerns with behavior3)Under 60 months and/or not in kindergarten.

First 5

RC; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

Insurance

Regional Center (RC)

When to Refer to:

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Which agency is most likely to approve services?

Case Example: 26 month old female child was referred to CFIS by PCP due to concerns with limited talking and concerns with feeding. Results indicate OT and SL Tx needed. Referrals processed to insurance and SDRC.

Upon referral to the family’s insurance, child was approved for OT but was denied speech services due to absence of underlying medical condition.

SDRC approves SL Tx.

First 5

Regional Center (RC)

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

RC: Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

First 5

Insurance

Case Example: Insured 15 month old presented with tonal variations and intermittent spasticity. Child was referred by PCP to CFIS for OT/PT/SL evaluation.

Insurance approved evaluation and Rx was transferred to Developmental Services for PT/OT/SL evaluation.

When to Refer to:

Which agency is most likely to approve services?

Therapists recommend referral to neurologist.

Developmental services to offer OT/PT/SL Tx contingent on neurological results.

RC; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

Insurance

Regional Center (RC)

When to Refer to:

INSURANCE; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

Which agency is most likely to approve services?

Case Example: 14 month old male child was referred to CFIS by PCP for PT evaluation due to not walking. Recommendations from eval are PT Tx through insurance. PT also refers to HDS for Developmental Assessment due to possible concerns with OT and SL.

Developmental Assessment results show mild SL and fine motor concerns.

Upon referral to the family’s insurance, child was approved for PT.

Recommendations from Developmental Assessment result in SL and OT services through First 5.

First 5

RC; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition and child does not have insurance or insurance denied.

First 5: Child has mild delays/no delays; child has moderate delays but RC and insurance denied.

First 5

Insurance

Regional Center (RC)

Case Example: 12 month old female child recently moved to the city with her Maternal Grandparents. Child was previously receiving ongoing support per Trisomy 21 diagnosis. Family unit is unfamiliar with the city’s developmental services network and seeks the assistance of a physician for referral to appropriate agency.

When to Refer to:

INSURANCE: Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition.

RC offers services per: 1)Child’s developmental delays and2)Qualifying diagnosis

Which agency is most likely to approve services?

RC; Child has moderate/severe delays; diagnosis; delays which are secondary to medical condition which are anticipated to present continuous barriers to self-sufficiency.

First 5: Child has mild delays/no delays; child has moderate delays but school district denied.

Regional Center (RC)

School District

When to Refer to:

School District: Child has moderate/severe delays in speech or cognitive domains. Child presenting with other delays without cognitive impairment is unlikely to receive services.

Which agency is most likely to approve services?

Case Example: 34 month old female child was referred to Developmental Services by PCP for speech evaluation hinging on intelligibility concerns. SL report states that language development is age appropriate; however, intelligibility concerns precipitate referral out.

Initial referral to school district is denied, based on child’s age.

First 5Interim services offered by First 5 until child reaches 36 months.

Intelligibility concerns persist; child referred again to school district upon reaching 36 months. School district offers speech treatment 1x every other week.