Project I-SCRN

Project I-SCRN: Improving Screening, Connections with families, and Referral Networks​

The American Academy of Pediatrics invites practices that provide pediatric primary care to apply to participate in a year-long quality improvement (QI) collaborative designed to provide practices with the strategies, tools, and resources needed to improve screening, referral, and follow-up for developmental milestones, autism, maternal depression, social determinants of health, and social-emotional development.

Participating practices will learn and apply quality improvement methodology to develop an efficient and effective workflow for screening, referral, and follow-up. Key areas of focus will include enhancing family-centered care, establishing a team-based approach, and engaging with community partners to develop a comprehensive referral network to support the needs of children and families.

​The specific goals of the project are for participating practices to increase:

  • Screening for target issues using appropriate tools at recommended visits

  • Discussion of screening results with families

  • Referrals for positive screenings

  • Number of referred families contacted to follow up on referrals


Recordings of these sessions will be posted on this webpage within 1 week of the webinar and will be available until the application deadline.

​Recruitment Flyers


    Benefits of Participation
    • ​Increase screening, referral, and follow-up rates
    • Enhance family-centered care
    • Expand referral partnerships
    • Learn new QI methods and tools
    • Network and problem-solve with expert faculty and other practices
    • Receive a $5,000 stipend for project-related expenses
    • Earn credits
      • Participating pediatricians will have the opportunity to earn American Board of Pediatrics Part 4 Maintenance of Certification (MOC) credit (awaiting approval)
      • The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAP designates this PI CME activity for a maximum of 20.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
        • This activity is acceptable for a maximum of 20.00 AAP credits. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of the American Academy of Pediatrics.
        • The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME. Physician assistants may receive a maximum of 20.00 hours of Category 1 credit for completing this program.
        • This program is accredited for 20.00 NAPNAP CE contact hours of which 0 contain pharmacology (Rx), (0 related to psychopharmacology) (0 related to controlled substances), content per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines.  

    • ​Practices that wish to participate must:
    • Provide pediatric primary care, including at least ten 1-6 month well child visits per month and ten each 9-, 18-, 24-, and 30-month well child visits per month. 
    • Secure approval from practice leadership to participate in this project.
    • Agree to the participation requirements.
    • Identify a core QI team that will be responsible for providing leadership and oversight within the practice for the initiative.  
      • The team should include, at a minimum, a primary care physician who will serve as physician champion and MOC local leader; a nurse; and an additional team member such as a front office person, practice manager, or care coordinator (this role will be responsible for data submission for the project).  Practices may choose to include additional members on the core QI team, and all practice staff can participate in educational offerings.
      • Practices must actively recruit a parent partner to serve on the core QI team.  The parent partner does not need to be identified prior to applying to participate in the project.  The parent partner will provide guidance to the practice team from the family perspective.
    • If required by their institution, seek Institutional Review Board (IRB) approval for participation. (Please note: The AAP IRB has approved this project. The AAP IRB approval is usually sufficient for most participating practices since no identifiable protected health information is being collected for this project.)
    Project Offerings

    All physicians and staff in participating practices are encouraged to participate in project activities.

    In-person learning sessionsTwo 1.5-day sessions with educational content and hands-on activities attended by core QI teams. Travel costs for 3 team members will be paid by the project.
    Interactive webinarsMonthly webinars that provide the opportunity for participants to review data, share common challenges and solutions, and receive education from faculty experts.
    CoachingIndividual and small-group phone sessions with QI and content experts held periodically to assist practices in addressing challenges.  Five practices will also receive a day-long coaching session at their location.
    Data collection and reporting using AAP Quality Improvement Data Aggregator (QIDA) systemSecure portal for chart review data entry that generates customized reports, enabling practices to monitor progress towards project goals. Practices will enter data from a minimum of 30 charts per month.
    Change package and resource packetLinks to resources and tools to assist practices in implementing changes, as well as printed patient handouts and AAP materials.
    Stipend to support project activitiesParticipating practices will receive $800 as a stipend for their parent partner and $4,200 to be used for project-related expenses, such as developing a community resource directory, making EHR modifications, holding a meet-and-greet for referral partners, and/or purchasing screening tools or other resource materials. ​

    Project Timeline

    ​​Pre-work period (1 month: June 2017)

    • Complete pre-project surveys (core QI team members and other participating physicians)
    • Attend kick-off webinar (all participants)​​
    • Attend data collection and entry webinar (team members responsible for data submission)
    • Submit baseline chart review data through QIDA (minimum 30 charts per practice)​​

    Action period (11 months: July 2017 – May 2018)

    • Attend in-person learning sessions: July 21-22, 2017 and March 2018 (core QI team)
    • Hold regular meetings with core QI team and other participating staff
    • Develop and implement improvements using PDSA cycles
    • Submit monthly chart review data through QIDA (minimum 30 charts per practice)
    • Conduct parent survey (minimum 30 responses) at baseline (month 1), midpoint (month 6), and conclusion of project (month 12)
    • Submit brief monthly progress report
    • Participate in project listserv
    • Attend monthly webinars
    • Participate in coaching sessions

    ​Project close-out

    • Complete post-project surveys and optional phone interview
    • Attend wrap-up webinar

    Participation Requirements

    ​Expectations for the core QI team:

    • Participate in the project for its duration of 12 months
    • Complete team and individual pre- and post-project surveys
    • Complete a brief monthly team narrative progress report
    • Submit required data for the project monthly through QIDA
    • Conduct parent survey at baseline, midpoint, and follow-up
    • Hold at least 9 team meetings to review data and plan and implement PDSA (Plan, Do, Study, Act) process improvement cycles
    • Participate in at least 6 project webinars or coaching calls
    • The physician champion/MOC local leader and two other team members, to be determined in consultation with project staff, will be required to attend the learning sessions (travel expenses paid by the project). The first learning session will be held July 21-22, 2017 in Elk Grove Village, IL

    Minimum requirements for pediatricians to receive Part IV MOC credit:

    • Be intellectually engaged in planning and executing the project
    • Implement the project's intervention (the changes designed to improve care)
    • Collaborate actively by participating in least 8 project or practice team meetings or conference calls at which data are reviewed, strategies discussed, and plans for new improvement activities are made (unless clinical care interferes)
    • Provide direct care at well child visits to patients 1-30 months of age as part of the project
    • Collect, submit, and review data in keeping with the project's measurement plan
    • Participate in the project for its duration of 12 months
    • Complete participation under current ABP certificate or MOC cycle​

    Additional responsibilities of physician champion/MOC local leader:

    • Assist in forming the QI team at the practice and serve as team leader or support and advise the team leader
    • Review monthly practice data
    • Support the participation of other pediatricians who are participating for MOC credit in implementing the project's interventions
    • Track participation in required activities and sign and submit Physician Attestation Forms verifying that pediatricians in the organization seeking credit for MOC Part 4 fulfilled the completion criteria
    • Resolve any disputes related to the validity of a pediatrician's participation in the project
    How to Apply

    ​Please submit your practice name and contact information to notify us of your intent to apply by May 10, 2017 (optional but much appreciated).

    Practices must apply through an online application by May 19, 2017. The application can be completed by the physician champion/MOC leader or their designee.

    If you are unable to finish the application in one session, you may return to the application at a later time; however, you must use the same computer and your computer must be set to accept cookies. If you do not have your computer set to accept cookies, you will have to restart the application from the beginning.  If you wish to review the questions and consider your responses before starting the online application, a PDF version of the application can be accessed here​

    Up to 20 practices will be chosen to participate.  Practices meeting eligibility requirements will be selected based on capacity for change and commitment to improving their screening processes.  Reviewers will seek to create a diverse cohort in terms of size and location of practices and current level of experience with screening. Practices with diverse and/or underserved patient populations will be given priority. Practices located in Alameda County, California; Lamoille County, Vermont; or West Palm Beach County, Florida; that are willing to participate in an external evaluation conducted by Chapin Hall will also be given priority.

    ​Practices will be notified of their acceptance by June 2, 2017.​

    Project Faculty and Advisors

    ​The following experts are providing guidance and direction to the development and implementation of project I-SCRN and will also serve as faculty and coaches throughout the collaborative.

    Quality Improvement Advisor

    Kori Flower, MD, MS, MPH, FAAP
    Senior Improvement Advisor, Population Health Improvement Partners

    Kori Flower, MD, MS, MPH, is a Senior Improvement Advisor at Population Health Improvement Partners. She is also Associate Professor of Pediatrics at the University of North Carolina, Chapel Hill and previously provided primary care to underserved families in a federally qualified health center. She has been involved in a wide range of quality improvement efforts, including a collaborative to implement the Bright Futures toolkit, a collaborative to improve oral health care for young children, and Maternal and Child Health quality improvement efforts in a multi-state project.  Since 2015, she has served as quality improvement measurement lead for the CDC-funded national EMPower collaborative to improve infant feeding practices in hospitals. She is also the project lead for Carolina Conexiones at UNC, a bilingual patient navigation program to improve care for Spanish-speaking families. Dr. Flower received additional training in quality improvement methods through the Advanced Improvement Methods Workshops at the North Carolina Center for Children's Healthcare Improvement and Cincinnati Children's Hospital. Her published work addresses multiple public health issues for children, including breastfeeding, childhood obesity, injury, and language barriers to health care. Dr. Flower received her MS degree from the University of California, Berkeley, her MD degree from the University of California, San Francisco and her MPH degree from the University of North Carolina, Chapel Hill. She completed a general academic research fellowship as a Robert Wood Johnson Clinical Scholar at the University of North Carolina, Chapel Hill.

    Chair, Project Advisory Committee

    Marian Earls, MD, MTS, FAAP
    Director of Pediatric Programs, Community Care of North Carolina

    Marian Earls, MD, MTS, is the Director of Pediatric Programs for Community Care of North Carolina, and was lead on the state CHIPRA Quality Demonstration Grant (2010 – 2015). From 1994 to July 2012, she was the Medical Director of Guilford Child Health, a large, non-profit, private pediatric practice that was the pediatric division of Triad Adult and Pediatric Medicine in Greensboro, North Carolina, which serves families at or below 200% of the Federal Poverty Level. Dr. Earls also is Medical Director of the Neonatal Follow-up Clinic (multidisciplinary) for the Level III NICU at Women's Hospital in Greensboro. She is board-certified in both General Pediatrics and Developmental and Behavioral Pediatrics. She is a Clinical Professor of Pediatrics for the University of North Carolina Medical School. Dr. Earls received her B.A. in Biology in 1976 from the College of the Holy Cross in Worcester, Massachusetts, her Master of Theological Studies (MTS) in 1978 from Harvard Divinity School, Harvard University, and her M.D. from the University of Massachusetts in 1984. Dr. Earls is a Past President of the North Carolina Pediatric Society (President 2008-2010). She was chair of the Mental Health/School Health Committee for NCPS until 2011. At the AAP she is Chair of the Mental Health Leadership Work Group, serves on the executive committee of the Council on Early Childhood, is an AAP Liaison to the American Academy of Child and Adolescent Psychiatry, and has served on the Committee on the Psychosocial Aspects of Child and family Health.

    Project Advisory Committee Members

    Rian Anglin, MD, FAAP
    Medical Director, WE CARE Alabama

    Dr. Rian Anglin is a general pediatrician in private practice and the Medical Director for WE CARE Alabama. Born and raised in rural Alabama, she attended Auburn University where she graduated summa cum laude with a BS in Molecular Biology.  Despite her strong allegiance to Auburn, Dr. Anglin graduated from the University of Alabama School of Medicine in 2007 with her MD and completed a residency at Children's Mercy Hospital in Kansas City, MO in 2010. Dr. Anglin's passions in practice include promoting early childhood literacy, reducing toxic stress in childhood, and improving the practice of pediatric medicine through office-based research. She currently serves as the young physician liaison to the Pediatric Research in the Office Setting (PROS) steering committee.

    Tumaini Coker, MD, MBA, FAAP
    Associate Professor of Pediatrics, University of Washington School of Medicine

    Tumaini Rucker Coker, MD, MBA, recently joined Seattle Children's as Associate Professor of Pediatrics in the Division of General Pediatrics, and Director of Research at Seattle Children's Center for Diversity & Health Equity. She was previously Associate Professor of Pediatrics and Associate Director of Health Services Research at Mattel Children's Hospital UCLA. Dr. Coker's research focuses on designing and testing new and innovative methods of delivering primary care services to children in low-income communities. She collaborates with community clinics and pediatric practices to design and investigate innovative ways to improve the delivery of primary care services to children of low-income families. Her current community-partnered projects are funded by PCORI, NIH, and private foundations, and focus on designing and testing innovative models for preventive care, using telehealth to improve behavioral health services, and addressing socioeconomic disparities in care for children. Her work has been published in various journals including JAMA, Pediatrics, and the American Journal of Public Health, and has been covered by mainstream media outlets including CNN, USA Today, and NBC. She is a recipient of several national awards, including the Nemours Child Health Services Research Award and the Association of American Medical Colleges (AAMC) Herbert W. Nickens Faculty Fellowship. 

    RJ Gillespie, MD, MHPE, FAAP
    Pediatrician, The Children's Clinic

    R.J. Gillespie, M.D., M.H.P.E, is a general pediatrician with The Children's Clinic in Portland. He served as the Medical Director of the Oregon Pediatric Improvement Partnership from 2010 through 2016.  From 2007 through 2010 he worked as the Medical Director of Quality Improvement for the Children's Health Alliance, where he designed and implemented QI projects for a network of 110 pediatricians in the Portland metro area.  Through this position, he gained experience in developing actionable practice-based quality measures, curriculum design for quality improvement initiatives, and analysis of multiple practice workflows. He has also taught Quality and Efficiency at Portland State University for the Healthcare Management Certificate Program.  He served as the lead physician advisor and trainer for the Screening Tools and Referral Training (START) project through the Oregon Pediatric Society, which is a statewide training program designed to improve developmental screening in primary care offices. He additionally designed the curriculum and training program for START's first expansion module, Screening for Peripartum Mood Disorders. His work in maternal depression earned him a place on the state's HB 2666 Maternal Mental Health Workgroup, and subsequent recognition with the Postpartum Support International's Healthcare Leadership Award. He has been actively involved as a member and advisor to a number of local quality improvement initiatives and state policy committees, including the Measurement & Reporting Committee for Oregon Health Care Quality Corporation, Community Health and Quality Committee for the Oregon Medical Association, the Patient Centered Primary Care Home Standards Advisory Committee for the Office of Health Policy & Research, and the Oregon Health Authority's Metrics & Scoring Committee, which decides quality and incentive metrics for the Coordinated Care Organizations in Oregon.  He attended medical school at Oregon Health Sciences University, graduating in 1997, and completed his residency and chief residency at Rush Children's Hospital in Chicago, Illinois in 2001. He also earned a Master of Health Professions Education from University of Illinois – Chicago in 2007. He completed the Clinical Innovations Fellowship with the Oregon Health Authority's Transformation Center, which supported his clinical project in Assessing Parental Adverse Childhood Experiences in Primary Care Pediatrics.

    Michelle Macias, MD, FAAP
    Director, Division of Developmental and Behavioral Pediatrics, Children's Hospital at the Medical University of South Carolina

    Dr. Macias is a Professor of Pediatrics and chief of the Division of Developmental-Behavioral Pediatrics at the Medical University of South Carolina in Charleston, SC. She is board certified in Developmental-Behavioral Pediatrics and Neurodevelopmental Disabilities. She began her career as a school-based speech-language pathologist in San Antonio, TX; she subsequently completed medical school and residency in Pediatrics at the University of Texas Health Science Center at San Antonio, followed by fellowship in Developmental-Behavioral Pediatrics at the University of North Carolina at Chapel Hill.

    Dr. Macias has an active clinical practice evaluating and treating children with a broad range of developmental and behavioral disorders. Her research interests and grant activities have focused on early detection of developmental disorders and biopsychosocial correlates of children with disabilities. She has served on numerous state and national committees, is past-president of the Society for Developmental and Behavioral Pediatrics, immediate past-chair of the American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics, and serves on the American Board of Pediatrics general pediatrics and developmental-behavioral pediatrics certifying committees. She has been involved with multiple activities within the AAP regarding developmental surveillance and screening, including the 2006 AAP Policy Statement and current revision, the national Developmental Surveillance and Screening Implementation Project ("D-PIP"), the Bright Futures EQIPP course, and the 2007 AAP autism spectrum disorders clinical reports. She is co-editor of the AAP Manual on Developmental and Behavioral Pediatrics and co-author of an AAP web-based educational module ("Pedialink") on coding and billing for developmental-behavioral problems. 

    ​Brenda Liz Muñoz, MS
    Parent Representative

    Brenda Liz (Bren) Muñoz is a 2014-2017 State of Georgia Governor Appointed and Executive Council Member with Georgia Council on Developmental Disabilities (GCDD), as well as a 2015-2016 Diversity Fellow and 2014-2016 Family Fellow/Trainee with Georgia's Leadership and Education in Neurodevelopmental and related Disabilities (GaLEND) competive academic leadership training program within the School of Public Health at Georgia State University. She is a former Georgia Department of Public Health/Autism Plan for Georgia/Parent to Parent of Georgia Parent Partner working with Dr. Isadore Leslie Rubin at Children's Healthcare of Atlanta. She is a freelance English-Spanish bilingual, multicultural advocate, cultural broker, educator and interpreter, translator and consultant.

    Bren obtained a Master of Science degree in Education with focus on Educational Foundations and Policy Studies, as well a Bachelor of Arts in Sociology and Spanish (dual major) and Women's Studies (minor). She holds a professional certificate as an Interpreter in Education from The University of Georgia, completed Georgia's Partners in Policymaking in 2014, and is a 2015 inaugural graduate of the Georgetown University, National Center for Cultural Competence, Cultural Diversity and Cultural and Linguistic Competence and Intellectual and Developmental Disabilities Leadership Academy funded through a cooperative agreement with the Administration on Intellectual and Developmental Disabilities (AIDD). Other leadership service includes work with the Association of University Centers on Developmental Disabilities (AUCD) on their Diversity and Inclusion Advisory and Action Teams, the award-winning Broad Prize in Urban Education, Gwinnett County Public Schools (GCPS) as an Advisory Council Member to the Local School Board, and with the American Association on Health and Disability (AAHD) as a state and regional liaison (Georgia, Puerto Rico and U.S. Virgin Islands). Bren is mentee to Mathew McCollough, Executive Director of the Washington D.C. Developmental Disabilities Council, and President-elect of the National Association of Councils on Developmental Disabilities (NACDD).

    Toni Whitaker, MD, FAAP
    Associate Professor of Pediatrics, UT Boling Center for Developmental Disabilities

    Dr. Toni Whitaker is an Associate Professor of Pediatrics and Developmental Pediatrics (Neurodevelopmental Disabilities) with the University of Tennessee, Health Science Center in Memphis. Her primary work is in interdisciplinary settings in clinical, academic, research, and community outreach endeavors. She is the Developmental Pediatrics Discipline Chief for the Leadership Education in Neurodevelopmental and Related Disabilities (LEND) multidisciplinary graduate-level training program at UT Boling Center for Developmental Disabilities. Dr. Whitaker has served as the Centers for Disease Control and Prevention's (CDC's) Ambassador to TN for the Learn the Signs. Act Early. program since 2011, and continues to be a member of the Planning Council for the statewide Autism Summit team. She worked with the American Academy of Pediatrics Division of Children with Special Needs on the expert workgroup for the "Don't Just Wait and See: Improving Developmental Screening and Follow-up" Maintenance of Certification Quality Improvement Project, and now serves as Project Leader for Phase 2.

    Jennifer Zubler, MD, FAAP
    Consultant, Centers for Disease Control and Prevention

    Dr. Jennifer Zubler is board certified in pediatrics. She worked in a large group practice in Atlanta, Georgia for ten years. She left private practice after one of her children was diagnosed with autism spectrum disorder in order to better meet her family's needs. She remained active in general pediatrics as a volunteer physician and her interest in early childhood development naturally expanded to early identification of developmental delays and early intervention based on her family's experiences. She is the clinic coordinator of a multidisciplinary developmental and behavioral clinic, where she helps families navigate diagnosis and services. She is actively involved with the Georgia AAP chapter working to improve physician awareness of developmental disabilities, early identification, early intervention services and support for families. 

    She completed a one year fellowship in the GA-Leadership Education in Neurodevelopmental Disabilities (LEND) program, a Maternal Child Health training program, and now works with the GA- LEND as a Systems of Care Course instructor. She also works as a pediatric consultant for the CDC's "Learn the Signs. Act Early" (LTSAE) program, which aims to improve early identification of children with autism and other developmental disabilities so children and families can get the services and support they need.  Through the LTSAE program she has been able to work with the AAP to develop a quality improvement project around developmental screening and referral, and is excited to begin the next phase of that learning cooperative. ​ 


Contact information

For questions regarding the collaborative or the application process, contact Sigal Shapira, Program Manager, at 847/434-4290
or at ​