State Profile: This Western state has a mid-sized population, about one-fifth are children younger than age 18, and about 13%–15% of children are CYSHCN. The state is majority White (66.5%), with a significant Hispanic/Latino (22.5%) population. The CYSHCN population is comparable with the adult population, with about half covered by public insurance and half by private insurance. Most counties are rural, and this includes two Native American reservations.
Refer to the full implementation guide for details.
Summary
This example shows the process for transforming developmental screening referrals from a fragmented, fax-based process into a sustainable, statewide electronic closed-loop system. Beginning with Title V funding and discovery work inspired by another program’s electronic referral pathway, the team identified critical gaps: fewer than half of children were screened, and nearly 30% of referrals were lost before evaluation. Through strategic partnerships with early intervention, health information exchange entities, and practice transformation organizations, this state piloted and scaled electronic referrals across multiple health systems and electronic health record (EHR) platforms. Key enablers included leveraging Title V performance measures, aligning with broader medical home initiatives, and applying implementation science frameworks. Despite challenges around financing, technology integration (application programming interface [APIs]), and role clarification, the project demonstrated measurable impact, reduced costs over time, and is headed for statewide scaling and sustainable processes in developmental screening and referral systems.
Exploration (2018–2021) 
- Originated from Title V work and early grants, with conversations across states examining how to implement closed-loop referral using electronic systems technology (approximately 2018)
- Inspired by another program’s electronic referral pathway
- Identified gaps: <50% of eligible children screened statewide, 30% of children lost in referral process, and fax-based referrals created inefficiencies
- Conducted discovery phase with $50–$75K Title V funds to explore electronic referral solution
- Engaged existing mechanisms for family feedback, including a developmental screening and referral policy council which includes family leaders, and the Early Childhood Comprehensive Systems Grant, which also has representation of family leaders for feedback on each phase
Installation (2020–2021) 
- Secured leadership support and funding (~$500–750K annually for first 3 years)
- Built strategic partnerships: agreements were made across state agencies, including the state health department, which administers early intervention. Other contracts included technical advisors, an organization experienced in practice transformation support, and the health information exchange (HIE). Investment during installation was approximately $250,000 across these contracts.
- Leveraged early intervention’s shift to centralized intake to streamline processes and reduce costs; built momentum for the innovation
- Formed implementation team and steering committee; clarified roles and responsibilities
- Used implementation science tools (eg, impact matrix) for planning and prioritization
Initial Implementation (2022–2023) 
- Phase 1: Pilot with one health system
- Developed standardized referral template
- Addressed technical challenges: API integration between EHRs and early intervention databases
- Provided incentives for health system participation
- Continuous evaluation using Early Childhood Comprehensive Systems (ECCS) grant data and provider/family feedback
Full Implementation (2023–2025) 
- Phase 2: scaled to Children’s Hospital; customized templates for larger systems
- Evaluation metrics: developed a strategic plan for how we are conducting consistent checkpoints; used family-centered metric of how quickly families were called; continually improved workflow
- Phase 3: expanded to five additional health systems (total: 7)
- Based on continuous improvement: customized caller ID for family recognition; identified champions for train-the-trainer model
- Phase 4 (2025–2026): sustainability planning
- Offboarding health systems using self-developed 15-point checklist
- Goal: offboard 4 of 7 sites by early 2026, and move to management by early intervention
- Costs decreased as systems adopted processes; early intervention assumed half of HIE costs
- Changes in roles: Title V is scaling new health systems; early intervention is sustaining already on-boarded systems and managing technological challenges
- Next Steps: plan for statewide scaling; target the larger referral sources for EICO in addition to areas of the state or health systems where there is evidence of a breakdown in successful rates of referrals and evaluations; examine what electronic health records are most utilized within the state; share model with other states.
Implementation Framework is Not Linear
The team worked across multiple implementation phases simultaneously. While scaling into full implementation with early partners, they were in initial implementation with newly added health systems. Continuous evaluation data often prompted returns to earlier phases to course-correct strategies, demonstrating the dynamic nature of system change.
Impact
The Developmental Screening and Referral (DSR) program significantly improved the referral process for early intervention by transitioning from fax-based referrals to an electronic, closed-loop system. This change reduced the number of children lost in the referral process, enhanced communication between health systems and early intervention, and built trust through real-time status updates and direct contact information. Continuous evaluation and scaling efforts led to streamlined workflows, increased family engagement, and measurable improvements in referral completion rates. By leveraging partnerships, implementation science, and Title V performance measures, the program demonstrated sustainable system change and positioned itself for statewide expansion.
Lessons Learned
- System change takes longer than you think.
- Tie funding to measurable outcomes by aligning project outcomes with Title V block grant performance measures (eg, national performance measure 6, later medical home referrals) to strengthen sustainability and justify scaling.
- Champions are needed at every level; investing in people and relationships was crucial, and having the right people on the team and identifying who could support the work was key to success.
- Include partners in training by bringing early intervention to training to help build relationships with providers and families, which builds trust between systems.
- Getting leadership on-board early is critical.
Quotes from Title V Leaders
Getting Leadership On Board for System Change:
“How do you get the support of your leadership to invest this kind of money in something that's kind of new and you don't know for sure if it'll work? And the program isn't even yours? How do you go to leadership and say, hey, we want to fund this system change for this other program, for this other department? How do you finesse that conversation? How do you get that leadership support is a really important step not to be overlooked. My supervisor is the Title V MCH director, and [we] had a lot of conversations about closed-loop referral and things in the past. So, when the Title MCH director heard about the diabetes prevention program pathway that was being utilized, she was able to identify this as an opportunity and connected the Title V CYSHCN Director to the program managers.
You can't invest this kind of money without leadership support. I think of them understanding the value, before we even had a return on investment— how do we show that it might save money or time or improve the referral outcomes? I think all those things are really important, and oftentimes those are things that kind of paralyze people from taking a leap of faith. I do think there was a certain level of risk that we had to sort of jump in with both feet. But we knew from the discovery that it was then possible. So, I think that discovery phase was also really helpful in us getting our leadership on board. … In the current funding landscape, it is becoming more challenging to justify this type of investment. It was really helpful to have the evaluation data to share at our most recent block grant review. It was really exciting and very impactful.”
Unintended Outcomes, Building Trust Between Systems:
[An unintended outcome we had was] re-establishing and building trust between two systems that at least within our state, had experienced significant challenges in believing that the other system was doing what they were supposed to. So, for example, a primary complaint of providers was that ‘I make a referral for a kid that I screened. I have concerns about them, but I don't know what happened. So, I don't really believe that early intervention is doing what they're supposed to do. And I don't know what they do. I don't know what happens to that child. I make the referral, it drops off, I send a fax, it's gone.’
Early intervention would then get a fax without all the information or a family member who's not sure why they were referred, they would lose a child in that complicated process. So, early intervention’s feeling was that the health system is not making appropriate and proper referrals. The one thing that this process reinforces, besides giving a 24-hour immediate status update to the health system, is that it actually connects people to people. It allows for connection, ‘This is your intake person, here's their name, here's their email, here's their phone number.’ At any point, you can contact one another and find out what's going on.
Providers started to realize, ‘hey, I made this referral. I'm actually really worried about this child. I know that this person's been assigned. I'm going to call them; I'm going to email them. And I immediately know how to do this.’ We have also started to include Early Intervention Colorado in the onboarding process with the health system and debunk myths like ‘oh, early intervention doesn't and can't do all the languages.’ Yes they can, and yes they do. And eliminate unnecessary steps. ‘Oh, I need fifteen pieces of paper to refer a child.’ No, you don't. I need these three things to make a referral happen. We also were able to pull early intervention in to work directly with providers, and say ‘hey, we let you know that we called this family three times. They never picked up the phone. Can you call them and help support the success of this referral?’
We built trust between these two systems and developed a partnership that includes shared goals and outcomes. It's been phenomenal.
Last Updated
03/10/2026
Source
American Academy of Pediatrics