Lessons Learned from Year One, Pediatric Medical Unit (PMU) Initiative
May 15, 2007
Background
The Social Security Administration (SSA) awarded a contract to the Association of University Centers on Disabilities (AUCD) to develop Pediatric Medical Units (PMUs) to provide specialized expertise for adjudicators who determine eligibility for childhood disability benefits. The contract is a 5-year effort, pending the availability of federal funding, that will support PMUs at selected member University Centers.
The PMU initiative furthers the agency's goal to help adjudicators make disability decisions as efficiently and as early as possible in the process. The actual disability determination remains the legal responsibility of state adjudicators. A PMU brings together a team of interdisciplinary clinicians with specialized developmental and assessment expertise to provide important support for state disability adjudicators by offering:
- Individual case assistance. The PMU clinicians perform record reviews to interpret medical and other records, explain inconsistencies, and recommend sources of evidence that can clarify the basis for decisions. They synthesize all available information, compare child's functional ability with same-age peers, and explain the degree of functional limitations.
- Quick consultations. The PMU clinicians respond to questions about case-specific or generic pediatric or disability issues.
- Interdisciplinary assessments. The PMU clinicians conduct specifically requested developmental and functional assessments when face-to-face evaluations will help determine potential eligibility.
The first three PMUs began receiving case referrals from state Disability Determination Service (DDS) offices in fall 2006. They include:
- Center for Disabilities and Development, Iowa's University Center for Excellence on Disabilities, University of Iowa
- Boling Center for Developmental Disabilities, University of Tennessee Health Science Center
- University of Washington LEND Program, Center on Human Development and Disability, University of Washington
The volume of referrals has varied by location. Participating DDS offices report that certain factors affect their ability to refer cases on a regular basis. These factors include, but are not limited to: availability of examiner staff to identify claims where outside medical expertise would be helpful; availability of administrative staff to transfer cases to the PMU; DDS staff comfort level with SSA's new technology to transfer cases electronically; volume of pending childhood claims; and availability of medical experts from DDS own staff or longtime pre-existing relationships with medical providers.
A fourth location - the Institute for Community Inclusion/UCEDD and Children's Hospital, University of Massachusetts in Boston - awaits final approval by SSA to help with childhood cases on appeal and hopes to begin work during summer 2007.
Four new PMU locations hope to begin to receive referrals in late spring and early summer 2007:
- JFK Partners, University of Colorado Health Sciences Center, Denver CO
- Mailman Center for Child Development, University of Miami Miller School of Medicine, Miami, FL
- Institute on Disability and Human Development at the University of Illinois UCE, Chicago, IL
- Nisonger Center, Ohio State University, Columbus, OH
Lessons Learned during the PMU Initiative's First Year
Orientation
Providing a face-to-face gathering for participants to understand the PMU initiative's goals is extremely beneficial. At a joint orientation, PMU and DDS representatives can learn about the initiative, its background and objectives. It also provides the opportunity for participants to meet each other, learn more about each other's expertise, begin to develop personal connections, and arrange the most convenient methods to communicate and coordinate case referrals.
Shared goals
The PMU is most successful when all participants feel that they have something to gain from the collaboration. The most satisfying arrangements occur when adjudicators believe that the PMU expertise can help them achieve case production goals and when PMU clinicians feel that their expertise can expedite high quality initial decisions.
DDS Administrators
A significant factor to ensure success is having the state agency Administrator actively involved. When an Administrator has a strong understanding of the initiative's goals, he/she can assign individuals who have the appropriate skills and experience and this helps facilitate successful and timely implementation.
Site selection
Working together, AUCD and SSA must select appropriate locations. From AUCD's perspective, this requires identifying Centers that have the requisite capacity to develop the collaboration. From SSA's perspective, this requires working with appropriate agency components to identify locations where adjudicators can best utilize the assistance of outside medical experts. Examples of factors to consider include leadership interest, availability of staff and in-house medical experts, and caseloads.
Staff continuity
Relationships flourish when the PMU and state agency can allow staff members to serve as the primary contacts for a long period of time. Providing this continuity creates the opportunity, over time, to establish efficient procedures and strong working relationships.
Building trust
Developing collaborations between a PMU and the state agency and its adjudicators is a process that requires some concerted effort. Although there are written policies and procedures, success is partly determined by the ability of both parties to work together toward mutual goals, learn more about each other's respective expertise and challenges, and problem solve to establish an efficient and effective partnership.
Face-to-face time
Participants benefited greatly from meeting each other to learn more about each other's background, operations and expertise. To help build a working relationship, staff report that it is extremely useful to visit each other at their respective locations. This personal interaction strengthens their understanding of each other and helps build a stronger team spirit. Although geographical proximity is not a pre-requisite for success, some face-to-face interactions are extremely valuable to help establish long-term working relationships. When distances prohibit meetings, it is worthwhile to use videoconferences or web-based technology to create more face-to-face time.
Regular communication
It is essential for PMU and DDS primary contacts to maintain regular, ongoing communication by email and/or telephone. With regular interaction, it is possible to resolve minor issues before they become more significant. Frequent communication also helps to build and support a long-term collaboration.
Clinical experience
Adjudicators report that it is very useful to receive reports from clinicians who regularly assess children with disabilities who can explain both the medical and functional impact of children's impairments. Reviews by specific discipline experts can help identify the existence of previously undetected impairments and describe the extent of resulting functional limitations.
Problem-solving skills
Written Operating Instructions for both the PMU and state agency participants are essential to establish specific policies and procedures. However, sites may find that they may need to modify some procedures to work effectively in their specific location. Although SSA has a history of using outside medical experts for consultative examinations, working with a PMU is a new way to reach a determination. The relationships work best when the primary contacts at each location work and communicate regularly to develop ways to resolve concerns that might arise as cases are referred and reviewed.
Mentoring
Although there are some differences between individual locations, there are many shared assumptions and procedures. As the number of locations expands, it is helpful for more experienced participants to exchange information and insights with the newer sites. We accomplish this now through regular conference calls for the Kansas City Region participants; PMU contacts; and DDS staff. In addition, PMU Principal Investigators and Site Coordinators regularly consult each other about specific issues. AUCD facilitated two Design Meetings for all participants to share ideas and experiences.
Data and feedback
Beyond the monthly conference calls and annual meetings, AUCD has established an on-line electronic database. This will provide important information about case characteristics and other aspects of the referral and review process. The on-line system also provides a way for participating adjudicators to indicate their satisfaction or concerns about their collaboration with PMU clinical experts.
