In terms of ethnic/racial distribution, the sample overall reflected the distribution of minority individuals living in Tennessee. This consisted almost exclusively of African-American children and they were clustered to a greater extent in the West and urban area of Nashville. They were over represented in the diagnoses of developmental delay and prematurity, both of which are also influenced by economic disadvantage status.
The remainder of the discussion section will be organized based on the seven proposed questions. In determining the services that children with disabilities receive, it is also useful to determine what evaluations the children received. The most common evaluation was speech and language followed by education. This is not surprising since speech and language delays were the most common diagnosis followed by developmental delays in other domains as the next most common. The prominence of speech and language problems is also reflected in the services received where again speech and language therapy was the most common service. Surprisingly PT services were the second most common with early intervention including home and center based only third. A major intent of the program has been to provide early interventions services. From our data, it suggests that the most commonly identified disability or delay in children birth to three years of age is in speech and language, and that the services for these children are specific speech and language interventions without other early intervention components. Based on the data presented in Table Eleven, these children most commonly receive just the one service. We were not able to identify sequences of services because the charts were not clear as to exactly when each service began.
The greatest allocation by TEIS was for speech and language services since this was the most common service while the most expensive service was nursing. Nursing was expensive because the children who required the service, required an extensive number of hours for each child, but the overall cost to the program was low because the number of children were very few. Center based earlier intervention services were more expensive than home based early intervention services, because they were also more intensive, Children with congenital defects required a greater number and more intense services because they frequently had multiple problems that required intervention from a number of disciplines. While this was true for some of the children who had been premature, there were a large number of premature infants who had mild impairments or were at risk.
Because a large number of charts did not have any comments about the progress the children made towards the goals as outlined in their IFSP (over half of lhe cases had no indications), any analysis has to be interpreted with caution. Notation about progress was most frequently made for infants with congenital defects and least frequently made for those with prematurity. While the rate of indication of progress was lowest for those with prematurity, this was still at 40% rate of those reporting.
In terms of who bears the cost of treatment, the families mostly used more than one source. TEIS was the most used source. A common combined pattern was TEIS, Medicaid and Other sources. We were not able to examine individual cases overtime, but between the two years of the analysis, there was a shift to more private insurance payers away from TEIS and CSS resources.
It is difficult to answer the question about individuals with different means of paying for those services differing in the types and amounts of services they receive because the results are confounded by the diagnosis of the child. Those with congenital anomalies received more services and required OT, PT and Nursing that are more likely to be reimbursed by the health care system (Medicaid and Private Insurance).
The reimbursement patterns did not change with regard to Medicaid between the first year (preTennCare) and the second year (conversion to TennCare). This slightly increased under TennCare. This may reflect no change in reimbursements or may be due to the fact that TenriCare was in its beginning phase and Managed Care Organizations initially maintained the Medicaid policies.