First Five Sonoma County

Why Screen and Refer for Developmental Delays?

Unidentified developmental delays can interfere with early learning and later academic success as well as diagnoses of underlying medical problems. Children from families below the federal poverty level have higher rates of developmental disabilities, in part due to greater exposure to poverty, family violence, parental substance abuse or other early trauma.  In spite of the importance of screening for developmental disabilities and disabling behavioral problems, less than half of children with these issues are identified before the age of five.

Over 80% of Sonoma County health center patients under 6 years of age are from households with incomes below the federal poverty level. By improving screening at well child visits and effectively referring children to early intervention services, low-income children will have an opportunity to reach their full potential


What We Do

The goal of this partnership between First 5 Sonoma County and Aliados Health is to improve systems for developmental screening and appropriate referral to early intervention services for children 0-5 years of age served by health centers in Sonoma County.

Over the three year project, Aliados Health worked in collaboration with local community health centers, First 5 Sonoma County, local early intervention service agencies, Sonoma County Office of Education (SCOE) and Sonoma County Special Education Local Plan Area (SELPA), Early Learning Institute, local school districts to develop and implement a sustainable system that support effective developmental screening and referral.

First 5 funding supported this collaboration, as well as health center pilot projects for implementation of developmental screening using evidence-based tools and successful linkages for assessment and treatment. Community health center pilots focused on achieving improvements in the rate of developmental screenings administered at periodic well-child visits, improvign referral processes to address positive screens and connecting families to much needed community resources.

The next steps of this work include Aliados Health staff participation in the establishment of a Help Me Grow System in Sonoma County which will focus on family and community outreach, child health provider outreach, data collection and analysis and establishing a centralized access point for referrals.

Clinical Guidelines

  • Ages and Stages Questionnaire 3
  • Ages and Stages Questionnaire Social-Emotional

For access to these tools, please contact Michelle Rosaschi.


Aliados Health Training Calendar

Who We Served

Health Center patients ages 0-5 in Sonoma County and their families.


This project was funded by First 5 Sonoma County.

Project Timeline

July 2014 – June 2017


Process Measures Outcome Measures
# of well-child visits for children ages 0-5 % children 0-5 years that receive recommended well-child visits
# of screenings completed % children 0-5 years administered the ASQ3 at periodic well-child visits
# of referrals to Early Learning Institute (ages 0-3) % of children 0-3 with positive screens receiving early intervention services
# of referrals to neighborhood school districts (ages 3-5)  % of children 3-5 with positive screens receiving early intervention services
# of referrals with evaluation/treatment reports sent back to health center % referrals for evaluation and treatment where report is received by health center
# of providers and staff trained


Accomplishments include:

  • Selection of the Ages and Stages Questionnaire (ASQ-3) as our standard evidence-based screening tool to identify developmental delays. ASQ-3 and ASQ-Social/Emotional screening tools and activity sheets (English and Spanish) were purchased by Aliados Health and made available to all member health centers.
  • Developed and tested a new streamlined referral process in Sonoma County for children under age 3 (refer to Early Learning Institute) and children ages 3 and older (refer to local school district).
  • In collaboration with community partners such as SCOE and SELPA, developed a universal referral/consent form for all Sonoma County schools.
  • Three pilot projects to develop health center workflows for developmental screenings and test the new referral pathways for children ages 0 through 5; Petaluma Health Center/Rohnert Park Health Center, Santa Rosa Community Health, and Sonoma County Indian Health Project.
  • Creation of a Developmental Screening Tool Kit to support our community in identifying developmental delays and linking to early interventions to ensure that all children reach their full potential. Tool Kit includes information on developmental surveillance, screenings and referrals and the new referral process for Sonoma County.

Lessons Learned:

  • Extracting data on developmental screenings and referrals is challenging for health centers due to how data are captured in unstructured fields in electronic health records.
  • Need buy-in and ongoing support/training for health center care teams including providers, medical assistants and referral coordinators.
  • Provider champion with capacity to lead the program is key.
  • Engage informatics team to implement clinical decision support tools.


Health Centers:

  • Petaluma Health Center
  • Santa Rosa Community Health – Southwest
  • Sonoma County Indian Health Project

Strategic Partners:

  • First 5 Sonoma County
  • Early Learning Institute (ELI)
  • North Bay Regional Centers (NBRC)
  • Sonoma County Office of Education (SCOE)
  • Special Education Local Plan Area (SELPA)
  • Partnership HealthPlan of California
  • Marin Community Clinics

Evaluation Assistance:

  • First 5 Sonoma County


For more information, please contact Michelle Rosaschi.


  • HRSA Health Center Controlled Network Grant
  • Partnership HealthPlan QIP
  • Aliados Health Child Health Work Group


Success Story

“MH is a 3-year old male who came to our health center several months ago for a well child exam, his first encounter with us. His mother expressed no concerns about his development, except that he was “shy with people he doesn’t know.” Because he was between 25 and 30 months of age we did a routine developmental screening. His mother easily completed the tablet-based ASQ-3 and was surprised by the results: MH had global developmental delays affecting three domains: communication, fine motor and personal-social. The MCHAT-R autism screen was normal. The child was referred to ELI through our referrals coordinator and is now completing his evaluation there.

This is a “screening success story,” as the parent was unaware that her child was delayed, and had no developmental concerns about her “shy” child. In addition, my assessment without the ASQ-3 would have been limited, as the child would not engage with me. Without the routine screening MH might have slipped through to school entry without getting the help that he needed.”

– Dr. Mark Sloan, Petaluma Health Center