Playing by the Rules: Integrated Care'sImpact on Quality of ADHD Management

Tawnya Meadows, Ph.D., BCBA-DShelley J. Hosterman, Ph.D

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session F1bOctober 17th, 2014

Faculty Disclosure

• We have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify simple data collection procedures to measure outcomes on standards of care outcomes.

• Compare ADHD outcomes in three domains between Integrated versus comparison sites.

• Identify procedures implemented to impact standards of care adherence.

• Discuss other pediatric standards of care in which behavioral health care can impact patient experience and outcomes.

Bibliography / Reference

• American Academy of Pediatrics [AAP], 2000, 2001, 2011

• Epstein, J. N., Langberg, J. M., Lichtenstein, P., Kolb, R., & Stark, L. (2010). Sustained Improvement in Pediatricians' ADHD Practice Behaviors in the Context of a Community-Based Quality Improvement Initiative. Children’s Health Care. Association for the Care of Children's Health, 39: 296-311.

• Sheldrick, R. C., Leslie, L. K., Rodday, A. M., Parsons, S. K., Saunders, T. S., & Wong, J. B. (2012). Variations in Physician Attitudes Regarding ADHD and Their Association With Prescribing Practices. Journal of Attention Disorder. DOI: 10.1177/1087054712461689.

• Wolraich, M. L. (2012). The new attention deficit hyperactivity disorder clinical practice guidelines published by the American Academy of Pediatrics. Journal of developmental and behavioral pediatrics, 33(1):76-7.

• Fothergill, K.E., Gadomski, A., Solomon, B.S., Olson, A.L., Gaffney, C.A., dosReis, S., & Wissow, L.S. (2013). Assessing the Impact of a Web-Based Comprehensive Somatic and Mental Health Screening Tool in Pediatric Primary Care. Academic Pediatrics, 13 (4), 340–347.

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Introduction

Assessment and treatment of ADHD

Greatly consumes PCP’s clinical attention and resources• 15% of pediatric PC practice consists of BX disorders

(ADHD most frequent). • 75% of ADHD patients are seen in PC, but only 2% see BH

specialists• One-third to half of pediatric BH referrals are for ADHD• At 3-10% of school-aged children, ADHD is the most

common childhood BH diagnosis• PCPs complete 1-2 new ADHD evaluations/month & most

spend 15-45 minutes at at least 2 visits to reach diagnosis5

AAP Guidelines

• Initiate evaluation when a child presents with ADHD-like symptoms

• Document that child meets DSM-IV criteria• Obtain evidence from parents regarding core symptoms

across settings, age of onset, duration of symptoms, and degree of impairment

• Retrieve information from teachers or school personnel• Assess for coexisting conditions

| 8

Multiple Barriers

• Less than 25% of physicians are familiar with & implement AAP guidelines in their practice

• Lack of training

• Limited time

• Difficult to coordinate information with school/teachers

  | 9

Possible Solution: PCBH

Behavioral health specialists located within a pediatrician’s office can assist with meeting practice guidelines. • High customer satisfaction• Low dropout rates• Increased cost effectiveness• Support adherence to standards of care• Assist in monitoring of treatment & providing behavioral

support

| 10

Methods

Methods:

Physician surveys:• 6-17 IPC & 24-54 control PCPs• Reported on use of screening tools & comfort in

diagnosing ADHD

Chart Review: • Key variables in PCP & IPC BH provider

documentation within EHR• Onset, diagnosis, medication, use of rating scales,

family hx, comprehensive physical & neurological exam, use of BH services

| 12

Intervention

• REACH training

• Psychologists on site

• Increased availability of rating forms

• Change of ADHD template

| 13

Results

Survey Results: Screening Instrument Use

ADHD0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Pre-IPCIPC 1 yearControl 1 year

PCPs in IPC clinics report significantly higher use of BH screening instruments compared to PCPs in control clinics (p< .01)

Survey Results: PCP Comfort Diagnosing

IPC PCPs report increased comfort in dx (*p< .01)

ADHD0

1

2

3

4

5

6

7

8

9

10

Pre-IPCIPC 1 yearControl 1 year

| 16

Survey Results: Comfort in Managing

IPC PCPs reported increased comfort in managing ADHD at year one (p< .01)

ADHD0

1

2

3

4

5

6

7

8

9

Pre-IPCIPC 1 yearControl 1 year

| 17

Survey Results: PCP Knowledge

IPC PCPs reported increased knowledge of common psychotropic medications and treatment post integration (p< .01)

ADHD0

1

2

3

4

5

6

7

8

9

Pre-IPCIPC 1 yearControl 1 year

| 18

Chart Review: Demographics

| 19

PCBH Sites Non PCBH Sites

Pre Post Pre Post

# Charts Reviewed

% Diagnosed with ADHD

% Female

% on Stimulant Medication

Chart Review: Assessment Adherence

| 20

Paren

t rat

ing s

cales

Teach

er R

ating

Sca

les

DSM c

riter

ia

Ons

et

Acros

s Set

tings

Altern

ative

Con

dition

s0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

PCBH prePCBH postControl preControl post

Chart Review: PCP Treatment Adherence

| 21

Stimulant 1st choice

Monitor side effects Weight check 1 month follow up School follow up0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%PCBH prePCBH postControl preControl post

|22

Conclusions/Implications

Implications

• All providers were not equal in documentation of standards of care.

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!