ASD Diagnosis within the Medical Home: Feasibility, Sustainability, and Satisfaction

Background:
Early accurate diagnosis of Autism Spectrum Disorder (ASD) currently represents a challenging public health and clinical practice issue. Despite the wide-scale availability of effective screening tools for young children, waits for diagnostic assessment are still often quite lengthy and impede access of appropriate early intervention services. Embedded processes for effective triage and diagnosis of children at-risk for ASD within the medical home may be a viable mechanism for reducing age of detection and initiation of services.

Objectives:
We examined (1) the feasibility and value of incorporating ASD-specific assessment and targeted treatment services in primary care settings, (2) analysis of sustainability and financial viability of services, and (3) physician satisfaction with services. We hypothesized that embedding a psychologist with specific skills and training related to ASD diagnostic consultation could help accurately and rapidly identify many cases of ASD and potentially represent a more realistic model for advancing ASD identification.

Methods:
We developed explicit ASD diagnostic consultation and support clinics embedded across two medical center affiliated pediatric primary care programs. A psychologist was physically embedded in the clinic one day per week and available solely for providing follow-up for ASD-related concerns (e.g., failed screenings, diagnostic referrals, behavioral consultation). Data about referral types, show rates, and latency to consultation and diagnosis were used to assess feasibility and impact. Specific data regarding time, cost, and resources associated with implementation were collected via electronic medical records. We also surveyed medical providers regarding the benefits and challenges of the embedded service. They were asked their level of agreement with statements about whether integration of behavioral-health services improves the quality/continuity of healthcare, reduces added healthcare costs, increases show rates, and increases their own ability to identify/manage behavioral health concerns.

Results:
The embedded psychologist saw over 400 children and adolescents over 24 months, 60% of the patients were referred due to concerns for ASD. Of those patients, 42% received formal diagnoses of ASD. It was possible to make a diagnosis within the initial consult session for 60% of the children; further testing was required for the remaining children. The latency to evaluation and diagnosis for referred children was less than two months, compared with a minimum of 7-8 months for other specialty clinic assessments. Similarly, the median age at diagnosis (32 months) was considerably lower than the national average of approximately 50 months. Provider feedback indicated significant improvements related to quality and continuity of care and decreased waits for service. Updated clinical data and data regarding financial viability of the program over time will be provided in detail.

Conclusions:
This study extends support for the value of embedding behavioral health services for children with ASD within pediatric primary care settings. Such models of care may reduce waits, age of diagnosis, and reduce other service barriers encountered by individuals with ASD and their families seeking services through referrals to traditional tertiary care facilities.