Primary Care Medical Home Designed for Young Adults with Autism Reduces Emergency Department Utilization

Background: Young adults with autism spectrum disorder (ASD) are at elevated risk for frequent utilization of the emergency department (ED) due to psychiatric conditions, medical comorbidities, and poor continuity of primary care. The Center for Autism Services and Transition (CAST) at The Ohio State University Wexner Medical Center (OSUWMC) was co-designed with adults with ASD, caregivers, and providers to reduce barriers to primary care access and develop strategies for improving patient self-management of healthcare conditions. Figure 1 provides a schematic representation of the CAST program. The overall goal of this program is to help adults with ASD build the skills they need to ultimately be able to obtain medical care anywhere from providers beyond CAST.

Objectives: The objective of this study was to examine the association between number of years in the CAST program and ED utilization.

Methods: A retrospective longitudinal design was used to analyze administrative records from CAST patients with at least one ED visit that occurred between the years 2015-2018 (n=61 patients). A majority of patients were male (79%), white (80%), and had a co-occurring intellectual disability (66%). The median age of patients in 2015 was 21 years (interquartile range [IQR]: 17, 25). During the study period, these CAST patients visited any OSUWMC ED a total of 311 times with a median number of 3 visits per patient (IQR: 2, 7). Repeated measures negative binomial regression was used to examine the association between number of years in the CAST program and number of ED visits per year for: 1) any reason, and 2) non-emergent conditions. Covariates included sex, race, age, co-occurring intellectual disability, and the number of OSUWMC ED visits in the year prior to CAST program enrollment.

Results: Enrollment in the CAST program for two (IRR=0.7 95% CI=0.5-0.9), three (IRR=0.6, 95% CI=0.4-0.9), or four years (IRR=0.4, 95% CI=0.2-0.8) was associated with a significantly lower rate of ED visits, relative to the first year of enrollment. Additionally, enrollment in the CAST program for two (IRR=0.5, 95% CI=0.3-0.9) or three (IRR=0.3, 95% CI=0.1-0.7) years was significantly associated with fewer ED visits for non-emergent conditions, relative to the first year of enrollment. Four years of enrollment was also associated with a decrease in non-emergent ED visits (IRR=0.2), although this finding did not reach statistical significance (95% CI=0.1-1.0). Figure 2 provides a graphical demonstration of how the risk for any ED visit and non-emergent ED visits decreases as years in the CAST program increases.

Conclusions: Two years of enrollment in the CAST program was associated with 30% reduction in the number of annual ED visits and a 50% reduction in risk of visits for non-emergent conditions. Additionally, program participation continued to reduce ED utilization after three and four years of enrollment. These findings suggest that the CAST program is effective at improving access to quality primary care, thereby reducing over-reliance on ED services. Further work is needed to examine the impact of this program on other aspects of healthcare utilization.