Increasing Access to Autism Spectrum Disorder Diagnostic Consultation in Rural and Underserved Communities: Streamlined Evaluation within Primary Care

Background: With the increasing prevalence of autism spectrum disorder (ASD) and wide-spread delays for diagnostic evaluations and initiation of services, there is a growing need for novel systems of triage and care for children with ASD and their families. To combat growing disparities within rural and underserved communities, integration of behavioral-health services within primary care settings is often the preferred service model. In prior work, we embedded ASD consultation and support clinics within our medical center’s primary care clinics. This change resulted in dramatically reduced waits for diagnostic consultation and follow-up. Many young children with ASD (and those without) were identified using a streamlined diagnostic model involving diagnostic interview, standard ASD rating scales, and the Screening Tool for Autism in Toddlers (STAT). These findings supported preliminary feasibility, accuracy, and clinical utility of this embedded streamlined assessment model that resulted in accurate diagnostic decision making, high levels of family/provider satisfaction, increased show rates, dramatic reductions in wait times, and reductions in referrals to an overtaxed tertiary diagnostic center.

Objectives: The present study investigates the impact of generalizing this model to a larger network of integrated primary care clinics located in the eastern region of our state with a largely rural and underserved catchment. This study extends previous work by providing data pre/post implementation of the streamlined model across a range of clinics, as opposed to comparing wait time reductions to local norms. This study also allowed us to study the impact of the embedded model when implemented by multiple clinicians across multiple primary care clinics that provide healthcare to rural and underserved communities.

Methods: Eighty children between the ages of 19 and 47 months old were seen across five different clinics. The participants were divided into four groups based on their status as primary care patients and whether they received an evaluation before or after implementation of the streamlined model. Data were collected via chart review from the electronic health record.

Results: Implementation of streamlined model resulted in a significant decrease in latency to diagnostic conclusion from a mean of 144.7 days to 49.9 days. Children were likely to experience a greater reduction in wait times if they were a primary care patient (mean reduction of 120.5 days) versus a non-primary care patient (mean reduction of 69.1 days). Lastly, data suggest that on average, diagnostic decisions were provided 1 month earlier in age post-implementation of streamlined model.

Conclusions: Results show significant reduction in wait times for ASD diagnostic decisions across both primary care and non-primary care patients. With implementation of the streamlined model, families had to wait an average of 95 days less than families not having access to the streamlined model. By reducing waits and identifying concerns more efficiently, we may increase the ability of families to access early intervention and support services as well as prepare them for the school-age transition at 3 years.