East Bay Community Action Program Attention-Deficit / Hyperactivity Disorder (ADHD) Project Story Board: East Bay Community Action Program PLAN STUDY Aim Statement: To improve care coordination and integration of behavioral health services amongst identified children with ADHD by 50% by 3/31/17. Outcomes / Results Percentage of Active Patients with ADHD, aged 3-17 years, who were Referred for Pediatric Behavioral Health Services Annotations: We removed 36 patients from the patient list after review of the population: 12 patients were not active primary care patients (dentist only or not seen in the past 2 years). 10 patients were already being actively managed by behavioral health An additional 14 were deemed stable by the providers and not applicable to this pilot project Problem: According to Truven’s Rl Behavioral Health Project Final Report on 9/15/15: 13.7% of youth aged 4-17 years have ever had attention-deficit/hyperactivity 11.3% of adolescents aged 12-17 years had at least one major depressive episode in the past year EBCAP would like to continue to transform their practice and align with PCMH Kids to identify a population of children with ADHD and make the appropriate BH services available to these patients. Findings: Through this improvement project, EBCAP’s findings are: Successfully identify a list of patients who are impactable and may benefit from pediatric behavioral health specialty interventions. Increase appropriate patient referrals to behavioral health services both internally and externally. Track patient referrals in EMR through electronic orders began in Nov2016. PDSA Goal: By 3/31/17, EBCAP Family Health Center will increase our percentage of BH by 50%. DO ACT Key Measures and Methods: Quantitative: The percentage of active patients with diagnosis of ADHD aged 3-17 years seen at the health center in the past 12 months and referred for follow-up pediatric behavioral health services (internal or external) or other ADHD related community resource as determined through referral tracking reports generated from EBCAP’s EMR, NextGen. Qualitative: NCM findings through interactions with patients Next Steps: Through this PDSA, EBCAP has successfully been able to identify appropriate patients who may benefit from additional behavioral health services. We will continue to generate this report and review the clinical team at least monthly. In addition, EBCAP has expanded its behavioral health services by adding a nurse specialist and merging with East Bay center. We have found that internal referrals allows for complete integration of care and will continue to be monitored on a regular basis. We identified that the internal BH referral process needs to be refined. In March 2017, we have added a new resource in the EMR, so that all referrals to BH will be entered in an electronic order to this resource. In addition, patients are required to outreach and call to initiate these services. EBCAP Family Health Center will strive to initiate in the office with the patient to assist the integrated, coordinated care.