1. Waitlist? What’s All the Fuss About? Improving Diagnostic Evaluation Wait Times for Children with Suspected Autism Performance Improvement Leadership Development Program University of Missouri – Columbia February 19, 2010

2. Members of the Team Executive Sponsor:Janet Farmer, PhD, ABPP Advisors:David Sohl, MHA Carol Nierling, MS, RN Team Members:Kristin Sohl, MD, FAAP Steve Kanne, PhD ABPP Krista Hughes, RN, BSN Judy Hall, MSW Katie Dunne, MS

3. Focus Area Autism Prevalence Rate now 1 in 110 Recognition in Missouri that autism rates are increasing State of Missouri set aside funds to the Thompson Center for early diagnosis, assessment, and treatment of autism Wait time for Thompson Center’s Autism Diagnostic Entry Clinic (ADEC) is too long

4. Aim Statement By April 1, 2010, we aim to decrease the wait time from receipt of paperwork to initial assessment of children ages 2 – 18 with a concern of autism from the current average of six (6) months to an average of two (2) months. We plan to do this by implementing a new evaluation clinic for children whose pre- appointment test scores suggest they are less likely to receive a diagnosis of autism.

5. Relationship to Thompson Center Goals Streamline process for diagnosis, assessment, and treatment of autism Expand capacity for autism clinical services Improve the Center’s interdisciplinary model Increase opportunities for professional training Maintain Center’s financial stability

6. Stakeholders Children and Families of Missouri (and surrounding states) Governor of Missouri (Governor’s Wait List) University of Missouri Health Care MU Thompson Center Thompson Center Foundation School of Medicine School of Health Professions University Physicians

7. Collecting Baseline Data Children seen in the Autism Diagnostic Entry Clinic (ADEC) each month during CY 2009 Calculated the wait time for those children: – From date we received their paperwork – To date of ADEC appt

8. Baseline Data

10. ADEC Flowchart

11. ADEC Flowchart (cont)

13. Factors that Impact ADEC Triage

14. Factors that Impact Triage Process Two Pieces to Triage Issue 1) Call Process – Receiving and routing calls 2) Screening at intake – placing Patient in appropriate clinic

15. Interventions Considered 1. Increase number of children seen in ADEC each day with current staff Barriers – Lack of clinic space – Lack of providers (multi-disciplinary clinic) – Amount of time needed to evaluate each child

16. Interventions Considered 2. Increase number of children seen in ADEC each day by hiring more staff Barriers – Lack of resources – Lack of qualified staff

17. Interventions 3. Improve the triage process of children needing a diagnostic evaluation Goal Improve the triage process by screening out individuals less likely to meet criteria for an autism diagnosis, thereby: – Reducing the number of children waiting for an ADEC evaluation, and – Reducing wait times for that clinic ConsideredChosen

18. Intervention Chosen Implement the use of a screening tool prior to scheduling an appointment The Social Communication Questionnaire (SCQ) is a parent report screening measure for autism spectrum disorders. – 40 Yes/No Questions – Cutoff Score of 15

19. Social Communication Questionnaire (SCQ) Reviewed 86 past SCQ scores collected in ADEC – 32% reviewed scored 12 and below – Only 5% diagnosed with ASD scored a 12, none below Children who scored < 12 – routed to the new “quick look” clinic (SURGE) Children who scored > 12 – routed to ADEC

20. SURGE CLINIC Psychology Clinic – Offers higher level of triage through in person screening interview with parent/caregiver and child – Allows for placement into more appropriate clinic – Support services can be expedited Speech Language Therapy Occupational Therapy Early Childhood Special Education Patient/Family Counseling

21. ADEC/SURGE Flowchart

22. SURGE Clinic Results ADEC436% referred back into ADEC DEVO0 AMC0 Neuro436% referred for Neuropsychology evaluation CAT218% referred for Clinical Assessment Team evaluation Other19% referred for other (e.g., counseling) Total1164% of patients who went through SURGE clinic were screened out of ADEC

23. Outcome Indicator Wait time for Autism Diagnostic Entry Clinic (ADEC) is reduced Appears that wait time was reduced Note – pilot project with small “n”: – Brief time span and few patients – Patients already had a scheduled ADEC appointment

24. Process Indicator All children with SCQ scores 12 or less are appropriately triaged to the SURGE Clinic

25. Anticipated Return on Investment Decrease wait time for children who need an diagnostic evaluation Save time/money Improve patient/family satisfaction

26. Lessons Learned Flowchart/fishbone diagrams – Show best place to target intervention – Show opportunities for future quality improvement projects Difficulties in changing the process – Provide data to support need for change – Involve many players to facilitate roll-out

27. Summary Overall, the SURGE clinic seems to be effective, but we need more data

28. Questions?