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 – ColumbiaFebruary 19, 2010

Members of the Team

Executive Sponsor: Janet Farmer, PhD, ABPP

Advisors: David Sohl, MHA Carol Nierling, MS, RN

Team Members: Kristin Sohl, MD, FAAPSteve Kanne, PhD ABPPKrista Hughes, RN, BSNJudy Hall, MSWKatie Dunne, MS

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

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.

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

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

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

Baseline Data

Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 090

5

10

15

20

25

1716

14

20

16

14

20

1716

21

14

13

Number of Children Seen in ADEC CY 2009

# Kids Seen in ADEC # Slots Available

Baseline Data

Jan 09 Feb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 090.00

20.00

40.00

60.00

80.00

100.00

120.00

140.00

160.00

50.8865.56 65.29

81.95

100.3195.50

128.40122.76

136.19 127.05 121.79124.62

Avg Wait Time for ADEC (in days)CY 2009

ADEC Flowchart

ADEC Flowchart (cont)

ADEC Flowchart (cont)

Factors that Impact ADEC

Triage

Factors that Impact Triage Process

Two Pieces to Triage Issue1) Call Process – Receiving androuting calls2) Screening at intake – placingPatient in appropriate clinic

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

Interventions Considered

2. Increase number of children seen in ADEC each day by hiring more staff

Barriers – Lack of resources– Lack of qualified staff

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

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

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

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

ADEC/SURGE Flowchart

SURGE Clinic ResultsADEC 4 36% referred back into ADECDEVO 0AMC 0Neuro 4 36% referred for Neuropsychology

evaluationCAT 2 18% referred for Clinical Assessment Team

evaluationOther 1 9% referred for other (e.g., counseling)Total 11 64% of patients who went through SURGE

clinic were screened out of ADEC

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

Process Indicator

• All children with SCQ scores 12 or less are appropriately triaged to the SURGE Clinic

Anticipated Return on Investment

• Decrease wait time for children who need an diagnostic evaluation

• Save time/money• Improve patient/family satisfaction

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

Summary

• Overall, the SURGE clinic seems to be effective, but we need more data

Questions?