An integrated care model to facilitate best practices for management of ADHD in primary care

Introduction: Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurobehavioral childhood disorder and presents major challenges to the health care system (1). The American Academy of Pediatrics (AAP) recommends behavior therapy for children with ADHD (2), but less than half have received any behavioral services in the past 12 months compared to three-fourths who have taken medication in the past week (2). The disjointed health care system constrains access to behavior health services and tasks primary care pediatricians (PCPs) with identifying and treating ADHD (3), resulting in poorer long-term patient outcomes and greater health care costs (4). Practice change: An ADHD Task Force was developed improve ADHD care within Michigan Medicine’s pediatric primary care clinics using an Integrated Behavioral Health (IBH) model. IBH psychologists work collaboratively with PCPs by conducting ADHD evaluations, delivering behavior therapy, and providing consultative support. The Task Force has also developed electronic medical record (EMR) tools to more efficiently measure symptoms, improve communication between providers and allow PCPs to deliver basic behavior therapy interventions. These will be introduced to all providers via training workshops. Aim and theory of change: The overarching purpose of the initiative is to ensure best practices for patients with ADHD by improving access to evidence-based behavioral health services. Research indicates patients are significantly more likely to follow through with PCP referrals to behavioral health providers within the same integrated system than those off-site. It is hypothesized patient outcomes will be improved the earlier they receive integrated services. Targeted population and stakeholders: Michigan Medicine services over 50,000 patients per year within its pediatric primary care clinics, 11% of whom are diagnosed with ADHD. At present, 5 of 9 clinics have IBH services. Timeline: The initiative is grant-funded from January 2018 to 2020. All workshops will be delivered October 2018 through February 2019. Highlights: Data below include all primary care patients aged 4-17 diagnosed with ADHD since the start of the grant period and are compared based on whether the patient received integrated care during diagnostic evaluation (IBH= integrated; NON= non-integrated). Evaluation included objective measures from a parent and teacher: IBH= 85%; NON= 29%. Behavior therapy by date of diagnosis: IBH= 100%; NON= 30%. Receiving behavior therapy at 3-month follow-up from date of diagnosis: IBH= 73%; NON= 39%. ADHD medication prescribed within 3 months of diagnosis: IBH= 49%; NON= 65%. Sustainability: Both psychologists and PCPs bill independently for services. Institutional leadership at Michigan Medicine has endorsed financial support for expansion of the IBH program to its four non-integrated clinics. Transferability: The essential components of the IBH model and training workshops can be implemented in most primary care settings. The EMR tools can be modified to other formats. Conclusions and Discussions: An integrated approach to ADHD management will be used to try to improve access to high-quality assessment and treatment for patients and reduce reliance on medication. Outcomes are tracked via the EMR. Lessons learned: Feedback from providers and patients will be used to modify trainings at subsequent clinics.