P1094 - The Developmental-Behavioral Extender - A Force Multiplier Quality Improvement Initiative

Background:
The incidence of Autism Spectrum Disorder (ASD) has been steadily rising with most recent estimates suggesting a prevalence of 1 in 54 children in the United States. There is mounting evidence that early identification and intensive intervention significantly improves outcomes for individuals and families affected by ASD. Despite this data, while services for children with ASD have been expanding, early and accurate identification of young children remains a challenge with the average age of diagnosis remaining above age 4. Diagnosis itself is often a key limiting factor in access to services, with time from suspicion of autism to diagnostic evaluation as high as 18-months in some studies. In the military, the need for prompt access and diagnosis is essential to maintain troop readiness in addition to optimal outcomes. Novel systems of care with approaches to ASD screening, evaluation, and diagnosis are thus required to advance early detection and intervention. We present data from the implementation of an extender healthcare model that combined asynchronous sub-specialist telehealth support with trained primary care providers strategically embedded within clinics possessing limited access to developmental/behavioral services.

Methods:
Two primary care providers were selected to certify as pilot “Developmental-Behavioral Extenders.” They received online and in-person training to administer / interpret the Screening Test for Autism in Toddlers (STAT). The STAT is an empirically derived interactive measure designed to be a second-tier screening for autism in children between 24 and 36 months. It possesses strong psychometric properties when combined with first-tier tools and compared with DSM-IV diagnosis in a clinical validation sample (Sn:0.92 /Sp:0.85 – PPV:0.86/NPV: 0.92). Referral guidelines and a concept of operations were approved by the Regional Developmental Consultant after-which eligible patients were evaluated by extenders then followed up by sub-specialist assessment within 3 months to validate diagnostic impressions.

Results:
From January 2019 to January 2020, 112 patients were evaluated in the Developmental-Behavioral Extender Clinic. The average time from referral to evaluation was 3.9 weeks; a local access improvement of 12.1 weeks. 48 children were given a provisional diagnosis of autism with access to services 15.2 weeks sooner than pre-pilot measures. Diagnostic accuracy when compared with sub-specialty confirmation was 98.1% with the two notable discrepancies being listed as “indeterminate” diagnoses by extenders (i.e., no false positives). The average age of diagnosis was 32.5 months, more than 15 months earlier than the national average. Secondary benefits included a 25% reduction in sub-specialty referrals and estimated cost avoidance of $135,856 during the study period.

Conclusion:
Utilizing strategically placed, properly trained, and well-supported pediatricians through an extender model that leverages telehealth/mentoring has potential to improve access to quality care, mission readiness, and healthcare costs for military families with developmental concerns.