Autism Spectrum Disorders Centers of Excellence July 19, 2017
Presenters Karrie Steving serves as Children s System of Care Administrator for Mercy Maricopa Integrated Care (Mercy Maricopa), the Regional Behavioral Health Authority in Maricopa County. Dr. Ramiro Guillen serves as Chief Medical Officer for Southwest Behavioral and Health Services. Dr. Bryan Davey serves as Chief Executive Officer (CEO) for Touchstone Health Services in Phoenix, Arizona. Lindsey Zieder serves as Children s System of Care Special Projects Lead for Mercy Maricopa Integrated Care (Mercy Maricopa), the Regional Behavioral Health Authority in Maricopa County.
Session Objectives Objective 1: Participants will be able to outline the evidenced based practices used to treat and improve whole-health outcomes for members with Autism Spectrum Disorder. Objective 2: Participants will be able to outline multi-systemic approaches for promoting coordination of care and consistency for youth/adults and families, while keeping the member and family at the center of the team. Objective 3: Participants will be able to discuss mechanisms for engaging families, multi-system/inter-disciplinary service providers, including the Arizona Department of Education to provide integrated physical and behavioral health services. Mercy Care Plan l Mercy Maricopa 3
Identified Need Enhance the whole-health outcomes for the Autism Spectrum Disorder population within our community. Efficiency and effectiveness of managing the coordination of services across systems, which include: - Diagnostic screening - Evidenced based practices - Collaborative with the Division of Developmental Disabilities, Primary Care and the Arizona Department of Education. Promote stability and permanency for youth and families - Incorporating comprehensive assessments - Early childhood screening tools - Oversight of developmental milestones and functional limitations 4
National Data Autism Spectrum Disorder (ASD) is a biologically based neurodevelopmental disorder. It is defined as delayed social communication skills, social interactions, and restricted, repetitive behaviors (RRB). Prevalence 1 in 68 (CDC, 2014). Early Intervention can considerably improve long-term development and social behaviors. 5x ASD is almost five times more common among males versus females. Autism is one of the fastest growing developmental disorders in the United States. American Psychiatric Association. Autism spectrum disorder. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p. 50. Christensen DL, Baio J, Van Naarden Braun K, et al. Prevalence and Characteristics of Autism Spectrum Disorder Among Children Aged 8 years Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2012. MMWE Surveill Summ 2016; 65:1 Mercy Care Plan l Mercy Maricopa 5
National Data About 1 in 6 Children have developmental disabilities. ASD is estimated to affect more than 3 million individuals in the United States. Variation linked to socio-economic status and culture. Approximately 50,000 individuals with autism spectrum disorder (ASD) turn 18 each year in the United States. Staggering rates on unemployment, lack of vocational training and/or college. 6
National Data CDC surveys (NHIS & NSCH) 7
National Practices Core Components As described by the Division of Adolescent and School Health of the Centers for Disease Control and Prevention, best practices for members with ASD include: (1) Early intervention services: birth to 3 years of age (2) Behavior and communication approaches (3) Relationship-based approaches (4) Dietary approaches (5) Medication (6) Complimentary and alternative medicine Mercy Care Plan l Mercy Maricopa 8
Response to the Community Need Medical and Behavioral Integration Key Elements Evidence-based Practice Comprehensive Assessments Autism Spectrum Disorder Center of Excellence Community Enrichment Continuity of Care Serve as the hub Drive holistic outcomes Advanced coordination of care Educate the community Specialized services Family and member advocacy Multi-system Involvement 9
Request for Information November 2, 2016: Mercy Maricopa Integrated Care and Mercy Care Plan issued a Request for Information (RFI) December 16, 2016: 9 responses were received Multi-disciplinary team came together to design the Autism Disorder Spectrum Centers of Excellence Model, in collaboration with the Division of Developmental Disabilities (DDD) Collaborative Efforts Children s System of Care Integration Cultural Competency Adult System of Care DDD Liaison Office of Individual and Family Affairs Integration Officer Physical Health Medical Director DDD Liaison Utilization Management DDD General Mental Health/Substance Abuse Representative Physical Health Manager 10
Autism Spectrum Disorder Centers of Excellence Touchstone Health Services Southwest Behavioral Health Services Mercy Care Plan l Mercy Maricopa 11
Southwest Behavioral & Health Services 12
Prevalence and early signs 13
Features of Autism 14
DSM Criteria for Autism 15
Psychopathology associated with ASD in psychiatrically referred populations J O S H I E T A L., 2 0 1 0, 2 0 1 3 16
Anxiety disorders in psychiatrically referred adults with ASD J O S H I E T A L., 2 0 1 3 17
Substance use disorders in psychiatrically referred adults with ASD J O S H I E T A L., 2 0 1 3 18
Comorbidity associated with ASD A U T I S M & D E V E L O P M E N T A L D I S A B I L I T I E S M O N I T O R I N G N E T W O R K S U R V E I L L A N C E Y E A R 2 0 0 2 ; L E V Y E T A L., 2010. 19
Targeting psychopharmacologic treatment Sleep Disruption ADHD Depression Anxiety Hyperactivity Inattention Impulsivity Social Communication Deficits Repetitive Behaviors Language Impairment Aggression Self- Injurious Behavior Tantrums M C D O U G L E E T A L., 2 0 1 6 20
Selected ASD Level 1 and Level 2 screening tools 21
ASD Level 2 interactive screening tests & other useful tools R I T A - T : R A P I D I N T E R A C T I V E S C R E E N I N G T E S T I N T O D D L E R S ; S T A T : S C R E E N I N G T O O L F O R A U T I S M I N T O D D L E R S A N D Y O U N G C H I L D R E N 22
The four A s A D A P T E D F R O M C O N J O I N T B E H A V I O R A L C O N S U L T A T I O N : P R O M O T I N G F A M I L Y - S C H O O L C O N N E C T I O N S A N D I N T E R V E N T I O N S, 2, E D I T E D B Y S. M. S H E R I D A N & T. R. K R A T O C H W I L L, 2 0 0 7 N E W Y O R K : S P R I N G E R S C I E N C E A N D B U S I N E S S M E D I A. 23
Touchstone Health Services 8 6 6. 2 0 7. 3 8 8 2 T O U C H S T O N E H S. O R G P H O E N I X M E S A A V O N D A L E T U C S O N 24
Evidence-based practices 25
Evidence-based practices Applied Behavior Analysis (ABA) Therapy Characteristics of Early Intensive Behavioral Intervention in ASD Early Intensive Behavior Intervention (EIBI) Efficacy of Early Intensive Behavioral Intervention (EIBI) DIR/Floor Time TEACCH: Treatment and Education of Autistic and Related Communication Handicapped Children TEACCH A Culture of Autism TEACCH: A Meta-Analysis TEACCH Method for Social Skills Training 26
Evidence-based practices National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author. Wong, C., Odom, S. L., Hume, K. A., Cox, C. W., Fettig, A., Kurcharczyk, S., et al. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-014-2351-z 27
Comparison of NPDC and NSP Practices Evidence-Based Practices Identified by the National Professional Development Center (NPDC) on ASD Antecedent-based Intervention Differential Reinforcement Discrete Trial Training Extinction Behavioral Interventions Cognitive Behavioral Interventions Modeling Modeling X X Prompting Reinforcement Response Interruption/Redirection X X X X X X X Natural Teaching Strategies Parent Training Established Treatments Identified by the National Standards Project (NSP) Peer Training Package Pivotal Response Training Schedules Scripting X X Task Analysis X Scripting Selfmanagement Social Skills Package Story-based Intervention Language Training Language training did not emerge as a focused intervention by the NPDC on ASD. Components of Language Training overlap with NPDC identified practices that may support language production, such as modeling, prompting, and reinforcement. Comprehensive Behavioral Treatment for Young Children The NPDC on ASD did not review comprehensive treatment models. Components of The Comprehensive Behavioral Treatment of Young Children overlap with many NPDC identified practices. Video Modeling X X Time Delay X Cognitive Behavioral Intervention X Naturalistic Intervention X Parent Implemented Intervention Peer-mediated Instruction & Intervention X X Pivotal Response Training X Self-management X Social Narratives X Social Skills Training X Visual Supports X Exercise Functional Behavior Assessment Functional Communication Training Picture Exchange Communication System Structured Play Groups Technology-aided Instruction & Intervention Exercise was identified as an emerging practice by the NSP. The NSP did not consider Functional Behavior Assessment as a category of evidence-based practice. Functional Communication Training was identified as an emerging practice by the NSP. Picture Exchange Communication System was identified as an emerging practice by the NSP. The NSP did not consider Structured Play Groups as a category of evidence-based practice. Technology-aided Instruction and Intervention was identified as an emerging practice by the NSP. NPDC 2017 Mercy Care Plan l Mercy Maricopa 28
Mercy Care Plan l Mercy Maricopa 29
Member-Centered Practices Primary responsibility of the Care Coordinator Communication Continuous between Care Coordinator in Accessible Language Communication between Providers Internal Database Develop a Process for Communication with Multi-Systemic Partners Members and Providers Participate in CFT 30
Member-centered practices Integrates Community Resources Supports and Facilitates Transitions Engages in Networking Opportunities Continuous Patient Communication Care Coordination Patientcentered Training Provides Coaching to Families and Providers Provides Case Management 31
THS Professionals: Psychiatrists Psychiatric Family Nurse Practitioners Doctor of Osteopathic Medicine (D0) Medical Assistants (MA) Board Certified Behavior Analyst (BCBA) Registered Behavior Technician (RBT) Licensed Associate Counselor (LAC) Licensed Associate Marriage and Family Therapist (LAMFT) Licensed Behavior Analyst (LBA) Licensed Clinical Social Worker (LCSW) Licensed Independent Substance Abuse Counselor (LISAC) Licensed Marriage and Family Therapist (LMFT) Licensed Master Social Worker (LMSW) Licensed Professional Counselor (LPC) Infant Early Childhood Program Intensive Outpatient Programs Psychiatry Services MMWIA: Whatever It Takes Behavior Analytic Programs: FCAP Language & Learning Center FBAs Severe & Complex Cases Coming Soon: Primary health care Medical assessment Screening for co- morbidities EPSDT assessments Employment Diet and nutrition Speech Language Communication Direct Service Providers ASD Informed Care Coordination Outside Agencies & Programs Respite Services 32
Family & provider engagement Collaboration ACEs can not provide all services Need for partnerships Medical Behavioral Educational Community Education Touchstone Health Services ACE Trainer Direct training for: Families Agencies Stakeholders Understanding the system and rights Services available in the system Evidence-based practices 33
THS ACE Trainings: Technical support for the whole community Applied Behavior Analysis Chronic stressors experienced by caregivers and family members of persons with ASD Early intervention for children with ASD Effective discipline practices Effective teaching practices Introduction to ASD Positive behavior supports (PBS) for classrooms and schools Writing measurable treatment/iep/cft/isp goals and objectives Nationally recognized best practices outlined in: - National Autism Center. (2015). Findings & conclusions: National standards (phase 2). Randolph, MA: Author. - Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., Schultz, T. R. (2013). Evidence-based practices for children, youth, and young adults with Autism Spectrum Disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence- Based Practice Review Group.
4 Years-old Limited language New Diagnosis of ASD Gastrointestinal issues External Referrals Gastrointestinal Specialist Recently removed from her home after abuse allegations Recently started biting her arm, breaking the skin Meet with ACE Team Lead Treatment Plan Work with Care Coordinator & Treatment Providers Internal THS Referrals Language and Learning Center Functional Behavioral Assessment Trauma Informed Care Reassess/ Discharge Mercy Care Plan l Mercy Maricopa First 7 Days of Care Next 21 Days of Care Continuing Care 35
Thank you