autism spectrum disorders centers of excellence · 10 request for information • november 2, 2016:...

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.

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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

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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

Mercy Care Plan l Mercy Maricopa

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

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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.

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National Data

CDC surveys (NHIS & NSCH)

Mercy Care Plan l Mercy Maricopa

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

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Response to the Community Need

Autism Spectrum Disorder

Center of Excellence

Medical and Behavioral Integration

Community Enrichment

Continuity of Care

Multi-system Involvement

Comprehensive Assessments

Evidence-based Practice

Key Elements

• Serve as the ‘hub’ • Drive holistic outcomes • Advanced coordination

of care • Educate the community • Specialized services • Family and member

advocacy

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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 Physical Health Medical Director

Integration DDD Liaison

Cultural Competency Utilization Management

Adult System of Care DDD

DDD Liaison General Mental Health/Substance Abuse Representative

Office of Individual and Family Affairs Physical Health Manager

Integration Officer

Mercy Care Plan l Mercy Maricopa

Autism Spectrum Disorder Centers of Excellence

Touchstone Health Services

Southwest Behavioral Health Services

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Southwest Behavioral & Health Services

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Prevalence and early signs

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Features of Autism

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DSM Criteria for Autism

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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

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Anxiety disorders in psychiatrically referred adults with ASD

J O S H I E T A L . , 2 0 1 3

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Substance use disorders in psychiatrically referred adults with ASD

J O S H I E T A L . , 2 0 1 3

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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 . ,

2 0 1 0 .

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Targeting psychopharmacologic treatment

Sleep

Disruption

Impulsivity Hyperactivity

Inattention

Tantrums

Language

Impairment

Depression

Repetitive

Behaviors

Social

Communication

Deficits

Anxiety

Aggression

Self-

Injurious

Behavior

ADHD

M C D O U G L E E T A L . , 2 0 1 6

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Selected ASD Level 1 and Level 2 screening tools

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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

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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 .

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

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Evidence-based practices

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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

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Evidence-based practices

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

National Autism Center. (2015). Findings and conclusions: National standards project, phase 2. Randolph, MA: Author.

Mercy Care Plan l Mercy Maricopa

Comparison of NPDC and NSP Practices

NPDC 2017

Evidence-Based Practices Identified by

the National Professional

Development Center (NPDC) on ASD

Established Treatments Identified by the National Standards Project (NSP)

Behavioral Interventions

Cognitive Behavioral

Interventions

Modeling Natural

Teaching

Strategies

Parent Training

Peer Training Package

Pivotal Response

Training

Schedules Scripting Self-

management Social Skills

Package Story-based Intervention

Language Training

Comprehensive Behavioral

Treatment for Young Children

Antecedent-based Intervention

X 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.

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.

Differential Reinforcement

X

Discrete Trial Training X

Extinction X

Modeling X X

Prompting X

Reinforcement X

Response Interruption/Redirection

X

Scripting X X

Task Analysis X

Video Modeling X X

Time Delay X

Cognitive Behavioral Intervention

X

Naturalistic Intervention X

Parent Implemented

Intervention X

Peer-mediated Instruction & Intervention

X

Pivotal Response Training X

Self-management X

Social Narratives X

Social Skills Training X

Visual Supports X

Exercise Exercise was identified as an emerging practice by the NSP.

Functional Behavior Assessment

The NSP did not consider Functional Behavior Assessment as a category of evidence-based practice.

Functional Communication Training

Functional Communication Training was identified as an emerging practice by the NSP.

Picture Exchange Communication System

Picture Exchange Communication System was identified as an emerging practice by the NSP.

Structured Play Groups The NSP did not consider Structured Play Groups as a category of evidence-based practice.

Technology-aided Instruction & Intervention

Technology-aided Instruction and Intervention was identified as an emerging practice by the NSP.

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Mercy Care Plan l Mercy Maricopa 29

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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

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Member-centered practices

Care Coordination

Integrates Community Resources

Engages in Networking

Opportunities

Patient-centered Training

Provides Case Management

Provides Coaching to Families and

Providers

Continuous Patient

Communication

Supports and Facilitates Transitions

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Psychiatry Services

MMWIA: Whatever It Takes

Direct Service Providers

Respite Services

Outside Agencies & Programs

Behavior Analytic Programs:

FCAP

Language & Learning Center

FBAs

Severe & Complex Cases

Intensive Outpatient Programs

Infant Early Childhood Program

ASD Informed Care Coordination

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)

Coming Soon: Primary health care • Medical assessment • Screening for co- morbidities • EPSDT assessments Employment Diet and nutrition Speech Language Communication

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

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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.

Mercy Care Plan l Mercy Maricopa

Meet with

ACE Team

Lead

External

Referrals

Internal THS

Referrals

Treatment

Plan

Work with

Care

Coordinator

& Treatment

Providers

First 7 Days of Care Next 21 Days of Care Continuing Care

Reassess/

Discharge

Language and Learning Center Functional Behavioral Assessment Trauma Informed Care

Gastrointestinal Specialist

4 Years-old

Limited language

New Diagnosis of ASD

Gastrointestinal issues

Recently removed from her home after abuse allegations

Recently started biting her arm, breaking the skin

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Thank you