Brief educational "curbside consultation": impact on attention-deficit/hyperactivity disorder referrals in an integrated healthcare setting.
Keywords: interdisciplinary consultation, ADHD, integrated primary care, ADHD evaluation, physician referral practices
Primary care providers (PCPs) are often the first providers parents contact when they have concerns regarding their children, encompassing both medical and behavioral health concerns. PCPs estimate that 15% to 18% of children who present to pediatric primary care have a behavioral health disorder (Williams, Klinepeter, Palmes, Pulley, & Foy, 2004), and behavioral health concerns are raised during approximately 25% of child primary care visits (Cooper, Valleley, Polaha, Begeny, & Evans, 2006). Furthermore, it is estimated that approximately 75% of all child behavioral health concerns are treated in pediatric primary care (Williams et al., 2004). Therefore, it is not surprising that pediatricians report behavior concerns as the most common and challenging problem seen during visits (Amdorfer, Allen, & Aljazireh, 1999). Attention-deficit/hyperactivty disorder (ADHD) has been reported as one of the most prevalent behavioral concerns in primary care (Williams et al., 2004), with approximately 4% to 12% of children and adolescents diagnosed with ADHD in this setting (Brown et al., 2001). In fact, it is common for PCPs to have one to two new ADHD evaluations per month (Chan, Hopkins, Perrin, Herrerias, & Homer, 2005).
Due to the impact of ADHD in the primary care setting, the American Academy of Pediatrics (AAP, 2011) provides clinical practice guidelines for the evaluation of ADHD in children and adolescents. Specifically, it is recommended that a comprehensive multimodal, multiinformant evaluation be conducted to determine symptomology and impairment across settings (i.e., home, school). Multiple barriers to adhering to AAP guidelines, however, exist in the primary care setting (Kelleher, Campo, & Gardner, 2006; Rushton, Bruckman, & Kelleher, 2002). PCPs have often not been trained in conducting behavioral health assessments nor are they allotted enough time to conduct a comprehensive evaluation during the primary care visit (i.e., typically 10 to 20 min). A comprehensive evaluation, which typically includes interviews with teachers and caregivers, behavior rating scales, and, at times, a school observation, can involve two to three hours of time. In contrast, PCPs report spending 15 to 45 min with patients over the span of several office visits to confirm the diagnosis of ADHD (Chan et al., 2005).
PCPs are more comfortable and equipped to manage medication for ADHD than they are with the evaluation process (Searight & McLaren, 1998) and subsequent behavior therapy. In primary care settings, ADHD is often treated exclusively through the use of stimulant medication without the addition of behavioral interventions (Wolraich et al., 1990) and only half of PCPs recommended behavior therapy in addition to medication management when treating ADHD (Rushton, Fant, & Clark, 2004). Thus, many children with ADHD may not be receiving the benefits of a combined medication and behavior therapy approach. Research has demonstrated that the use of a combined medication management and behavioral therapy approach has positive effects on outcomes for children diagnosed with ADHD (Jensen et al., 2001; Molina et al., 2009; MTA Cooperative Group, 1999; Pelham & Gnagy, 1999). Specifically, the MTA study found that combined medication and behavior therapy resulted in a small significant reduction of ADHD symptoms on parent and teacher ratings of ADHD, greater improvements on academic and conduct measures when comorbidities existed, and higher ratings of parent and teacher satisfaction with the treatment plan. The use of a combined approach has also been shown to allow for the use of lower dosages of stimulant medications (Pelham & Gnagy, 1999). Finally, it has also been suggested that the use of a combined approach may assist parents who may also have ADHD in implementing treatment consistently (AAP, 2011).
Given the chronic nature of ADHD, the PCP should adopt a medical home model of care to promote comprehensive and coordinated treatment. It has been suggested that an effective approach for PCPs working with patients with behavioral health concerns, including ADHD, is to develop close working relationships with behavioral health providers (Rosman, Perry, & Hepburn, 2005; Wildman & Langkamp, 2012; Williams, Shore, & Foy, 2006). Recently, there has been a move to integrate behavioral health services into primary care medical homes to better optimize patient care and increase the availability of behavioral health services to families. Having behavioral health integrated into primary care clinics increases the likelihood that PCPs will consult with or refer to behavioral health providers (Guevara, Greenbaum, Shera, Bauer, & Schwarz, 2009) and referred patients are more likely to follow through with recommended services (Valleley et al., 2007). This suggests that integrating behavioral health into primary care clinics may improve patient care in both the evaluation and treatment of mental health concerns such as ADHD.
Although there has been much discussion in the field on the importance of increasing collaboration and consultation between medical and behavioral health providers, few studies have examined effective methods for increasing referrals for evidence-based evaluation and behavioral health treatment. This study examined whether two brief education sessions specific to the diagnosis and treatment of ADHD led to an increase in ADHD referrals from in-house pediatricians to the psychologist colocated at the clinic. It was hypothesized that the number of ADHD referrals to the behavioral health clinic (BHC) would increase following brief education. In addition, it was hypothesized that due to providing increased education on AAP recommendations for evaluation and treatment of ADHD, pediatricians would engage in greater diagnosis deferral to comply with evidence-based multimodal, multiinformant recommendations for assessment. Thus, of the children referred to the BHC for ADHD, researchers expected that fewer children would already have a diagnosis of ADHD and fewer would be taking medication for ADHD compared with children referred prior to the brief educational "curbside consultations."
Participants and Setting
The BHC where this study took place was colocated within an independently owned suburban pediatric primary care clinic in the Midwest. Behavioral health providers had been co-located in the practice for approximately five years providing treatment services two days per week. Behavioral health providers included a licensed psychologist, a postdoctoral fellow, and a predoctoral intern. The pediatric clinic employed seven pediatricians (5 full-time) with an average of 11 years of experience (range 3 to 17 years). Three of the physicians were female and four were males. BHC referrals were accepted from the PCPs (on-site referrals) as well as outside providers (outside referrals). Demographic data from outside referrals were not collected for the purposes of this study. Outside providers did not receive any education or have contact with the behavioral health providers.
During the two 6-month periods in which data were collected, 147 children were scheduled for an appointment at the BHC, with 107 referred by the pediatricians at the primary care clinic. Of those referred from within the primary care clinic (on-site referrals), 89 children (83.2%) showed for their initial intake appointment. The sample consisted of 64 males (72%) and 34 (38.2%) were referred specifically for concerns related to ADHD. Mean age for participants was 8.34 years (SD = 4.28). Information on patient race and ethnicity was not collected at the time of this study. Of those referred for concerns related to ADHD, 29 (82.9%) were diagnosed with ADHD following evaluation at the BHC. Equal numbers of referrals by the PCPs occurred across the two time periods (i.e., 54 children prior to the consultation and 53 following the consultation). Of those referred by outside providers (n = 36), 35 (97.2%) showed for their initial appointment. The sample consisted of 20 males (57.1%). Thirteen children (37.1%) were referred specifically for concerns related to ADHD, and eight (22.9%) were diagnosed with ADHD following evaluation at the BHC.
Prior to provision of brief education, the behavioral health provider had informed on-site PCPs that comprehensive evaluations and treatment services for ADHD were available. Additionally, behavioral health providers routinely shared assessment results on ADHD evaluations and progress notes for behavioral health visits and were available for "curbside consultations" regarding behavioral health concerns of patients within the practice. In an effort to increase the knowledge and evidence-based practice of on-site PCPs in the evaluation and treatment of ADHD, two minieducation sessions were conducted by the on-site behavioral health provider in the early fall of 2012. Brief education initiated by the behavioral health provider was conducted with each individual PCP in a "curbside consultation" format in order to meet the needs of clinic flow, circumvent barriers related to PCP availability and time, and maintain established personal consultative interactions with the on-site behavioral health provider.
The first educational consultation involved a brief discussion of the AAP's, (2011) Guidelines for the Diagnosis, Evaluation, and Treatment of ADHD, including provision of a printed copy of the guidelines. The behavioral health provider highlighted AAP recommendations for a comprehensive, multi-informant, multimodal approach to evaluation and informed PCPs of the behavioral health provider's current approach to ADHD assessment (e.g., comprehensive diagnostic interview, normative assessment through parent and teacher behavior rating scales [e.g., both broadband and narrowband; to compare symptoms to same-age, same-gender peers; to determine alternative explanations or comorbidities], and availability to conduct school observations and teacher interviews). Additionally, the behavioral health provider discussed evidence-based treatment for ADHD, including the benefits of a combined medication and behavioral therapy approach. Finally, the behavioral health provider outlined a behavioral therapy approach for children with ADHD. Specifically, it was discussed that the behavioral health provider trains parents and school professionals in specific techniques (e.g., use of rewards, discipline, differential attention) to shape child behavior and improve child self-regulation.
During the second educational consultation, the behavioral health provider discussed relevant information learned during an all-day workshop given by an ADHD expert (workshop attended by behavioral health provider only). A two-page handout was utilized to guide this discussion and provided to each pediatrician. Specifically, the handout discussed the etiology of ADHD, common comorbid conditions, ADHD as a developmental disability of executive function, experimental, weak, and unproven treatments, and an overview of empirically supported treatments.
A review of records was completed for intakes at the BHC conducted for the 6-month period following the educational consultations (October 2012-March 2013) and the same 6-month time period prior to the consultations (October 2011-March, 2012) of the previous year. In addition to demographic information, the following information was collected to determine differences in the PCPs' referral rates and treatment recommendations following the brief educational "curbside consultations:" number of PCP referrals, patient diagnosis status (ADHD vs. no diagnosis) prior to referral, medication status (e.g., prescribed medication to treat ADHD) upon referral, and treatment services (e.g., medication, behavioral therapy, combined approach) following referral.
This study was a quasi-experimental design, as participants were assigned based upon referral to the BHC clinic before versus after the brief educational curbside consultation. A series of chi-square tests for independence were conducted. When the chi-square assumption of minimum expected cell frequency was violated and more than 20% of cells had expected frequencies less than or equal to 5, Fisher's exact test was utilized. When each variable had only two categories, the continuity correction was utilized. For all other cases, the Pearson chi-square was utilized. A t tests for independent means was also conducted. Significance level was set at p < .05. Seasonal variation was controlled by examination of the same months of the year pre- and post-intervention.
Results for analyses are available in Table 1. A chi-square test for independence indicated a significant difference in ADHD referrals following consultation, [chi square](1, 101) = 4.08, p = .04, [phi] = -.22. There were significantly more ADHD referrals post-consultation. A marginally significant difference was found related to patient diagnostic status (i.e., ADHD vs. no diagnosis) upon referral, [chi square](1, 35) = 2.66, p = .059, [phi] = .343. Children referred following the educational consultation were less likely to have been diagnosed with ADHD prior to the initial session. Finally, a marginally significant difference was found for patient medication status upon referral, [chi square] (1, 34) = 2.73, p = .079, [phi] = .357. Children who were referred following the consultation were less likely to be prescribed medication prior to the initial behavioral health session.
Thirteen children were referred for ADHD from outside referral sources. A chi-square test for independence indicated no significant difference in ADHD referrals post-consultation for outside referrals, [chi square] (l, 36) = 0, [phi] = 1.0, 4> = - .007. Additionally, no significant differences were found for patient diagnostic or medication status following consultation.
Total ADHD Referral Sample
For patients and families specifically referred for ADHD concerns, a series of chi-square tests were conducted to examine differences in care prior to on-site provider education and interventions chosen by the family following provider education. A chi-square test indicated significant differences in treatment services based on pre-referral diagnostic status, [chi square] (3, 46) = 12. 97, p < .01, [phi] = .531. Refer to Tables 2 and 3 for information on treatment patterns prior to and following educational curbside consultations.
A chi-square test for independence also indicated significant differences in treatment services based on patient medication status at the time of referral, [chi square] (3, 46) = 16.11, p < .01, [phi] = .592. For patients previously prescribed psychotropic medication to treat symptoms of ADHD (n = 13), zero received behavior therapy only, five received a combined approach, and two did not return for follow-up treatment prior to the brief educational consultation. Zero received behavioral therapy and six received a combination approach following educational curbside consultation. For patients not previously prescribed psychotropic medication (n = 34), two received behavior therapy only, three received a combined approach, three participated in behavioral therapy for a diagnosis other than ADHD, and one did not return to clinic prior to the brief consultation. Following the educational curbside consultation, 13 received behavior therapy only, five received a combined approach, four did not return for treatment, two received behavior therapy for a behavioral health concern unrelated to ADHD, and data were missing for one participant. In addition, a i-test for independent means was conducted to examine utilization of behavioral health services post-referral. Results indicated patients prescribed psychotropic medication upon referral attended significantly fewer behavioral health sessions (M = 2.43, SD = 1.13) than patients prescribed medication following behavioral health evaluation (M = 4.80, SD = 3.43), t(18.91) = 2.41, p < .05.
Following two brief psychoeducational sessions regarding best practices for the evaluation and treatment of ADHD with on-site PCPs, results indicated an increase in on-site referrals to behavioral health providers for evaluation and/or treatment. In comparison, an increase in ADHD referrals for off-site PCPs was not observed. Results suggest that brief education provided to PCPs in a "curbside consultation" format may increase PCP adherence to AAP and best practice guidelines for ADHD. Although the exact mechanism for change in referral rates was not examined, components such as increasing PCP knowledge of AAP recommendations, empirically supported ADHD evaluation and treatment practices, and behavioral health services available on-site may have influenced PCPs in their decision to refer more patients for ADHD evaluation and/or treatment to behavioral health.
There was some evidence to suggest that, following the educational curbside consultations, fewer children referred to the behavioral health provider had previously received a diagnosis of ADHD and/or pharmacological treatment for ADHD. This suggests that the consultations may have changed PCP attitude and behavior regarding the management of ADHD. It appears that the PCPs may have been utilizing the behavioral health provider to assist in the diagnosis of ADHD, thus delaying pharmacological intervention until a more comprehensive evaluation confirmed the diagnosis. Children treated pharmacologically following referral to the BHC attended significantly more behavioral health therapy sessions compared to children previously prescribed psychotropic medication.
There were several limitations to this study. First, the brief education sessions were not uniform and different information or focus of information may have been shared with each PCP at the clinic. For example, PCPs may have asked varying follow-up questions or inquired about specific patients. Additionally, PCPs may have sought out the behavioral health provider outside of the educational consultations for additional follow-up. Second, the brief educational consults were conducted at a clinic where behavioral health providers had been available to the primary care clinic for several years. The impact of the consultations may have been different had they been conducted in a pediatric practice in which behavioral health providers were newly integrated. Specifically, familiarity with on-site behavioral health services, development of trusting, collaborative relationships, and receipt of potentially positive feedback from patients outside of this study regarding their behavioral health experience may have mediated the relationship between provider education and increased referral rates. Finally, due to a lack of access to the PCPs' medical files, the number of patients diagnosed with ADHD by a PCP and the number of patients who received medication management alone were unable to be determined.
As there continues to be a move to integrate behavioral health services into primary care, research should continue to examine methods to increase referrals and collaborations between behavioral health providers and PCPs. This study suggested that brief, informal education provided in a "curbside consultation" format may increase referrals for the assessment and behavioral treatment of ADHD. Educational "curbside consultations" may also be an effective way to establish the credibility of the behavioral health provider and the services they can provide in an integrated clinic. In addition, consults may allow behavioral health providers to provide PCPs with updates on the management of patients' behavioral health concerns, a collaborative effort PCPs identify as valuable (Williams et al., 2004). Future studies should employ experimental procedures to clarify what factors (e.g., length of relationship, receipt of positive feedback from patients regarding their behavioral health experience, discussion of cases, responsiveness to PCP questions, provision of education) in the consultation relationship are most important for increasing referrals and improving patient care.
It will also be important to conduct additional research on treatment status (e.g., behavioral therapy, pharmacotherapy, combined approach) following a diagnosis of ADHD. The AAP (2011) has recommended that school-age children receive both medication management and behavioral health services for the treatment of ADHD. This study provided evidence that children who were not on psychotropic medication at the time of the initial behavioral health consultation attended more behavioral health sessions compared to children who had already been placed on medication by their PCP. It was inferred that the children already placed on medication used to treat ADHD by their PCP had been diagnosed with ADHD by their PCP prior to the initial behavioral health consultation. This suggests that the treatment options used by families may be impacted by whether they are diagnosed with ADHD by their PCP compared with a behavioral health provider, as families diagnosed by a behavioral
health provider may be more open to behavioral management interventions for the treatment of ADHD. Future research should be conducted on how families choose treatment following their child's diagnosis of ADHD and whether choices are impacted by which professional provides the diagnosis. Future research should also examine PCPs' medication management of ADHD symptoms and whether or not this is impacted by collaboration with behavioral health providers (e.g., collaborative case management; use of data-based decision making to monitor symptoms and side effects).
Future studies should also examine the impact of educational consultations across diverse clinics and behavioral health concerns. This study was limited to a private, suburban pediatrics clinic in the Midwest. It would be important to determine whether the same effects are able to be captured in clinics located in high need, underserved areas or clinics with diverse structure (e.g., frequent turnover due to resident training). Additionally, it will be important to examine the impact of consultations in clinics where behavioral health providers are newly integrated into the clinic.
One of the most common behavioral health concerns identified by pediatricians is the diagnosis and treatment of ADHD (Williams et al., 2004). The AAP (2011) has provided guidelines for pediatricians that emphasize the need for comprehensive evaluations and behavioral interventions for preschool and school-age children who are suspected of having ADHD. Due to time constraints and costs of treating behavioral health concerns for pediatricians (Cooper et al., 2006; Meadows, Valleley, Haack, Thorson, & Evans, 2011), integrating BHCs into primary care centers is one way to optimize patient care for children and adolescents with behavioral health concerns. As integration occurs, so does the necessity of researching methods to increase collaboration between behavioral health providers and PCPs and to inform PCPs on the many ways behavioral health providers can contribute to PCP practices. As a combination behavior therapy and medication management approach is the preferred and recommended treatment for ADHD, methods to evaluate and monitor this treatment modality are needed. The current study provides some preliminary evidence that two brief educational consultations with PCPs may increase both referrals for ADHD concerns and may influence the way PCPs diagnose and address behavioral health concerns.
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Received November 9, 2015
Revision received April 26, 2016
Accepted June 1, 2016
Erin L. Olufs, PhD
Oregon Health and Science University
Rachel J. Valleley, PhD, Kristen C. Hembree, PhD, and Joseph H. Evans, PhD
University of Nebraska Medical Center
Erin L. Olufs, PhD, Department of Psychology, Institute on Development and Disability, Oregon Health and Science University; Rachel J. Valleley, PhD, Kristen C. Hembree, PhD, and Joseph H. Evans, PhD, Department of Psychology, Munroe-Meyer Institute, University of Nebraska Medical Center.
Correspondence concerning this article should be addressed to Kristen C. Hembree, Department of Psychology, Munroe-Meyer Institute, University of Nebraska Medical Center, 985450 Omaha. NE 68198-5450. E-mail: firstname.lastname@example.org
Table 1 Patient History Prior to and Following the Brief Educational Curbside Consultation Pre-consultation Post-consultation (n = 16) (n = 32) Inside Outside Inside Outside referral referral referral referral Patient history (%) (%) (%) (%) Previous diagnosis of ADHD Yes 5 (31.3) 2 (12.5) 4 (12.5) 3 (9.4) No 6 (37.5) 3 (18.7) 19 (59.4) 5 (15.6) Prior medication Yes 5 (31.3) 2 (12.5) 3 (9.4) 3 (9.4) No 6 (37.5) 3 (18.7) 20 (62.5) 5(15.6) Table 2 Treatment Approach for Patients With Previous ADHD Diagnosis Inside referral Outside referral Treatment approach Pre (%) Post (%) Pre (%) Post (%) Behavior therapy 0 (0) 1 (25) 0 (0) 0 (0) Combination approach 4 (80) 3 (75) 1 (50) 3 (100) Other (a) 0 (0) 0 (0) 0 (0) 0 (0) Did not return 1 (20) 0 (0) 1 (50) 0 (0) Missing data 0 (0) 0 (0) 0 (0) 0 (0) (a) Behavior therapy for a condition other than ADHD. Table 3 Treatment Approach for Patients With No Previous ADHD Diagnosis Inside referral Outside referral Treatment approach Pre (%) Post (%) Pre (%) Post (%) Behavior therapy 1 (16.7) 9 (47.4) 1 (33.3) 3 (60) Combination approach 3 (50) 5 (26.3) 0 (0) 0 (0) Other (a) 1 (16.7) 2 (10.5) 2 (66.7) 0 (0) Did not return 1 (16.7) 2 (10.5) 0 (0) 2 (40) Missing data 0 (0) 1 (5.3) 0 (0) 0 (0) (a) Behavior therapy for a condition other than ADHD.
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|Author:||Olufs, Erin L.; Valleley, Rachel J.; Hembree, Kristen C.; Evans, Joseph H.|
|Publication:||Families, Systems & Health|
|Date:||Sep 1, 2016|
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