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Meeting the Measure: Improving ADHD Care in the Medical Home
Heidi Schwarzwald, MD, MPH; Agnes Hernandez-Grande, MD; Stephanie Chapman, PhD; and Stephanie Marton, MD, MPH
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Meeting the Measure: Improving ADHD Care in the Medical Home

Heidi Schwarzwald, MD, MPH; Agnes Hernandez-Grande, MD; Stephanie Chapman, PhD; and Stephanie Marton, MD, MPH
Quality improvement methodology was implemented to ensure that patients receiving medications for attention-deficit/hyperactivity disorder (ADHD) returned for an appointment within 30 days of initiating medication.
Innovations in the treatment of other chronic medical conditions may help guide future work aimed at improving ADHD care. An example of a chronic medical condition that requires careful adherence to medication and treatment plans is HIV. One study has shown that providing outpatient clinics with educational materials, such as brochures, posters, and messages about the importance of not missing clinic visits actually impacted clinic attendance.9 This strategy could be adapted to messaging for parents of children with newly diagnosed ADHD. Additionally, a recent inpatient study had the pharmacist dispense controller medications for asthma directly to the patient prior to hospital discharge.10 This model could be adapted in our outpatient clinic by having the clinical pharmacist dispense the ADHD medication to the patient in the room, thereby providing ample time and opportunity to ask medication-related questions and ensure the follow-up date is established. Looking at novel interventions from other areas of chronic illnesses and pediatric care could help improve care for children diagnosed with ADHD.

Limitations

This study has several limitations, including that the findings of this study are correlational in nature. The HEDIS metrics (a measure of our clinic’s TCHP members) do not match the actual patient population represented in the chart review. Furthermore, this study was a retrospective chart review looking at a period of time in which 2 PDSA cycles were conducted. A randomized controlled trial would more clearly demonstrate that the elements within this intervention were responsible for the change seen. Additionally, during this project, our team identified several missed opportunities for improved care and integration. Better communication among the teams will help improve registry maintenance, as our team missed placing patients on our registry 36% of the time. Even if patients were placed on the registry, however, missed calls due to missing numbers or unreturned voicemails limited phone communication. 

Despite the clinic’s integrated model, most patients newly initiated on medications were seen by members of the behavioral health team 1 or more times during the first 30 days, with some of these patients not getting back to their prescribing provider within the 30-day window. Better coordination of care between behavioral health and pediatric appointments may improve initiation follow-up rates. Better communication and care coordination will help ensure the registry continues to remain a useful tool in allowing our clinic to achieve our ADHD HEDIS metric. In the future, additional registries may be developed that could be useful for other pediatric chronic diseases, such as obesity.  

Conclusions

Partnership between clinicians, families, patients, and managed care organizations utilizing standardized HEDIS metrics can improve care and service to vulnerable patient populations. Our study showed that 2 simple interventions carefully constructed and implemented by multiple stakeholder improved our clinic’s HEDIS metric and ultimately our clinic’s quality of care. Integrated medical home models of care are increasing in number within the country and may be sites where QI methodologies can be fully harnessed with the ultimate goal of improved behavioral healthcare for patients. 

Author Affiliations: Department of Pediatrics, Baylor College of Medicine (HS, AH, SC, SM), Houston, TX; Texas Children’s Health Plan (HS, SC, SM), Houston, TX.

Source of Funding: None. 

Author Disclosures: Dr Schwarzwald is a board member of Ronald McDonald House charities. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (HS, AH, SC, SM); acquisition of data (AH, SM); analysis and interpretation of data (AH, SM); drafting of the manuscript (HS, SC, SM); critical revision of the manuscript for important intellectual content (AH, SC, SM); statistical analysis (HS, SM); provision of study materials or patients (HS); and supervision (HS, SM).

Send Correspondence to: Heidi Schwarzwald, MD, MPH, Texas Children’s Health Plan, 700 North Sam Houston Pkwy West, Houston, TX 77067. E-mail: hlschwar@texaschildrens.org.
REFERENCES

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4. American Academy of Pediatrics; Subcommittee on Attention Deficit/Hyperactivity Disorder. ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics. 2011;128(5):1007-1022. doi: 10.1542/peds.2011-2654.

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8. Geltman PL, Fried LE, Aresnault LN, et al. A planned care approach and patient registry to improve adherence to clinical guidelines for the diagnosis and management of attention-deficit/hyperactivity disorder. Acad Pediatrics. 2015;15(3):289-296. doi: 10.1016/j.acap.2014.12.002.

9. Gardner LI, Marks G, Craw JA, et al; Retention in Care Study Group. A low-effort, clinic-wide intervention improves attendance for HIV primary care. Clin Infect Dis. 2012:55(8):1124-1134. 

10. Hatoun J, Bair-Merritt M, Cabral H, Moses J. Increasing medication possession at discharge for patients with asthma: the Meds-in-Hand Project. Pediatrics. 2016;37(3):e20150461. doi: 10.1542/peds.2015-0461.
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