P3C114: Enhancing the Care of Intellectually and Developmentally Delayed Patients in the Primary Care Setting

Background: MedNorth Health Center is a Federally Qualified Health Center located in Wilmington, North Carolina. Among MedNorth pediatric patients, the prevalence of Intellectual and Developmental Delay (IDD) is 5%, which is twice the national prevalence of IDD. This high prevalence of IDD also correlates with a high prevalence of childhood adversity among MedNorth patients. In addition, two thirds of MedNorth patients are members of minoritized groups including non-English speaking immigrants and refugees. Meeting the needs of these families was challenging due to resource barriers, language barriers and cultural barriers.

Methods: We created an Intellectual and Developmental Delay Team which includes a pediatrician, family medicine physicians, a licensed clinical social worker, and a care manager. This team meets at scheduled monthly to bimonthly intervals to review patient cases and discuss process changes. The presence of the IDD Team provides medical providers an internal process for beginning evaluation and treatment of IDD patients. Even prior to forming the IDD Team, interested staff researched local resources designed to meet the needs of families with IDD. The IDD Team also created a collaboration with a local psychology practice who agreed to expedite psychological evaluations for MedNorth patients if the in-house licensed clinical social worker completed a comprehensive clinical assessment to precede the referral. The IDD Team also has arranged several didactic sessions for MedNorth staff that have including topics such as Feeding Disorders. Ultimately, once Medicaid Managed Care was implemented in North Carolina, it impacted our IDD Team function as well. MedNorth Health Center was approved as a site that could provide Tailored Plan Care Management to serve patients impacted by mental illness and developmental delay.

Results: Implementing intentional processes to enhance the care of families impacted by IDD has yielded significant results. Frequent case presentations allows the IDD Team to benefit from our collective brain trust to access the most pertinent resources for our families. In addition, as the team formalized processes in the IDD Team, all MedNorth Staff have gained a greater awareness of the needs of this special population. Our team has also reaped the benefit of increased collaboration with community resources such as therapists, psychologists, external mental health providers and local school systems. In summary, referrals for these families have increased and families are more often connected to needed services like Individualized Educational Programs, home health, respite, preschool, therapies, and mental health services for any impacted family member.

Conclusion: In conclusion, MedNorth Health Center successfully continues to enhance the care of patients with Intellectual and Developmental Delay through intentional processes. Scheduled meetings, collaboration with external entities, and continuing education has yielded improved touchpoints for our families impacted by IDD.