Evaluating Implementation of a Patient Navigator Intervention to Improve Access to Diagnostic and Treatment Services for Children with Autism Spectrum Disorder

项目摘要 在获得诊断和治疗服务方面， 自闭症谱系障碍（ASD）儿童。因为早期获得ASD服务可以改善长期 结果，延迟参与这些服务可能导致大量发病率。这种模式 卫生服务中断的主要原因-护理延误，导致可预防的发病率-存在于世界许多地区， 美国医疗保健系统。在过去的十年里，一个有希望的解决方案得到了广泛的研究， 患者导航。患者导航是一种非专业提供的病例管理策略，旨在减少健康 通过帮助弱势群体克服心理和后勤方面的障碍来提供护理，从而消除了不平等现象。导航 已证明对多种疾病如癌症和艾滋病毒有效，早期数据支持其作为一种 促进ASD儿童及时参与循证服务的战略。然而，在这方面， 尽管导航的有效性数据很可观，但多项研究表明其影响正在减弱， 和可变的成功，当在现实世界的实践中实施。这种“研究-实践”的差距- 有效的临床创新未能在现实世界的临床实践中被采用（或以适当的保真度实践） 实践-在医疗保健中无处不在;但对于低收入和少数民族人群来说， 以及为他们服务的机构。此外，尽管有相反的指导，很少有临床试验主动 收集有关影响后续治疗的复杂患者、提供者和组织因素的数据 正在测试的临床创新的实施。由于错过了这个机会， 战略往往是任意的，容易失败。因此，在这个K23应用程序中，我建议使用新兴的 传播和实施科学领域评估关键实施进程的技术 在一项正在进行的NIMH资助的多中心随机对照试验中， 患者导航系统旨在改善低收入ASD儿童的护理 （R01MH104355，Feinberg）。这项工作的目标是阐明可以增加快速发病可能性的因素。 以及在多样化的真实世界实践环境中持续采用患者导航。我的教育目标 通过以下目标获得传播和实施科学方面的培训和经验： 学习过程映射和分析;学习新的定性方法;学习和应用新的 定量技术-多层次模型。本提案中的研究直接建立在我之前的工作基础上， 该项目的重点是利用多学科团队来改善自闭症儿童获得服务的机会， 家庭我已经确定了一个经验丰富的指导团队和一个支持性的研究环境， 确保我实现我的短期和长期目标。在获奖结束时，我将能够开发一个 可测试的数据驱动的实施策略，以促进患者的快速传播和实施 导航到患有ASD的弱势儿童。

PROJECT SUMMARY Significant racial, ethnic, and socioeconomic disparities exist in access to diagnostic and treatment services for children with autism spectrum disorder (ASD). Because earlier access to ASD services improves long-term outcomes, delayed engagement with these services can be responsible for substantial morbidity. This pattern of health service break-down – delay in care, leading to preventable morbidity – exists in many sectors of the US health care system. One promising solution, which has been studied extensively over the past ten years, is patient navigation. Patient navigation is a lay-delivered case management strategy designed to reduce health disparities by helping vulnerable populations overcome psychological and logistical hurdles to care. Navigation has proven effectiveness in multiple disorders such as cancer and HIV, and early data support its use as a strategy to promote timely engagement with evidence-based services among children with ASD. However, despite navigation's substantial effectiveness data, multiple studies demonstrate the attenuation of its impact, and variable success, when implemented in real-world practice. This “research-practice” gap – whereby effective clinical innovations fail to be adopted (or practiced with appropriate fidelity) within real-world clinical practice – is ubiquitous in healthcare; but it is particularly problematic for low-income and minority populations and the institutions that serve them. Furthermore, despite guidance to the contrary, few clinical trials proactively collect data on the complex patient, provider, and organizational factors that impact subsequent implementation of the clinical innovations being tested. As a result of this missed opportunity, implementation strategies are often arbitrary and prone to failure. Therefore, in this K23 application, I propose to use emerging techniques in the field of dissemination and implementation science to evaluate key implementation processes of patient navigation in the context of an ongoing, NIMH-funded, multi-site randomized controlled trial of a patient navigation system designed to improve access to care for low-income children with ASD (R01MH104355, Feinberg). The goal of this work is to elucidate factors that can increase the likelihood of rapid and sustained uptake of patient navigation in diverse, real-world practice settings. My educational objectives are to gain training and experience in dissemination and implementation science through the following goals: to learn process mapping and analysis; to learn new qualitative methods; and to learn and apply a new quantitative technique - multilevel modeling. The research in this proposal builds directly on my prior work, which focused on using multidisciplinary teams to improve access to services for children with ASD and their families. I have identified an experienced mentoring team and a supportive research environment, which will ensure that I attain my immediate and long-term goals. At the end of the award, I will be position to develop a testable data-driven implementation strategy to promote the rapid dissemination and implementation of patient navigation to vulnerable children with ASD.