Autism Screening and Referral in Rural Primary Care: A Quality Improvement Project

Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental condition that requires early identification and intervention to optimize developmental outcomes. Despite recommendations from the American Academy of Pediatrics (AAP) for standardized autism screening at 18 and 36 months during well-child visits, implementation remains inconsistent in rural primary care settings. Many factors in rural areas, including limited provider training, time constraints, and lack of standardized processes, limit ASD screening. Local Problem: In the Uintah Basin, a rural region in Utah with limited pediatric specialists, most children receive care from family practice providers who may not consistently implement ASD screening. Screening rates among family practice providers in the region are undocumented but presumed to be low. Common ASD screening tools are often time-consuming and challenging to integrate into busy clinic workflows. This project addressed these barriers by implementing a more time-efficient, standardized ASD screening protocol in rural primary care clinics. Methods: A quality improvement initiative using the Plan-Do-Study-Act (PDSA) framework was conducted to integrate the Parent's Observations of Social Interactions (POSI) screener into routine well-child visits at three rural clinics. Providers and staff received training on the POSI administration process, and pre-and post-implementation surveys assessed provider confidence, feasibility, and workflow impact. Data were collected on provider-rated satisfaction, the project's feasibility, and user-rated usability. Interventions: The POSI screener was implemented at well-child visits for children aged 18-36 months. Medical assistants administered the screener during vital sign collection, and the results were communicated to providers. Children screened at risk were referred to the local health department for further evaluation and early intervention services. Training sessions and real-time feedback loops addressed implementation challenges, and workflow adjustments were made throughout the intervention. Results: Post-implementation findings revealed an increase in standardized ASD screening rates. POSI utilization rose from 0.15% pre-implementation to 69% post-implementation. Provider satisfaction with the screening process reached 85%, and confidence in autism screening improved from 15% to 62%. Referral pathways were improved, and 64% of providers reported improved confidence when making referrals. Challenges included EHR integration limitations and the necessity to rely on support staff to remember to implement the screeners without EHR prompting or recording, which were addressed through workflow modifications. Conclusion: This project demonstrated that integrating standardized ASD screening in 18-36 month well-child visits was satisfactory for rural family practice providers. The intervention increased provider confidence and adherence to standardized screening practices and strengthened the usability of these processes. Future projects should focus on sustaining the intervention through continued provider training, advocating for EHR integration, and addressing administrative barriers to referral follow-through.