When a child is diagnosed with autism, families — understandably — have questions. They are likely to direct those questions to their child’s primary care provider.
Several years ago, clinicians at the primary care clinic at Monroe Carell Jr. Children’s Hospital at Vanderbilt recognized a gap in care: There was no protocol to help direct follow-up care after an autism diagnosis. Now, the Primary Care Autism Team, a multidisciplinary group of physicians, a nurse practitioner, psychologists and administrative professionals, has developed and implemented a follow-up care protocol for children diagnosed with autism — and expanded it to five primary care clinics within the Vanderbilt Health System.
For their collaboration and commitment to improving care for children and families, the Primary Care Autism Team was honored with the Team Award during the January 2025 VUMC Leadership Assembly.
“There are a lot of moving parts for families when they learn that their child has autism. Families ask their pediatrician very specific questions about what to do next, and we noticed that many primary care providers were not equipped to answer all these different questions,” said Jeffrey Hine, PhD, a psychologist in the Division of Developmental Medicine at Monroe Carell and leader of the Primary Care Autism Team.
The team created a care pathway that included automatic scheduling for a new autism-focused clinic visit with the child’s primary care provider. To equip providers for these visits, the group developed and loaded into the electronic health record (EHR) system a set of clinical decision-making guides with linked educational handouts for families, and team members trained providers to use these guides and resources.
“The clinical templates help providers walk through what to do, what to say, what tests to order, what resources are available … and they can populate handouts with information for families,” Hine said.
Implementation of the new care pathway has been successful. In the 12 months preceding the program, 71 patients received an autism diagnosis, and only 21% had an autism-specific follow-up visit. In the 13 months following the program launch, 119 children received an autism diagnosis, and 89% had an autism-specific follow-up visit.
In REDCap surveys, providers “indicated high levels of EHR template usability, satisfaction with the new system, and agreement that the follow-up protocol helped providers better follow best practice guidelines for caring for children with autism and their families,” according to the Team Award nomination.
“This program dramatically improved continuity of care, implementation of best practices, and patient/provider education. This was truly a collaborative and impactful effort across disciplines, roles and departments,” the nomination read.
Because a majority of primary care providers at the Monroe Carell clinic are pediatric resident physicians, the team’s effort was also impactful as an educational program to prepare future pediatricians, Hine noted.
In addition to expanding the care pathway at Vanderbilt Health from one clinic to five, the clinical templates have been made available to other health organizations that use the Epic EHR system. Members of the team have presented about the care pathway at conferences, and projects are underway to build similar templates for clinic visits focused on advocating for special education services and for transition to adulthood for patients with autism.
“It took a lot of coordination and inclusion of a very broad group of people trying to squeeze another thing into primary care — which is already extremely busy at all times,” Hine said. “I think it was a nice demonstration of the flexibility and commitment of the team and the department that we want to help families and children with autism.
“We were all surprised in a good way about this award and excited that we put together a pretty impactful program. There were a lot of high-fives around.”
Members of the team are:
- Laleh Bahrami, MD, assistant professor of Pediatrics, Division of General Pediatrics
- Kathryn Carlson, MD, MMHC, associate professor of Clinical Pediatrics and medical director of the Vanderbilt Pediatric Primary Care Clinic, Division of General Pediatrics
- Ryan Coleman, PhD, assistant professor of Pediatrics, Division of Developmental Medicine
- Tori Foster, PhD, assistant professor of Pediatrics, Division of Developmental Medicine
- Jeffrey Hine, PhD, associate professor of Pediatrics, Division of Developmental Medicine
- Victoria Lawrence, administrative supervisor, Division of General Pediatrics
- Cara Miller, MD, pediatrics resident, Child Neurology Residency Program
- Holly Miller, MSN, APRN, associate in Pediatrics, Division of General Pediatrics
- Barron Patterson, MD, associate professor of Pediatrics and vice chair for Ambulatory Services, Division of General Pediatrics
- Sharlinda Robertson, patient service specialist, Division of General Pediatrics
- Anna Kathleen Spitler, research analyst, Vanderbilt Kennedy Center TRIAD
View the Primary Care Austism Team video from Leadership Assembly.
If you are a VUMC employee, you can nominate a colleague for an Elevate Credo Award, Five Pillar Leader Award, or Team Award. Visit the Elevate website to fill out a nomination form. Employees demonstrate credo behaviors when: they make those they serve the highest priority; respect privacy and confidentiality; communicate effectively; conduct themselves professionally; have a sense of ownership; and are committed to their colleagues. Elevate award nominations are accepted year-round. If a nomination is received after the cutoff for an award selection period, the nomination will be considered for the next period. VUMC VOICE will post stories on each of the award winners in the weeks following their announcement.
