Interagency Collaboration for Pediatric Autism Spectrum Disorder: Perspectives of Community-Based Providers

Abstract

Background:

Interagency collaboration between community and school settings is one mechanism to serve the complex needs of pediatric patients with autism spectrum disorder (ASD).

Purpose:

We surveyed a national sample of community-based providers to examine their perspectives on interagency collaboration with school-based providers when serving pediatric patients with ASD.

Method:

Medical and behavioral/mental health professionals practicing in community settings were recruited. Participants (N = 116) completed an online survey about their interagency collaboration experiences with schools.

Results:

The majority of the sample reported engaging in interagency collaboration with school-based providers; however, the frequency was limited and was associated with the number of years working in the field. Community-based providers wanted more didactic and hands-on experiences in collaboration. Barriers and facilitators were related to schools’ administration, school personnels’ training in ASD, information exchange, and delineating between identification systems.

Discussion and Conclusion:

Our findings highlight the importance of leadership support and the need for innovative training experiences to support school-community interagency collaboration.

Interagency collaboration has become increasingly important in order to provide high-quality services in school, healthcare, early childhood, and social service systems. This approach occurs when two or more service providers from different settings collaboratively work together to serve the needs of patients.^1–4 These service providers may be from the same or different professions. A triad of needs – (1) limited financial resources, (2) providers’ capacity to serve a growing number of patients, and (3) co-occuring conditions common in most disorders - warrants collaboration (e.g., sharing of assessment data or exchange of therapeutic progress) between service-providing agencies.² Interagency collaboration is also an integral component to ensuring population health.^5,6 Consequentially, it is one mechanism to intervening in a more comprehensive, efficient, and ecologically valid manner to enhance the quality of services for patients with complex needs.^1,4,7,8

Factors and Outcomes Associated with Interagency Collaboration

Researchers have found that collaboration across agencies is more challenging than collaborations within agencies. More specifically, professionals find it difficult to engage in interagency collaboration when differences exist between the cultures (e.g., the extent to which employees work together, the preferred modes of communication, the supervisor-supervisee relationship) of agencies. Other interagency-specific challenges to collaboration include geographic distance, difficulties in matching schedules, different processes for billing, and a lack of systematic communication.²

A large body of research describes factors that facilitate or inhibit collaboration between agencies. Facilitators include effective two-way communication; joint planning, trainings, and coaching; shared understandings; mutual values; strong leadership support; protocols on interagency collaboration; and a named care coordinator.^1,11–13 The accumulating evidence on facilitators has been consolidated into four broader categories: (1) facilitating working relationships, (2) encouraging inter-agency processes, (3) ensuring resources, and (4) and establishing management and governance mechanisms.^1,14 Barriers outlined in the literature are often the obverse of the facilitating factors, including inadequate funding and resources, differences in perspectives and values, poor communication and trust, and confidentiality issues.^1,12,15

However, when implemented successfully, interagency collaboration is associated with many benefits given that agencies that work in collaboration can tackle significant, intractable “cross-over” problems (i.e., pervasive challenges that occur in two or more settings) more effectively than agencies working in isolation.³ Research has found that successful interagency collaboration is perceived as positive, valuable, and helpful by some patients and professionals.^1,8 Professionals report that collaboration across agencies enables them to arrive at better decisions because they obtained a more comprehensive view of patients.¹³ Finally, effective collaboration facilitates patients’ timely access to resources and reduces service gaps, decreases anxiety for providers, increases quality of case monitoring and support, and eliminates the duplication of services.^7,10,12

Interagency Collaboration between Schools and Community Agencies

Effective collaboration between service-providing agencies is even more crucial for patients with complex health care conditions, such as attention-deficit/hyperactivity disorder (ADHD), intellectual disability (ID), and/or autism spectrum disorder (ASD).¹² These youth often present with medical and behavioral health care needs that warrant psychosocial and pharmacological interventions that span across service agencies, including schools and community-based clinics.¹⁶ However, there are particular challenges to effective collaboration between community agencies and schools. For example, in a recent study, 31 representatives from 4 agencies – Probation, Mental Health, School, and Health Services – participated in an interagency collaboration within juvenile detention facilities to serve youth with developmental disabilities (DD). Participants discussed concerns about sharing information between agencies, the differing definitions of DD across the agencies, and the lack of feedback about clients to other agencies once the youth were released from one agency.¹³

There are more studies that have examined the challenges of interagency collaboration from the perspective of school personnel. For example, school psychologists report a mismatch in eligibility criteria for educational versus a medical diagnosis, lack of delineated roles and responsibilities for team members, and a limited infrastructure around information sharing.^17,18 Teachers serving students with emotional and behavioral disorders in self-contained and alternative settings reported frustrations when attempting to collaborate with community-based providers.¹¹ Some frustrations include being excluded from the behavioral health care management of their students, delays to intervention, and poor communication with agencies.¹⁵

Interagency Collaboration for Youth with ASD

ASD is a neurodevelopmental disorder affecting 1 in 54 children in the United States (US).¹⁹ ASD has a heterogenous presentation often with medical (eg, sleep disturbances, gastrointestinal issues) and behavioral/mental health (eg, anxiety, depression) challenges.^20,21 The co-occuring conditions present in ASD necessitate care from a variety of service agencies, including primary care, community-based specialty clinics, and schools. The precipitous rise in the prevalence of ASD has warranted a demand for interagency collaboration to ensure timely diagnosis and the receipt of evidence-based treatments.¹⁹

The extent to which interagency collaboration occurs for pediatric patients with ASD has also been examined from the perspective of school-based providers. More specifically, a recent national survey found that more than half of practicing school psychologists engage in collaboration with professionals outside the school system when serving students with ASD. These collaborations most frequently occurred with behavioral specialists, speech-language pathologists, occupational and physical therapists, and psychologists. Interestingly, school psychologists who engaged in more interagency collaboration were older and had been working longer.¹⁷

While studies are available that address school-based providers, there is a gap in the literature addressing interagency collaboration from the lens of community-based providers. The purpose of this study was to examine the perspective of community-based providers when engaging in interagency collaboration with school-based providers to serve pediatric patients with ASD. Our research questions span five topic areas – (1) description, (2) associated variables, (3) training needs, (4) barriers, and (5) facilitators – of interagency collaboration.

Method

Participants

Medical and behavioral/mental health professionals (N = 116) practicing in community settings (e.g., hospitals, academic medical centers, community mental health centers) in the US participated in the study. Participants were required to be currently providing services to patients for at least 20 hours a week in a community setting. Providers who offered services a minimum of 20 hours a week in schools through contract work were ineligible.

The majority of participants were White (n = 96, 82.8%) and female (n = 98, 84.5%). Participants were from 26 US states and one US territory (Puerto Rico) and represented 13 professional disciplines. The South (n = 55, 47.4%) was the most represented geographical region and psychologist (n = 41, 35.3%) was the most common discipline. Participants had been practicing an average of 10.7 years (SD = 9.73). The majority of participants were practicing in urban settings (n = 71, 61.2%) with approximately 51–75% of their patient population receiving insurance through Medicaid. Table 1 includes complete participant demographic information.

Table 1.

Participant Demographics (N = 116)

	n (%)
Gender
Female	98 (84.5)
Male	13 (11.2)
Prefer Not to Respond	2 (1.7)
Race
Asian	6 (5.2)
Black or African American	2 (1.7)
Latino	9 (7.8)
Multiracial	3 (2.6)
White	96 (82.8)
Other	1 (0.9)
Highest Degree Earned
Bachelor’s	5 (4.3)
Master’s	55 (47.4)
PhD/PsyD	43 (37.1)
MD/DO	12 (10.3)
Other	1 (0.9)
Region**
West	29 (25.0)
South	55 (47.4)
Midwest	16 (13.8)
Northeast	6 (5.2)
Puerto Rico	1 (0.9)
Population Setting
Urban	71 (61.2)
Suburban	34 (29.3)
Rural	7 (6.0)
Patients receiving Medicaid
0%	7 (6.0)
1–25%	9 (7.8)
26–50%	21 (18.1)
51–75%	46 (39.7)
76–99%	28 (24.1)
100%	1 (0.9)
Practice Setting
Hospital	43 (37.1)
Community Clinic	15 (12.9)
Private Practice	20 (17.2)
University-Based Clinic	31 (26.7)
Home-Based Care	3 (2.6)
Other	4 (3.4)
Discipline
Behavior Therapist	11 (9.5)
Psychiatrist	4 (3.4)
Neuro/Developmental and Behavioral Pediatrician	7 (6.0)
Nurse	7 (6.0)
Occupational Therapist	7 (6.0)
Pediatrician	1 (0.9)
Physical Therapist	2 (1.7)
Psychologist	41 (35.3)
Speech-Language Pathologist	19 (16.4)
Social Worker	10 (8.6)
Mental Health Counselor or Therapist	4 (3.4)
Psychometrician	2 (1.7)
Other	1 (0.9)
Formal Education in School Collaboration
None	24 (20.7)
Minimal	39 (33.6)
Some	25 (21.6)
Comprehensive	18 (15.5)
Post-Training Education in School Collaboration
None	7 (6.0)
Minimal	26 (22.4)
Some	57 (49.1)
Comprehensive	16 (13.8)

^**Regions were determined using the U.S. Census Bureau Regions and Divisions.

Procedures

We collected data using a two-phase recruitment process. In the first phase, we sent recruitment e-mails to the directors of all University Centers for Education on Developmental Disabilities (UCEDD) and Leadership Education in Neurodevelopmental and related Disabilities (LEND) programs, which are associated with the Association on University Centers for Disabilities (AUCD). These programs were targeted because of their work with individuals who have ASD. The recruitment email, which included study information and a link to the survey, requested that directors share our request with any providers/employees they thought met inclusion criteria. In the second phase, we sent the same recruitment email to prominent ASD centers/clinics in the US.

Measures

Interagency Collaboration Survey.

We developed the survey for the purposes of this study based on the literature on interagency and interprofessional collaboration, as well as the authors’ clinical experiences. The survey inquired about demographics, training experiences, and practice behaviors regarding their interagency collaborations with school-based providers in serving pediatric patients with ASD. Questions pertaining to demographics, training, and practices were multiple choice, with various response options. Participants also completed three open-ended questions on perceived training needs, barriers, and facilitators related to interagency collaboration.

Quantitative Items.

Participants were asked to report on how frequently they collaborated with school-based providers in serving pediatric patients with ASD within the last year. Categorical response options included: (1) never, (2) once every few months, (3) about once a month, (4) a few times per month, and (5) at least once per week. Due to small cell sizes across categories, response options were collapsed into: (1) never or infrequently, (2) at least once a month, and (3) at least once per week. Participants also reported on how their pre-service education and post-education training (eg, continuing education) prepared them to collaborate with school-based providers. Categorical response options for these two questions included: (1) no education/training, (2) minimal education/training, (3) some education/training, (4) comprehensive education/training. Also due to small cell sizes across categories, response options were collapsed into three categories: (1) no to minimal education/training, (2) some education/training, and (3) comprehensive education/training. Finally, participants were asked to report on which school-based providers they collaborated with and via which modality.

Qualitative Items.

Participants were given an open-ended question about how training programs could ease the process of collaboration between community- and school-based providers when working with pediatric patients who have ASD. Participants who reported they had collaborated with school personnel to serve a pediatric patient with ASD also completed open-ended questions regarding their perceptions of general challenges and facilitators to collaborating with schools. Participants who had not collaborated with schools received two separate open-ended hypothetical questions asking them to speculate perceived challenges and facilitators to collaborating with schools. Unfortunately, responses to these hypothetical questions had too few responses for meaningful analysis and were excluded.

Attitudes Toward Health Care Teams Scale – Revised (ATHCT-R).

The ATHCT is a measure of attitudes towards health care teams designed for providers and/or trainees and supervisors in training programs.^22,23 The original ATHCT is a 20-item measure with 5-point Likert scale response options and two subscales: (1) Quality of Care/Process and (2) Physician Centrality. We utilized a recently validated version of this measure, the ATHCT-R, in a sample of nationally representive interprofessional providers. This version of the ATHCT-R is a 13-item measure using a 6-point Likert scale with response options ranging from 1 (Strongly Disagree) to 6 (Strongly Agree). Exploratory factor analysis indicated that this version of the ATHCT-R has two subscales: (1) Provider Efficiency (α = .90) and (2) Outcomes of Care (α = .74). Provider Efficiency captures respondents’ perceptions regarding the efficiency of team-based care for providers. Outcomes of Care measures respondents’ perceptions regarding the associated outcomes of team-based care for both patients and providers.²⁴

Data Analytic Plan

Quantitative Data Analysis.

We ran descriptive statistics, including calculating frequencies, means, standard deviations, and percentages, to further describe the sample. We conducted a multivariate analysis of variance (MANOVA) to examine differences in interagency collaboration frequency. The independent variable was the frequency in which providers engaged in interagency collaboration (categorization described above) with school-based providers and the dependent variables were the ATHCT-R Provider Efficiency score, ATHCT-R Outcomes of Care score, and years working.

Qualitative Data Analysis.

Researchers qualitatively analyzed the three open-ended responses using classical content analysis.²⁵ Two investigators reviewed all qualitative responses before creating themes with unique subthemes for each question. After a review of responses, the investigators identified and agreed on four to five codes for each question before assigning phrases/statements to a code. They next compared coding results and resolved any discrepancies through discussion until consensus was reached. Finally, the investigators calculated a percentage for each coded theme within each open-ended question (ie, number of coded responses for a theme divided by total number of coded responses within each question). This process has been used in prior studies examining qualitative responses to open-ended questions in online surveys.^17,26

Results

Research Area 1: Descriptive Understanding of Interagency Collaboration

One hundred and five (90.5%) participants responded to the question about interagency collaboration frequency. Of these, 93 (88.6%) participants reported engaging in interagency collaboration with school-based providers when delivering services to pediatric patients with ASD within the last year. Forty-two (36.2%) engaged in this collaboration once every few months, whereas 20 (17.2%) engaged in this collaboration about once a month. Seventeen (14.7%) and 14 (12.1%) engaged in this collaboration a few times per month and at least once per week, respectively. Only 12 (11.4%) participants said they had not engaged in such collaboration within the last year. Intervention/management (n = 78, 62.2%) was the most common reason for collaboration. Participants collaborated the most with special education teachers (n = 66, 56.9%) and the least with physical therapists (n = 6, 5.2%). When engaging in interagency collaborations, the modes used by community-based providers most and least frequently were phone calls (n = 77, 66.4%) and video conferencing (n = 4, 3.4%) or Health Insurance Portability and Accountability Act (HIPAA) complaint web-based portals (n = 4, 3.4%), respectively. With regard to referring patients with ASD and their families, 68 (n = 68, 70.1%) and 83 (n = 83, 86.5%) reported doing so for evaluation and intervention services, respectively. See Table 2.

Table 2.

Description of Interagency Collaboration with Schools for Pediatric ASD (n = 116)

	M(SD)
ATHCTS-R: Provider Efficiency	18.64 (2.89)
ATHCTS-R: Outcomes of Care	46. 38 (4.42)
	n (%)
Collaboration with Schools in Past Year
Never	12 (10.3)
Once Every Few Months	42 (36.2)
About Once a Month	20 (17.2)
Few Times per Month	17 (14.7)
Once per Week	14 (12.1)
School-Based Providers Who Collaborated	In the Past Year	Most Common
Administrators	37 (31.9)	5 (4.3)
Behavior Specialists	37 (31.9)	4 (3.4)
Nurses	16 (13.8)	2 (1.7)
Occupational Therapists	22 (19.0)	5 (4.3)
Physical Therapists	6 (5.2)	2 (1.7)
School Psychologists	38 (32.8)	17 (14.7)
School Counselors	27 (23.3)	6 (5.2)
Social Workers	30 (25.9)	6 (5.2)
Speech-Language Pathologists	48 (41.4)	19 (16.4)
Special Education Teachers	66 (56.9)	21 (18.1)
General Education Teachers	43 (37.1)	8 (6.9)
Other	8 (6.9)	6 (5.2)
Purpose of Collaboration
Data Sharing for Evaluation	56 (48.3)
Data Sharing for Intervention/Management	78 (67.2)
Data Sharing for Response to Intervention	32 (27.6)
Data Sharing for Response to Medication	5 (4.3)
Referral to Schools	For Evaluation	For Intervention
Never	29 (25.0)	13 (11.2)
Sometimes	40 (34.5)	26 (22.4)
Often	16 (13.8)	22 (19.0)
Almost Always	12 (10.3)	35 (30.2)
Modality of Communication with Schools
Phone System	77 (66.4)
Email System	73 (62.9)
Postal Mail	7 (6.0)
In Person Meeting	32 (27.6)
Video Conferencing	4 (3.4)
HIPAA Compliant Web-Based Portal	4 (3.4)
Other	3 (2.6)

Research Area 2: Relation between Interagency Collaboration, Interprofessional Team-Based Care, and Experience

Results from the multivariate MANOVA (see Table 3) revealed no significant main effects of the frequency of interagency collaboration on perceptions of team-based care for the Provider Efficiency subscale, F(2, 82) = .630, p = .535, η² = .015, nor Outcomes of Care subscale, F(2, 82) = .351, p = .705, η² = .008. Results did yield a significant main effect of the frequency of interagency collaboration on years working, F(2, 82) = 3.436, p < .05, η² = .077. Post hoc analyses showed that participants who reported collaborating with schools never or infrequently (M = 9.35, SD = 8.85) had been working for significantly fewer years than participants who reported collaborating with schools at least one per week (M = 15.69, SD = 11.87), p < .05.

Table 3.

ANOVA Table of Results (n = 85)

	SS	df	Mean Square	F	p	η2
ATHCTS: Provider Efficiency	10.74	2	5.37	.63	.535	.015
ATHCTS: Outcomes of Care	13.92	2	6.96	.35	.795	.008
Years Working	544.51	2	272.26	3.44	.037	.077

Research Area 3: Training Innovations to Improve Interagency Collaboration with Schools

Of the 93 (80.2%) responses for the question about training needs, 83 were codable. Items were uncodable if participants did not answer the question (e.g., responded that they were not in a position to answer). Table 4 includes the response percentages for each coding theme. The most common (61%) theme related to increasing the number of didactic training opportunities on interagency collaboration with schools. This category included didactic training on school policies and procedures, special education law (i.e., Individuals with Disabilities Education Improvement Act [IDEIA]), and the roles and functions of school personnel. One participant stated, “More training on the types of services that schools are able to provide and the [Individualized Education Program] IEP process so that providers better understand what is practical for a school to do to help students with ASD and what may be better served through outpatient services.” Others suggested, “A seminar/course to learn special/general education program structure and policy,” and, “Workshops between schools and community providers to understand each other’s roles.”

Table 4.

Response Percentages in Qualitative Coding Categories

Survey Question	Coding Category	Response Percentage
The role of training programs in collaboration (n = 93)	Didactic experiences in school collaboration	61
	Hands-on experience in collaborating with schools	46
	Didactic experiences in general interprofessional collaboration and coordination	14
	Hands-on experience in generally collaborating with a interprofessional team	8
Barriers to interagency collaboration (n = 83)	Broad school system administrative challenges	55
	Lack of time or reimbursement for coordination	46
	School personnel lack of training and expertise in ASD	28
	Lack of knowledge regarding educational eligibility vs clinical diagnosis	15
	Difficulty sharing confidential records	11
Facilitators to interagency collaboration (n = 77)	Broad school system administrative supports	74
	Ease in the process of sharing information	32
	Methods to effectively coordinate schedules	11
	School personnel training and expertise in ASD	9
	Knowledge regarding educational eligibility vs clinical diagnosis	7

The second theme (46%) described the need for training programs to provide more hands-on experiences in collaborating with schools. Specific recommendations under this category included shadowing or observing school personnel in a school setting and attending school meetings (eg, IEP meetings for special education eligibility). One participant responded, “Trainees should shadow mentors at IEP meetings, 504 Plan meetings, and during classroom observations.” Another stated, “Provide opportunities to consult with schools as part of graduate practicum experiences.”

The third theme (14%) described general didactic experiences in collaborating with and coordinating services across different agencies. This theme captured didactic training that is not necessarily school specific, but still involved multiple professions. Participants included examples such as “LEND fellowship” and “Interdisciplinary cross program training.” One participant recommended, “Teaching that interdisciplinary care coordination is best practice and essential despite the discipline you primarily work in.”

The fourth theme (8%) represented general hands-on experience with interprofessional collaboration across different agencies. This theme characterized responses that included applied experiences that were not school-specific, but included a multidisciplinary team. One participant noted that training programs should provide, “Interactions with students from other professions to learn where their thought process is and how to best collaborate with them.” Another participant stated, “Multidisciplinary trainees at our center participate in observations with psychologists, special educators, speech pathologists, and autism resource specialists.”

Research Area 4: Community-Based Providers’ Perceived Barriers to Interagency Collaboration with Schools

Of the 83 (71.6%) responses regarding barriers to interagency collaboration with schools when serving pediatric patients with ASD, 80 were codable. See Table 4 for response percentages. The most common theme (55%) broadly covered school system administrative supports. This category included responses mentioning a lack of buy-in from schools in collaborating with community-based providers, lack of funding or incentives to collaborate on the part of community-based providers, and a lack of resources when collaborating. Other responses indicated that schools were not open to visits (e.g., attending meetings, conducting observations) from community-based providers. Another participant noted, “Most schools are ill-equipped with a lack of resources, special education teachers, skills, etc. to even provide appropriate education protected under law.” Another stated that a challenge was “Overall buy-in and committing and following through with collaboration.”

The second theme (46%) reflected the lack of time and insurance reimbursement when collaborating with schools. Participants often reported there was little time to collaborate or that it was difficult to coordinate schedules between providers in different settings. Likewise, community-based providers found it challenging that insurances did not reimburse for time spent during these collaborations. Participants indicated, “Lack of time for both school staff and professionals to coordinate,” and, “ABA [applied behavior analysis] codes cannot be billed during the time the client is in school, making formal collaboration difficult.” One participant stated, “Time constraints are challenging, as the school professionals tend to be most available when school lets out, whereas that is my busiest time for seeing clients.”

The third barrier (28%) identified issues related to a lack of training and expertise in ASD among school personnel. Responses suggested that school IEP goals or interventions are not well aligned with evidence-based practices for children with ASD. Examples include, “Limited knowledge of evidence-based approaches for helping kids with ASD,” “Variability with how teachers and other school professionals understand how to work with students with ASD,” and, “Differing opinions about the nature of the problem. Differing opinions about the treatment for the problem.”

The fourth theme (15%) indicated a lack of knowledge regarding differences in the special education eligibility category of Autism and a medical diagnosis of ASD. This category also included differences in understanding the procedural or IEP process. Example responses included, “There are just inherent challenges in collaborating between the medical model and the educational model,” and, “Schools are often not directly helpful in explaining the nuts and bolts of the evaluation and IEP process.”

The final barrier (11%) reported by respondents reflected difficulties in sharing information. Often, responses referred to HIPAA and Family Educational Rights and Privacy Act (FERPA) restrictions and receiving the release of information consents from families. For example, one participant stated, “Difficult to get releases signed to communicate with the school and reach the correct person.” Another noted, “The potential risks of privacy violations with such communications.”

Research Area 5: Community-Based Providers’ Perceived Facilitators to Interagency Collaboration with Schools

Seventy-seven participants (66.4%) answered the question regarding facilitators to effectively collaborating with school-based providers when serving pediatric patients with ASD, and 76 of these responses were codable (see Table 3). The most common theme (74%) represented the importance of broad school system administrative supports. Specifically, participants mentioned positive attitudes toward collaboration from schools, putting the needs of the child and family first, effectively coordinating services between community- and school-based providers, and schools allowing community-based providers to come into schools. All of these aspects are only possible with administrative support. Example responses include, “Acknowledging each person’s expertise and finding ways to get all people involved,” “Schools willingness to collaborate,” and, “Attending IEP meetings also helps build rapport and establish open dialogue.”

The second theme described mechanisms to make the process of sharing information easier between parties. Thirty-two percent of responses indicated that this facilitates interagency collaboration. Specifically, respondents mentioned easily working with HIPAA and FERPA restrictions, rapidly retaining the release of information consent from families, engaging in collaborative meetings, and having teleconferences were identified as facilitators to effective interagency collaboration. Participants stated, “Having copies of IEPs or other treatment documents is always helpful,” “Phone conversations where both parties can be heard,” and, “Parents bridging the gap by helping exchange contact info, signing releases, effectively communicating current supports at school.”

The third facilitator (11%) described methods to effectively coordinate schedules between community- and school-based providers. Responses reflected the importance of allowing school personnel to have dedicated times in their schedules specifically for community-based providers. They also noted the importance of having billing reimbursement for phone calls and other care coordination with school-based providers around shared patient care. One participant noted, “Make sure to work around the school staff schedule as they are typically more challenging.”

The fourth theme (9%) indicated the importance of school personnel having sufficient training and expertise in ASD. One participant stated, “We rely on information from schools for our autism diagnostic clinics and greatly value teacher perspectives on social skills.” Others mentioned, “Schools that have specific programs for ASD already established,” and, “School teams being well-versed in and supportive of learning differences.”

The final theme (7%) indicated the importance of school-based providers’ knowledge of special education eligibility classifications and medical diagnoses of ASD. This theme also covered knowledge and understanding of the procedural and IEP processes. When describing facilitators to interagency collaboration, one participant wrote, “Having knowledge about educational classification criteria.”

Discussion

Interagency collaboration between community and school settings is one mechanism to serve the complex needs of pediatric patients with ASD.^1,4,7,8 Using a national survey, we found that a majority of community-based providers reported engaging in interagency collaboration with school-based providers when serving pediatric patients with ASD. The frequency of participants’ interagency collaboration was associated with the number of years working in the field. With regard to training, community-based providers wanted more didactic and hands-on experiences in interprofessional, interagency collaboration. Several perceived barriers and facilitators to interagency collaboration with schools were reported.

Given the limited research on interagency collaboration between schools and community agencies, particularly for pediatric patients with ASD, we were interested in understanding the descriptive nature of interagency collaboration. Although a majority (88.6%) of community-based providers reported collaborating with school-based providers, the frequency of interagency collaboration was limited. Only a third reported engaging in interagency collaboration once every few months, characterizing this type of work as networking, rather than collaboration. The literature on interprofessional practice suggests that there is a spectrum that includes networking, coordination, collaboration, and team-based care. In networking, professionals meet and work together on a periodic basis, which is in contrast to collaboration where professionals regularly come together through frequent communications, shared goals, and collective resources.^3,27,28

The infrequency of interagency collaboration suggests that community-based providers may be working with school-based providers for only a selection of their patients with ASD, perhaps the most complex cases. Research has indicated collaborative care improves patient outcomes, particularly for complex patients.^12,29 Collaboration between systems that share complex patients is an effective way to reduce service overutilization, improve service delivery, and reduce costs associated with care.³⁰ In our study, more than half of these collaborations were with special education teachers, conducted over the phone, and were about intervention/management practices. This finding suggests that what is taking place can more adequately be described as interprofessional, interagency collaboration. However, this collaboration does not take a preventative approach (e.g., identification purposes). Rather, community-based providers are directly engaging with special education teachers to problem-solve intervention practices for their pediatric patients with ASD.

In addition to understanding interagency collaboration descriptively, we also were interested in factors associated with interagency collaboration. We found that the frequency of interagency collaboration was associated with the number of years a provider reported working. More specifically, community-based providers who have been working in the field for fewer years reported limited collaboration with schools, which aligns with prior research focused on school psycholoigsts’ interagency collaboration. Interestingly, the frequency of interagency collaboration was not related to perceptions about the efficiency and outcomes associated with team-based care. Our findings are consistent with research showing that cognitive perceptions only account for some variation in actual behavior. The theory of planned behavior suggests that the performance of a behavior (ie, engaging in interagency collaboration) is determined by one’s motivation or intention to engage in that behavior. Intention is determined by whether the behavior is evaluated positively (i.e., attitude), the view of significant others (i.e., subjective norm), and the extent of control one has (i.e., behavioral locus of control). Perceived behavioral control can also directly impact actual behavior.³¹ Community-based providers who have been working longer in the field may engage in more frequent interagency collaboration with schools for patients with ASD because they are motivated. These providers may also have a positive view of interagency collaboration and understand the positive social implications of engaging in such collaborations (e.g. supervisors seeing them go above and beyond for their patients). Reaping the benefits of interagency collaboration, the more experienced community-based providers may be finding the time and resources (i.e., control) to engage in such collaborations.

Along with understanding the content (quantitative) of interagency collaboration, we also wanted to elucidate the context (qualitative) with which interagency collaboration occurs with schools. We probed community-based providers to describe their training needs, as well as barriers and facilitators to interagency collaboration with schools. When asked about the role of training programs, the most common theme related to the need for increased didactic training opportunities (e.g., formal coursework, seminars, and workshops in interagency collaboration), specifically in collaborating with schools, including understanding school policies/procedures, special education law, and the roles of the various school personnel involved with students with ASD. Almost half of the participants also requested more hands-on experiences in collaborating with schools, such as observing school personnel and attending IEP meetings. Although not as common, community-based providers also wanted more didactic and hands-on experiences in interprofessional collaboration in general. Our findings are a call to training programs to re-think their curricula to train providers who have the capacity to engage in interprofessional collaboration within and across systems of care. Allowing more didactic and hands-on experiences with collaborations from a variety of disciplines early on in the training sequence may allow providers to feel more self-efficacious when engaging in interagency collaborations independently in the work force. With increasing expectations for agencies to work in collaboration with one another, training programs will need to follow suit and incorporate theoretical, clinical, and practical aspects of interprofessional, interagency collaboration into their curriculum.^3,32

With regard to barriers and facilitators to interagency collaboration, community-based providers indicated that school systems’ administration plays a key role in enhancing or impeding interagency collaboration. Some barriers reported included a lack of buy-in from school administrative staff, thus preventing community-based providers from attending important school meetings, such as IEP meetings. Participants also mentioned facilitators such as, “acknowledging each persons’ expertise” and “building rapport and open diaglogue.” These factors resonate with the Interprofessional Collaborative Practice core compentencies, such as roles and responsibilities and interprofessional communication, respectively.⁵ Focus groups and individual interviews with local education and state personnel suggests that leadership support is a critical factor in fostering interagency collaborations at schools. More specifically, administrators who value such collaborations can pay for substitutes allowing their teachers to collaborate more effectively.³³ Further, school-based providers are more likely to collaborate with community-based providers in schools where administrators foster a culture and climate of collaboration with providers outside the school. Strong leadership has consistently been identified as a facilitator for interprofessional and interagency collaboration.^1,13

Another facilitator and barrier reported by community-based providers was school personnels’ training and expertise in ASD. Given the diversity of fields that come together to serve students with ASD in schools (e.g., special education, school psychology, school counseling, social work), it is imperative that some in-service professional development days are dedicated to ensuring that staff have the same threshold of knowledge in ASD. More community immersion experiences (e.g., shadowing community-based providers at ABA clinics) may be necessary for adequate experiences in ASD. Although experiential learning is not a new concept in educational training programs, experiential learning in different contexts may be necessary to train the next generation of educators.³⁴

The ease with which information is shared between community- and school-based providers also emerged as a barrier and facilitator, although it was reported more frequently as a facilitator. This is consistent with prior research showing that sharing information between agencies is a major factor for interagency collaboration.¹³ Policies at the administrative level, both for schools and community-based clinics, may be necessary to facilitate a more streamlined process for sharing confidential information between agencies. Capitalizing on technology, such as HIPAA/FERPA compliant portals, may be one avenue for information sharing.³⁵

The final theme that was reported as a barrier and facilitator to interagency collaboration was knowledge about educational eligibility verses medical diagnosis. Although this theme was reported as both a barrier and facilitator, it was only endorsed by a minority of participants - 7% and 15%, respectively. This is in contrast to a prior study showing that school-based providers perceive that the disconnect between educational classifications and medical diagnosis is a larger barrier when collaborating with outside providers. More specifically, 30% of school psychologists reported this as a problem.¹⁷ The disconnect between community- and school-based providers on this issue may in and of itself impede interagency collaboration.

It is noteworthy that community-based providers primarily indicated barrires and faciliators within the educational system (and not within their own systems). Interestingly, school psychologists attribute their lack of collaboration with outside agencies to a lack of awareness and knowledge on the part of community-based providers, specifically related to differences between medical diagnostic criteria and educational classification, as well as educational services offered and the constraints of the school setting. Another similar barrier/facilitator reported was difficulty sharing information.¹⁷

There are limitations to note about the present study. First, we limited our sample to community-based providers who engaged in at least 20 hours of clinical services and worked with patients who have ASD, which limited our sample size, and may potentially impact the generalizability of our findings. However, is it noteworthy that nationally there are limited providers who work with pediatric patients with ASD. Second, we recruited from UCEED and LEND programs, as well as major autism centers around the country, which are often affiliated with major universities. Therefore, our findings may not be representative of all community-based providers. Third, in the qualitative component of the study, we did not inquire about barriers and facilitators separately for assessment versus intervention. For example, sharing information may be more of a barrier in assessment practices compared to intervention. Fourth, the community-based providers who completed our survey were primarily female and from urban areas. We had less representation from males and rural providers. However, it is unclear whether we were not able to recruit these providers or there are indeed fewer male and rural providers who serve pediatric patients with ASD.

Conclusion

Findings from the present study have implications for the practice of interagency collaboration. First, is the critical role of school-based administrative support. The three barriers and facilitators identified in our study – (1) school personnel training and expertise in ASD, (2) sharing information, and (3) delineating between special education classification and medical diagnosis – could all be better addressed with leadership to support interagency collaboration. In schools, a top-down approach may be necessary to encourage school-based providers to collaborate with community-based providers to more effectively address the complex needs of students with ASD. Second, our findings highlight the need to promote innovative training experiences in interprofessional, interagency collaboration. For example, pairing junior clinicians with their more senior colleagues from different disciplines may be one way to obtain more education and hands-on experiences with providers who have been working longer in the field (and likely to engage in interagency collaboration more frequently). As service-providing agencies are pressured to abandon a siloed approach to care, interagency collaboration is a promising model to not only increase service use and access, but also to enhance the quality of service provision for pediatric patients with ASD.