According to the Ministry, agency staff and stakeholder groups, one of the main complaints from families in the three regions we visited was disagreement with the discharge decision. The Ministry informed us that the decision to discharge a child from IBI therapy is a clinical one made by the lead service agency in each region, regardless of whether the child receives services provided by a lead service agency or private services paid by the Ministry. Between 2006 and 2012, more than 3,500 children in Ontario were discharged from IBI services as follows: 70% no longer needed IBI, 8% declined services, 3% moved out of region, and 19% for other reasons. To understand what “no longer needed IBI” means, we sampled a number of files in the regions we visited and found that discharge reasons could include: benefits from IBI Figure 4: Percentage of Children Receiving Different
Durations of IBI Services Under Each Service Delivery Option
Source of data: Ministry of Children and Youth Services
Direct Service Direct Funding Option (%) Option (%)
<1 year 22 19
>1–2 years 33 19
>2–3 years 31 23
>3–4 years 9 16
>4 years 5 23
Note: Percentages are based on files for children discharged from IBI in the 2012/13 fiscal year.
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have been maximized, IBI has not been effective in changing developmental level, IBI has been effect-ive and child will benefit more from learning in a natural environment, and child has not made any significant progress since last assessment.
Over the years, attempts have been made to establish consistent provincial discharge or
“continuation” criteria. The first set of clinical continuation criteria was developed in 2006 by clinical directors in service agencies but was not finalized. Instead, in November 2007, the Ministry assembled an expert panel to determine “clinical practice guidelines.” Subsequently, the Ministry struck another panel to arrive at benchmarks for the newly developed guidelines. These benchmarks
were presented to the Ministry in September 2008.
In March 2010, the Ministry hired a consultant to conduct a pre-implementation review of the bench-marks, but the consultant found that there was not enough information in the clinical files to be able to conclude on the benchmarks. Although it has spent
$330,000 to date, the Ministry has not concluded on discharge criteria. Other jurisdictions do not need discharge criteria given that their services usually end when children reach a specified age.
In October 2012, the clinical directors of the IBI programs agreed on and approved a common set of discharge criteria, which are more comprehensive than previous benchmarks. The three lead service agencies we visited indicated that they would be Direct service option
Direct funding option
Central Eas 0 t
5 10 15 20 25 30 35 40 45 50
Central West
Eastern
Hamilton–Niagar a
North East* Northern South Eas t
South West Toront o
Figure 5: Average IBI Duration in Months for Children Discharged During 2012/13, by Region and Service Delivery Option
Source of data: Ministry of Children and Youth Services
*This region does not have any direct funding option clients due to a lack of private providers in the region.
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implementing these revised criteria in their regions.
But at the time of our audit, each was following different discharge criteria, which included a combination of the updated clinical continuation criteria from 2006 and the 2008 clinical practice benchmarks. However, we also noted that the region that uses benchmarks indicated it would refer to them on a case-by-case basis, and clinicians would apply professional judgment in making dis-charge decisions.
In December 2012, the Ministry formed yet another expert panel to, among other things, pro-vide advice on whether benchmarks are appropri-ate for IBI discharge/continuation decisions. At the time of our audit, the committee was expected to report back to the Ministry in October 2013.
Also in December 2012, as mentioned previously, the Ministry introduced an independent review mechanism, empanelled by a roster of independ-ent reviewers managed by an external agency, to be used when families disagree with the service providers’ decision on eligibility or discharge. We were informed that reviewers will use their clinical judgment to rule on whether the decision made by the original IBI service provider was consistent with the information noted in the child’s file.
At the time of our audit, the Ministry told us that there has been and continues to be disagreement among the expert community on whether there should be a consistent set of discharge criteria. How-ever, without consistent criteria, there is no assur-ance that clinicians assessing the same child would reach the same decision on whether the child should continue or be discharged from IBI. Furthermore, there is a conflict, whether real or perceived, when the lead service agency is responsible for determin-ing when services should end, while at the same time being responsible for managing wait lists and meeting targets for the number of people served.
ports and services, the Ministry of Children and Youth Services (Ministry) should:
•
work with the Ministry of Health and Long-Term Care and the medical community to facilitate the identification and diagnosis of autism in children before age 3, in accord-ance with the original objective of the Min-istry’s intensive behaviour intervention (IBI) program; and•
monitor wait times as well as wait-list data across the province for both IBI services and applied-behaviour-analysis-based services.To help improve program transparency and ensure equity of service in the best interests of the child, the Ministry should:
•
ensure that clear eligibility, continuation and discharge criteria for IBI services are developed and are applied consistently, so that children with similar needs can access a similar level of services;•
ensure that service providers clearly specify, for every child, the reason that the child is discharged from the IBI program and report this information to the Ministry for analysis;•
review the reasons for significant regional and differences in the use of the direct service option and the direct funding option, and ensure that decisions on the capacity to pro-vide each service are being made objectively.MINISTRY RESPONSE
As part of a review of autism services initiated in August 2013, the Ministry is reviewing barriers to early identification, diagnosis, assessment and treatment with a view to identifying oppor-tunities for improvement. After focused discus-sions with families, research experts, health and medical professionals, and inter-ministerial partners in education and health, the Ministry will develop a plan to improve early identifica-tion and access to diagnosis and assessment.
RECOMMENDATION 1
To help ensure that children with autism and their families have earlier access to autism
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