501 - Maintaining A Protocol for Standardized Anxiety Screening for Adolescent Patients at a Community-Based Clinic: A QI Approach

Publication Number: 4492.501

Anum K. Hussain, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Rebecca Kow, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Emily Fine, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Kobi Axelrod, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Hanna Swerdin, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Kahmun Lo, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Eric Takoushian, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Lauren Mica Yoder, New York Presbyterian Weill Cornell, New York, NY, United States; Katelyn Jackson, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Ambreen F. Zaidi, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Brandon Loh, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Paige Heiman, NewYork-Presbyterian Komansky Children’s Hospital, New York City, NY, United States; Victoria Cheung, Weill Cornell Medicine, New York, NY, United States; Snezana Nena Osorio, Weill Cornell Medicine, New York, NY, United States; Nadia Nikroo, NewYork-Presbyterian Komansky Children’s Hospital, New York City, NY, United States

Background: Anxiety affects 1 in 10 children 3-17 years of age in the United States. The United States Preventative Services Task Force (USPSTF) recommends screening patients ≥8 years old. In 2024 our resident -led QI team introduced standardized screening with the aim to improve outcomes for patients with anxiety.

Objective: To improve both, anxiety counseling to 90% and referral to mental health services to 60% for patients who score positive using the Screen for Child Anxiety Related Disorders (SCARED-5) questionnaire at well child checks by May 1st, 2026.

Design/Methods: In this ongoing observational QI study at a community-based primary care clinic affiliated with a tertiary academic medical center, residents used the model for improvement to design a SMART AIM, project measures and a Key Driver Diagram (Figure 1). All patients aged 12-18 years presenting for well child checks were included. We used a family of measures including the % of patients screened for anxiety, the % of patients with anxiety diagnosis added to the problem list (process), the % of patients with documented anxiety counseling, the % of patients referred to mental health services and % of patients who received counseling and /or were referred to therapy with improved SCARED scores (outcome). Our balancing measure was the % of patients who declined referral to mental health services. We tested several interventions including resident education about anxiety counseling, EMR adjustments to support documentation and standardizing a referral workflow. We collected data via EHR review and performed analysis using run charts and Shewhart charts. We applied run chart and API rules to detect a signal of change and special cause variation respectively.

Results: In this study of 1903 patients, we screened 1721 for anxiety (90%). Overall anxiety rate is 15% (n=262) of which 18% were already in therapy (n=48). We improved addition of anxiety diagnosis to the problem list from 39% to 65% (Figure 2). Likewise, we noted a special cause in counseling documentation from 10% to 74% (Figure 3). Referral rate to mental health services was steady at 40% (n=106). To date 63% of referred patients have been re-screened for anxiety. There was no change in declining a referral (31%, n = 66).

Conclusion(s): For patients who were positive for anxiety, we improved resident anxiety counseling and adding anxiety diagnosis to the problem list, while maintaining high screening rates. Our next steps include identify risk factors for declining mental health referrals and analyzing rescreening scores.

Figure 1
Key Driver Diagram with three primary key drivers, including clinic staff engagement, partnership with patients and caregivers and workflow screening.

Figure 2
Documentation of anxiety diagnosis improved from 39% to 65% (anxiety diagnosis added to the problem list)

Figure 3
Documentation of providing counseling improved from 10% to 74% following resident education on how to provide anxiety counseling
and Electronic Health Record modification to capture documentation.