88 - Beyond the Checkbox: A QI Initiative to Improve Screening, Documentation, and Referrals for Justice-Involved Youth

Publication Number: 4086.88

Shiv Ayappa, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Joyce H. Lee, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Jaz-munn Johnson, Johns Hopkins Children's Center, Baltimore, MD, United States; Julia Myers, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Deena Haque, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Kiara Smith, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Benjamin Bodnar, Johns Hopkins University School of Medicine, Baltimore, MD, United States

Background: Adolescents and young adults (AYA) from marginalized and under-resourced communities face higher risks of juvenile justice involvement (JJI) due to structural inequities, systemic biases, and increased individual risk-taking behaviors. Even when pre-visit questionnaires (PVQs) are used to screen for JJI, PVQ utilization by providers, documentation of findings, and implementation of evidence-based interventions for patients with JJI is inconsistent. As such, this quality improvement project was developed with the goal of increasing community-based organizations (CBO) referrals to help facilitate community integration after JJI.

Objective: For all AYA who screen positive for history of JJI, we aimed to increase the percentage of referrals placed to a local CBO from 0% to 40% by Nov 1st 2026.

Design/Methods: Using the Plan Do Study Act (PDSA) framework, we performed a root cause analysis on inefficiencies in the clinical workflow using a provider survey, Ishikawa fishbone diagram (Fig. 1), DOMOWIT matrix, and 5-Why diagrams. Targeted interventions were developed using a Benefit-Effort chart, then sequentially implemented at the start of each 1-month interval ("blocks") spanning 6 months. At the end of each block, all PVQs were reviewed for completion and JJI, and patient charts were reviewed for documentation of risk and consent for CBO referral.

Results: Provider survey results showed widespread workflow deficiencies, with 97% (n=29) either unaware that the PVQ screened for JJI or forgetting to review PVQ after completion by the patient. Documentation was also a barrier, with 79% (n=22) unsure how to best document JJI. 93% (n=26) said they did not discuss JJI with patients due to lack of training surrounding what to recommend or what evidenced-based intervention could be implemented.

Despite the PVQ completion rate fluctuating, the average case finding rate and positive screening rate both increased (2.87% to 6.68% and 10.9% to 14.09%, respectively). Additionally, even with sub-optimal documentation and referral rates, the 6 month average CBO referral rate was 9.6% and the last 2 blocks demonstrated that 100% of patients with documented JJI received CBO referral (Table 1).

Conclusion(s): This QI intervention resulted in increased JJI case-finding rates, case documentation rates, and CBO referral rates, especially resource referral rates for AYA with documented risk. Continued interventions and analysis are needed to achieve sustained improvement. This work illustrates how clinic-wide education, workflow alteration, and CBO collaboration can lead to improvements in care for AYA with JJI.

Table 1: Outcomes Summary Table of Process Measures based on Monthly Intervention
Caption: Sequential implementation of interventions and corresponding process measures across 6 monthly blocks. Key process improvement measures include PVQ completion rate and documentation rate.

Figure 1: Ishikawa Cause & Effect Fishbone Diagram
Ishikawa fishbone diagram identifying barriers that contribute to lack of screening, documentation, and implementation of evidence-based interventions for youth with a history of juvenile justice involvement. Root causes were categorized under: people, materials, methods, environment, and equipment.