An Integrated Care Model for the Diagnosis and Treatment of Comorbidities in Individuals with Intellectual and Developmental Disabilities and Autism

Background: Individuals with Intellectual and Developmental Disabilities (IDD) and Autism commonly face multiple medical and psychiatric conditions, which are often underdiagnosed or mismanaged, mainly due to communication barriers and fragmented healthcare systems. According to 2024 Medicaid data, a majority of adults with ID/DD had behavioral health conditions (56.5%) or physical health conditions (60%). This session will explore prevalent comorbidities and discuss effective strategies for their timely diagnosis and management through an integrated care approach.

 

Approach: At Woods, we implemented an integrated care model designed to address the complex needs of individuals with IDD and Autism. This model unites primary care, behavioral health, psychiatry, dental care, and other specialty services, creating a collaborative, patient-centered approach. Care delivery occurs both on-site at the Medical Center and in patients’ homes through a hospital-at-home program for medically and behaviorally fragile individuals. Interdisciplinary teams—including physicians, nurses, dentists, therapists, and social workers—work collaboratively with families and caregivers, co-designing care plans tailored to each patient’s unique needs. This approach emphasizes early identification of comorbidities such as allergies, gastrointestinal issues, sleep disturbances, seizures, and memory impairment, ensuring timely interventions and continuity of care. Case examples will illustrate how the model effectively bridges gaps between specialties and improves access for a population that historically faces significant healthcare disparities.

 

Results: Implementation of the integrated care approach has produced measurable improvements across multiple domains. Patients now experience fewer emergency visits and hospitalizations, and this reduction has decreased stress and trauma for both the individuals themselves and their caregivers. Health outcomes have improved in several areas, including oral hygiene, seizure control, and monitoring for medication side effects. At the same time, unnecessary polypharmacy has been reduced, contributing to safer and more effective treatment. The enhanced coordination and communication between primary care and specialty care providers has strengthened care continuity, allowed for earlier interventions, and improved overall patient well-being. Families have reported higher levels of satisfaction and greater confidence in the care system, which reflects the model’s success in addressing both the medical and behavioral needs of patients.

 

Implications: The integrated care model at Woods demonstrates a replicable framework for delivering whole-person care to individuals with IDD, autism, and complex comorbidities. By involving families, caregivers, and interdisciplinary teams in co-designing interventions, this approach ensures patient-centered care that addresses both medical and behavioral needs. The model has inspired expansion, including a satellite center in a nearby county and plans for additional centers in neighboring states where individuals with IDD and Autism lack access to high-quality healthcare.

 

International delegates can learn strategies for interdisciplinary collaboration, family and caregiver engagement, and co-designed care planning that improve diagnosis, treatment, and overall quality of life. The model also demonstrates scalable solutions, such as hospital-at-home programs and satellite centers, which can be adapted to diverse healthcare contexts. By highlighting measurable improvements in health outcomes, reduction in hospitalizations, and enhanced patient-centered care, this approach provides actionable insights for policymakers, clinicians, and program designers seeking to improve care for vulnerable populations globally.