Construct

Definition

Illustrative Quotes

Coherence

The initial sense-making work that is involved in ultimately implementing new tools and methods in practice. This sense-making involves both individual and communal aspects, such as individuals defining internal motivation for learning about these new practices, as well as identifying their roles as individuals and within a community of providers as they begin to think about how these practices will be applied.

105: “Being able to think and understand how pediatricians approach a patient, as well as the concerns and challenges they face in thinking from that behavioral health lens…. What could we do? What could we hold with them so they’re not holding it alone?”

109: “I think that I’ve felt more confident through hearing other health centers talk about maybe those challenging cases…. How do you talk about what [autism] is…. When we look at it through a lens of a biomedical sort of Western medicine-informed diagnostic entity…. but I’m seeing a newly immigrated from Albania family that doesn’t speak English… In their culture, there’s an idea that… not talking until the age of five is actually pretty typical, and [the family is] not concerned about that at all…. We need to somehow meet each other in the middle… and do what we think is in the child’s best interest while honoring that family’s values…. I think the ECHO was also really useful to hear different clinics talk about those types of dilemmas, and this is how I would talk to the parent about that...”

Cognitive participation

Problem identification, collaborations within a clinic to work towards solving the problem, and how clinicians can confidently sustain their practices. Participants identified the pieces that need to come together to lead to positive change in their individual and clinic-level practice. This thinking involves identifying the individuals who will bring about this change and the context in which they will be doing so. Further, participants reflected on whether they are confident that they have the tools and people necessary to exact change.

102: “… Better able to talk about like what’s available in the moment… For instance, Early Intervention for the younger kids or school and getting them set up at schools, and then again like the ABA for afterwards.”

106: “As I said, we’re sort of working on, we had just started trying to become more autism friendly and… then the pandemic came. So, I think that sort of a combination of that, plus the ECHO plus [clinician]’s mini fellowship. [Clinician] and I are working on making almost sort of a mini developmental clinic day type thing so that we have much better, we have more wraparound services than we had before.”

Collective action

Refers to the action steps that participants need to take to implement new practices they learned from BCAEP. This involves interacting with the systems already in place (e.g., referral process), barriers (e.g., COVID-19), allocating time and resources, and building systems of accountability (e.g., defining staff roles and responsibilities) to ensure that these changes are implemented effectively.

107: “…One aspect of diagnosis is that the visit… schedule goes from every two months to… every year… very quickly….. Then what happens is that kid is too old for Early Intervention, [but] too… young for school…. And the specialists already have a one year waiting list for kids that are 19 months old…. So now, we want to build something in our practice to catch that… but we don’t have enough kids in our practice to build that system - to run 1000 kids through in that age group, you know what I mean? So… the math doesn’t work for practices I guess.”

109: “There’s talk at the clinic of expanding the training for other providers including the pediatricians themselves to become more skilled with the RITA-T and the CARS [Moderator1: Yeah]. Training them in how to do the diagnostic… letter… that insurance will accept… in order to get ABA, the IEP, all those services going… And that sort of to get better as a clinical team… [in] involving behavioral health staff, involving primary care provider, to… maybe catch those kids that fall under the bucket.”

Reflexive working

When participants evaluate the training that they received as well as the implementation of strategies that they learned during BCAEP.

103: “…It’s always nice to hear about how things run differently in different clinics, because you start to realize well, maybe we could be more efficient in this way. You know, we could… adopt some of the the processes that are used in other clinics. And so… I feel like it’s nice, … not only for getting to know folks in the community, but also… sharing ideas about what’s worked, what hasn’t worked… in their clinics and ways to improve ours.”

110: “…So I guess the only thing I’ll say is that it made us even less tolerant of the wait times and moving more things and like doing more work to kind of move heaven and earth to not let the wait times be a barrier for our patients. [Moderator 2: Mhm] That’s probably the way that—yeah. That’s probably the way that the ECHO impacted things.”

108:“Just to agree with 101. After the… training, [I] made a point of using the word [autism]. And… I don’t know if I was shy about it before or not, but what I learned was that most parents were thinking it anyway, and if you didn’t say it, then they continued to worry inside that they might be crazy or something, because… almost none of them rebelled against it. You know, they almost all, like, appreciated hearing that.”