Implementation of risk reduction strategies for ADHD management among college students using a standardized care pathway: a quality improvement initiative

Abstract

Background: Attention-deficit/hyperactivity disorder (ADHD) impacts 5.2% of U.S. adults, significantly affecting college students who face high risks of stimulant misuse and diversion, with 45% reporting prescription misuse and 70% admitting diversion (Jain et al., 2017; Loskutova et al., 2020; SAMHSA, 2020). Local Problem: College student health centers face challenges in delivering consistent and safe ADHD care management due to the absence of national guidelines, variations in monitoring practices, and a lack of standardized protocols. Methods: Guided by the Plan-Do-Study-Act framework, this quality improvement initiative revised and standardized ADHD care pathways at a Northwestern U.S. college health center, incorporating diagnostic certainty, structured follow-up protocols, and monitoring strategies. Interventions: Key components of the pathways included initial and annual urine drug screening, prescription drug monitoring program reviews, stimulant contracts, and consideration of alternative treatment strategies. Standardized electronic health record templates and provider education supported adherence. The project evaluated providers' perceptions of the revised care pathways, confidence in managing ADHD among students, and extent to which the pathways were utilized. Evaluation metrics included run charts to assess template utilization, with a 75% target adherence rate, and pre/post-intervention surveys aiming for a 50% confidence increase. Results: Across 45 ADHD-related visits, overall template use reached 28.9%, with greater use during establishing care appointments. Urine drug screening and stimulant contracts were documented in 100% of New Mental Health and 66.7% of Initial visits. Prescription monitoring checks were documented in 44.4% of total visits. Two providers completed both pre- and post-surveys, showing an average confidence increase of 21.6%, with the greatest gains, 33.3%, in managing positive drug screening results and applying consistent workflows. Conclusion: While full template adoption was limited, strong uptake of safety measures and early gains in provider confidence indicate meaningful progress toward safer, more consistent ADHD care. These findings support continued refinement of scalable models that embed risk mitigation into routine workflows and can be adapted across student health settings.