Innovative Strategies to Improve Mental Health Integration in Pediatric Primary Care

Transcription

1 Innovative Strategies to Improve Mental Health Integration in Pediatric Primary Care 30th Annual Children's Mental Health Research & Policy Conference March 6, 2017 One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

2 Collaborating Partners One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health 2

3 Chair & Discussant Carol A. Zahm, PhD DC Gateway Project Director DC Department of Behavioral Health Presenters Leandra Godoy, PhD Program Manager Children s National Medical Center Elizabeth Davis, MHA Program Associate Children s National Medical Center One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

4 Washington, D.C. Quick Facts 2015 Facts about the Nation s Capital: Total Population in DC: 647,484 Population Under 18: 110,588 Per Capita Income: $47,675 Greatest income disparity in country (Top 10% make more than 6 times the bottom 10%) Race & Ethnicity: Percentage of African American: 48.9%/ White 40.2%/ Hispanic or Latino 10.2% /Asian 3.7% Percentage of families with children under 18 in poverty: 21.8% Percentage of children under 18 in poverty = 26.7% One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health 4

5 Improving Access within a SOC SAMHSA SOC grant- DC Gateway District wide Oversight DC System of Care for SED Children & their Families Policy and Funding Change Identifying the unique needs of pediatric practices Public-DBH/ Private- CNMC & Georgetown Univ Hospital Partnership One Agency. One Mission. One Voice. Providing learning opportunities Ongoing flexibility and responsiveness District of Columbia Department of Behavioral Health

6 Leandra Godoy, PhD, Lee Beers, MD, Melissa Long, MD, Tamara John Li, MPH, Matthew Biel, MD, & Mark Weissman, MD March 6, 2017 Mental Health Screening Quality Improvement Learning Collaborative

7 Learning Objective To examine changes in routine mental health (MH) screening practices and beliefs following completion of a QI learning collaborative.

8 Case for Routine MH Screening Opportunity to address large unmet MH needs early (before reach crisis) 1-3 Yet clinical impression alone may fail to identify up to 50% of children at risk for a mental health disorder 4 Screening, even in early childhood, is feasible and well validated : AAP Task Force on MH : AAP Clinical Report 7

9 But Many PCPs already feel ill-equipped to meet the psychiatric needs of their patients, particularly young patients.

10 Local Context: Washington, DC July, 2013: New requirement by DC Medicaid for annual MH screening using an approved standardized tool. Age Range Screen 0-12 mo Edinburgh Postpartum Depression Scale (EPDS) 3-66 mo Ages and Stages Questionnaire: Social- Emotional (ASQ-SE) 2-17 yrs Strengths and Difficulties Questionnaire (SDQ)* 18+ yrs Patient Health Questionnaire-9 (PHQ-9)* * Alcohol and suicide screening also recommended

11 Learning Collaborative Aims Increase practice readiness to implement and sustain mental health screening at well visits using an approved standardized tool. Increase the number of well visits where an approved MH screening tool is administered, scored, documented, and billed.

12 Project Overview Free 16-month QI Learning Collaborative for primary care practices serving children in DC and surrounding areas ABP and ABFP Maintenance of Certification Part IV credit CME credit available for all project activities AAP MH Toolkit ASQ:SE

13 Startup Period Project Overview 2014 Technical Assistance Only Jan Feb Mar April May June July Aug Sept Oct Nov Dec Round Jan Feb Mar April May June July Aug Sept Oct Nov Dec Round 2

14 Participants 10 Practices participated in both Rounds Private practices 20% FQHCs 20% Academicallyaffiliated community health centers 60% Practice size: 3-20 providers (average 11 PCPs) 107 Participants

15 Project Overview Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun x x x x x x x x x x x x x x x x Team Leader Calls x x x x x x x x x x x x x x Learning Sessions x x x x x x x x x x x x x x x x x Practice Team Meetings x x x x x x PDSA Cycles x x x AAP MH Practice Readiness Inventory x x x Balancing Measures x x x x x x x x x x x x x x Chart Audits

16 Preparing Practices: Self-Assessment AAP MH Practice Readiness Inventory Completed by practice team 5 domains: Community resources Health care financing Support for children and families Decision support for clinicians Clinical information systems/delivery system redesign

17 Preparing Practices & Providers MH Resource Guide Screening SmartForms QI & MH Coaching

18 PLAN PDSA Example I plan to: Complete screening with all 5 year olds I hope this produces: 100% screen completion for that age group Steps to execute: 1) Nurses give out in exam room; 2) Nurses score; 3) Doctors review and discuss with families during visit DO What did you observe? Nurses overwhelmed; not enough time to STUDY How did it go? 60% completion rate; of those, 50% made it to PCP before visit; ACT What did you conclude? Not enough time; too many demands on nurses What can you do differently? Front desk gives out to complete in wait room

19 Preparing Families

20 Results: Practice Readiness Pre-Project Feb, 2014 n=10 practices Mean (SD) Mid-Project Oct, 2014 n=8 practices Mean (SD) End-Project June, 2015 n=8 practices Mean (SD) % Change Community Resources 2.3 (0.3) 1.8 (0.5) 1.7 (0.4) 20% Health Care Financing 2.5 (0.5) 1.7 (0.3) 1.8 (0.5) 23% Support for Children and 2.0 (0.3) 1.8 (0.4) 1.5 (0.4) 17% Families Clinical Info System 2.5 (0.8) 2.4 (0.3) 2.4 (0.1) 5% Redesign Decision Support for Clinicians 2.2 (0.0) 2.0 (0.5) 1.7 (0.4) 17% Scores range from 3- We do not do this well to 1- We do this well **Low is good**

21 Mental Health Screening Chart Review Well child visits 1-18 years Approved MH screening tool: Administered Scored/documented Clinical range Billed (96110 or CPT code) Pre-project (30 charts) Monthly (10 charts+)

22 Results: Mental Health Screening Screening rates increased and were sustained

23 Results: Outcomes of Screening On average: - 11% of children had previously identified mental health issues - 30% of completed screens had scores in the clinical range Screening helped to identify children with mental health needs

24 Results: Scoring & Documenting Screening

25 Results: Billing for Screening

26 Additional Results: DC Medicaid Screening Claims Data or CPT (Current Procedural Terminology) Codes FY13 FY14 FY15 FY16

27 Next Steps Learning Collaborative Round 1 Round 2 Ongoing Efforts: Resource guide online, searchable format Education and technical assistance as needed through DC MAP (e.g., smartform development, videos on screening) Advocacy: Screening parity Pilot District-Wide

28 Conclusions QI Learning Collaborative can be an effective, efficient model for multi-practice change related to screening. Keys to Success: Longitudinal and comprehensive practice support Automating in EMR Preparing and empowering clinicians Engaging an array of stakeholders and champions Limitations Data self-reported Urban setting with strong primary care/academic infrastructure Resources to provide practice support May be harder to get buy-in without regulatory requirement

29 Thank you!! Questions?? Leandra Godoy, PhD

30 References 1. Perou, R. et al., Mental Health Surveillance Among Children United States Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report, 60(2), Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among U.S. children: variation by ethnicity and insurance status. Am J Psychiatry, 159(9), Shannon Stagman & Janice L. Cooper, National Center for Children in Poverty, Children s Mental Health: What Every Policymaker Should Know 3 (2010). 4. Sheldrick, Merchant, & Perrin, Identification of Developmental-Behavioral Problems in Primary Care: A Systematic Review. Pediatrics, 128(2), Carter, AS & Briggs-Gowan, MG (2008). Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics, 121(5): Foy JM, American Academy of Pediatrics Task Force on Mental Health. Enhancing pediatric mental health care: report from the American Academy of Pediatrics Task Force on Mental Health. Introduction. Pediatrics. 2010;125 Suppl 3:S69-S Weitzman C, Wegner L, Section on Developmental and Behavioral Pediatrics, et al. Promoting optimal development: screening for behavioral and emotional problems. Pediatrics. 2015;135(2): The integration of mental health and pediatric primary care: A mixed methods needs assessment of DC. March, Horwitz et al., Barriers to the Identification and Management of Psychosocial Issues in Children and Maternal Depression. Pediatrics;119;e208-e Shannon Stagman & Janice L. Cooper, National Center for Children in Poverty, Children s Mental Health: What Every Policymaker Should Know 3 (2010). 10.American Academy of Pediatrics. Letter to Chairman Harkin, Chairman Kingston, Ranking Member Moran, and Ranking Member DeLauro. Child Access to Mental Health Specialists, Medical Subspecialists, and Surgical Specialists. 11. Pediatric specialist physician shortages affect access to care. Children s Hospital Association report. August, The integration of mental health and pediatric primary care: A mixed methods needs assessment of DC. March, Horwitz et al., Barriers to the Identification and Management of Psychosocial Issues in Children and Maternal Depression. Pediatrics;119;e208-e Massachusetts Child Psychiatry Access Project (MCPAP) Primary Care Clinician (PCC) Satisfaction Survey Fiscal Year 2012 (July 1, 2011 through June 30, 2012) with Multi-Year Analysis including Baseline, FY 2008, FY 2009, FY 2010, FY Available on mcpap.org

31 Children s Mental Health Research & Policy Conference March 6, 2017 Leandra Godoy, PhD, Amelia Buttress, PhD, & John Straus, MD

32 Summarize national data on child psychiatry access programs.

33 High (~80%) child unmet MH needs (CDC 2013) The population of youth < 20 is projected to grow by ~33% in the next 40 years and demand for services expected to increase (U.S. Bureau of the Census, 2010, U.S. Bureau of Health Professions, DHHS, 2000). Workforce shortage: ~1 child psychiatrist for every 10,000 children with MH problems (AACAP)

34 Primary care advantage (e.g., longitudinal, trusting relationship, decrease stigma) Access to pediatric primary care is good Yet, gaps in knowledge, training, confidence of PCPs CPAPs: Massachusetts pilot in 2003 and statewide in 2004 National Network of Child Psychiatry Access Programs (NNCPAP) started in 2011 Facilitate linkages across programs Advocacy Improving model through evaluation and research

35 40,566 CONSULTATIONS (PAST 12 MONTHS) 35% CHILDREN <18 COVERED (NATIONWIDE) 28 ACTIVE PROGRAMS

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38 Additional Areas Covered in Some States Perinatal (8) Substance abuse (8) Early psychosis (10) Transition age youth (6)

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40 Expand reach/support to states Streamline/coordinate data entry and outcome measures

41 Leandra Godoy, PhD

42 DC MAP: Mental Health Access in Pediatrics DC Department of Behavioral Health Funded Project Elizabeth Davis, Leandra Godoy, Lee Beers March 6, 2017 One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

43 Objectives 1) To provide an overview of DC MAP 2) To review major lessons learned since launching in May 2015 One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

44 What is DC MAP? DC Mental Health Access in Pediatrics (DC MAP) is a free mental health consultation program for pediatric primary care providers in Washington, DC. One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

45 Partnership Children s National Health System MedStar Georgetown University Hospital One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

46 Goals of DC MAP 1) Increase collaboration between PCPs and MH providers 2) Promote MH within primary care 3) Improve identification, evaluation, and treatment 4) Promote the rational utilization of scarce specialty mental health resources for the most complex and high-risk children One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

47 Our Services Live, phone consultation with child MH experts within 30 minutes of initial phone call Brief, time-limited face to face consultations as clinically indicated Mental health training and education Resource guide maintenance One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

48 One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

49 Call Volume 396 calls/consultation requests to DC MAP were initiated since December 31, DC MAP Call Volume One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

50 Primary Reasons for Calls to DC MAP One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

51 Enrollment Enrollment has steadily increased over the past year and a half. As of December 31, 2016: 25 practices enrolled 134 providers enrolled One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

52 Major Lessons Learned One of the most common barriers in connecting families to resources is getting in contact with the families (3 consecutive failed attempts). Outreach to providers and practices is more than just s, phone calls, and newsletters. It s about building relationships. One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

53 Conclusions DC MAP can be duplicated in other locations to help integrate mental health experts into pediatric primary care by helping providers feel more comfortable in managing their patients mental health concerns. One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health

54 For More Information One Agency. One Mission. One Voice. District of Columbia Department of Behavioral Health