The Periscope Project: An Approach to Improving Access to Specialized Psychiatric Care in the Perinatal Period CHRISTINA L. WICHMAN, D.O., F.A.P.M. M E D I C A L D I R E C T O R, T H E P E R I S C O P E P R O J E C T A S S O C I AT E P R O F E S S O R O F P S YC H I AT R Y A N D O B S T E T R I C S A N D G Y N E C O LO G Y D I R E C T O R, W O M E N S M E N TA L H E A LT H M E D I C A L C O L L E G E O F W I S C O N S I N Objectives 1. List standard of care recommendations regarding screening and management of perinatal mood and anxiety disorders. 2. Describe the evidence base regarding psychiatric teleconsultation services. 3. List three components of The Periscope Project. Overview I. Project Inception II. Project Description III. Outcomes IV. Clinical Examples of Utilization V. Sustainability Project Inception Importance of Perinatal Mental Health Prevalence of depression is similar for pregnancy and non-pregnancy women. Suicide is the second leading cause of death among post-partum women. Mental health disorders are the most common complication of pregnancy. Standard of Care Recommendations Screen for depression in pregnant and postpartum patients Utilizing a validated screening tool With appropriate systems and follow up in place October 2010: May 2015: January 2016: 1
Need in Wisconsin Fill the critical gapbetween statewide depression screening initiatives and the lack of perinatal psychiatric treatment services. Shortage of psychiatrists, especially with perinatal sub-specialization: Wisconsin has < 3 FTE perinatal psychiatrists for 66,000 annual births across 65,556 square miles of urban and rural geography. Delays in diagnosis and treatment initiation: Providers often discontinue, mismanage or delay initiation of antidepressant medication when pregnancy or lactation due to fears about medication safety. Lack of overall coordination of services and knowledge of how to access services. Leverage services already in place. The Need Patient Perspective Becky s Schroeder, MS Co-Founder Moms Mental Health Initiative Teleconsultation Child Psychiatry Models National Network of Child Psychiatry Access Programs Several models across the country > 30 Child Psychiatry Access Programs Variations of services involving teleconsultation, face-to-face consultation, provider education, care coordination Massachusetts Child Psychiatry Access Program established in 2005 84% of clinics utilize the service within 1 year of enrollment High utilization by PCPs Increasing providers (5% to 33%) agreeing adequate child psychiatry access Ability of PCPs to meet needs of children with psychiatric problems increased from 8% to 63% Teleconsultation Outcomes Increased patient choice Build capacity of PCPs to treat mild-to-moderate behavioral health conditions Cost savings more studies warranted! State of Wyoming Medicaid = 1.82:1 return-on-investment 42% reduction in the number of children aged < 5 years using psychotropic medications MCW s Child Psychiatry Consultation Program (CPCP) established 2015 SARVETB ET AL. PEDIATRICS 2010. 126:6; 1191-1200. TOWNLEY AND YALOWICH. NASHP 2015; HTTPS://NASHP.ORG/WP-CONTENT/UPLOADS/2015/11/TELEMEDICINE.PDF Perinatal Psychiatry Teleconsultation MCPAP for Moms Operational since July 2014 Funded by MA Deptof Health & surcharge to commercial insurers proportionally for their utilization Statewide and available to all providers caring for perinatal women Components: 1. Real-time provider teleconsultation 2. Provider education 3. Care coordination Randomized control study comparing MCPAPs for Moms vs. PRISM 2
The Periscope Project is free resource for health care professionals caring for perinatal women who are struggling with mental health orsubstance use disorders. Providing health care professionals access to: Real time provider-to-provider psychiatric teleconsultation Educational presentations and tools Community resource information Provider to Provider Teleconsultation 877-296-9049 theperiscopeproject@mcw.edu Monday Friday from 8am to 4pm CST, excluding holidays Provider is connected with a perinatal psychiatrist within 30 minutes E-mails returned within one business day When to Call Psycho-pharmacology or substance use treatment Preconception, during pregnancy, or while breastfeeding Diagnostic clarification, screening tools and follow up recommendations How to discuss mental health with pregnant & postpartum patients General questions on behavioral health during perinatal period Provider Education and Tools Online www.the-periscope-project.org Provider Toolkit Free downloadable PDFs Evaluation guides, screening tools, treatment algorithms Modules Ex. Antidepressant Use in Pregnancy, Perinatal Psychiatric Disorders, Psychotropic Medication Use in Breast-feeding, Conversation Starters In-Person Didactic & Grand Round Presentations upon request Community Resource Information Access through Triage Coordinator Types of resource resources Psychotherapy providers AODA treatment centers Peer to peer & community support groups Psychiatrists and PCPs Will provide: Resource name & description, location, and best way to establish with resource Focused in the greater Milwaukee area, currently expanding 1. Provider calls/emails Periscope Staff to triage & record in REDcap Triage provides resource info 2. REDcapsends page to on-call perinatal psychiatrist 3. Psychiatrist calls provider within 30 minutes 4. Provider-to-provider teleconsultation 5. Perinatal Psychiatrist enters consultation into REDcap 6. REDcapsends a 3 question post-encounter satisfaction survey to provider Process & Flow Provider Enrollment Eligibility Requirements: Health care professional Caring for pregnant or postpartum patients Online Enrollment Process: Individual provider level enrollment Agree to terms of participation Basic provider information Less than 3 minutes to complete Pre-enrollment not necessary for utilization Open to Non-Prescribers All teleconsultation topics remain within the scope of practice of the inquiring provider 3
Evaluation Plan Partnered with University of Wisconsin-Milwaukee College of Nursing Role of Advisory Council Member of Planning and Implementation Team Evaluation Plan includes: Program Operations Measuring changes in provider knowledge, attitudes towards care, resource availability, confidence in prescribing psychotropic medications in perinatal population Program Economic Impact Direct and Indirect measures of program impact Utilizing Medicaid data Ensure Ensure The Periscope Project is responsive to the needs of providers Promote and Support Promote and support The Periscope Project growth and development Connect Connect The Periscope Project team to organizational leaders who can assist with advancing the Project s mission The Periscope Project Outcomes Outcomes: Core Services Tele- Consultations Provider Education 180 Provider-to-provider, perinatal psychiatric consultations. Total educational presentations. 37 online modules viewed. 48 11 in persondidactic presentations to 455 providers. Community Resource Information Providers were e-mailed information on additional resources to 52 support the mental health and wellbeing of their patient. Enrolled Providers Utilizing Providers 350 300 250 200 150 100 50 0 2017-2018 Monthly Enrollment Provider Enrollment by Month Cumulative Enrollment 249 212 185 166 305 255 271 280 Exceeds June 2018 Goal of 250 124 88 22 66 36 42 47 19 17 6 16 9 25 May June July August Sept Oct Nov Dec Jan Feb Mar PA 1% Pediatrics Other 3% 8% Psychiatry 19% Family/Inter nal 10% BX Health 6% OB/GYN 54% 4
Turn Around Time Periscope Project Encounter Topics As of April 1, 2018 180 160 Call From 221total service related encounters 140 120 100 Triage Less than 5 mins. Average 9 mins. Average 8-10 mins. Patient typically remains in the care of provider 180 provider-toprovider consultations (82% of total) 80 60 40 20 0 Medication Related Received Community Resource Information Diagnostic or Screening Tool General Education Other **Topics are not mutually exclusive Provider may discuss multiple topics. Patient Status 204 encounters regarding questions for a specific patient Provider Satisfaction and Service Impact Based on 3 question post encounter survey with a 70% response rate: 100% of providers agreed or strongly agreed they were satisfied with the encounter. 60% Pregnant 24% Postpartum 1 st Trimester -24% 2 nd Trimester -20% 3 rd Trimester -16% 100% of providers indicate their most recent encounter with The Periscope Project helped them to more effectively manage their patient's care. 100% of providers indicate they will incorporate the information they learned in the future care of patients. Alternative Options for Providers Medication-related adjustment (42%) Refer patient to another provider (39%) Do further research (12%) I don t know (2%) What does delayed care mean? Providers say that referral would have most often been to a mental health provider Wait times are often months Not all women will make an appointment Not all women will get to the appointment Teleconsultation minimizes delayed care Clinical Consults 5
Consultation Example Consultation Example PERISCOPE INQUIRY PSYCHIATRIST RECOMMENDATION PERISCOPE INQUIRY PSYCHIATRIST RECOMMENDATION OB provider o26 weeks pregnant ohistory of anxiety disorder outilized desvenlafaxine prior to pregnancy; discontinued upon learning of pregnancy ostruggling with increased anxiety and panic symptoms in recent weeks, typically occurring 2-3 times weekly oepds = 14, with elevated scores on items asking about anxiety oreturn to utilization of desvenlafaxine (Pristiq) given history of success with it. oas needed low-dose lorazepam (Ativan) for break-through panic symptoms not to utilize more than thrice weekly. ogiven information on a local therapist specializing in the pregnancy population Using the education received during the consultation, the provider discussed these options with the patient. Nurse Practitioner onewly postpartum patient, 19 years old, Spanish speaking, little social support oconcerns of mental health disorder during pregnancy, patient did not follow up with behavioral health oepds score = 20, positive question for bipolar disorder oprovider does not feel comfortable managing a patient with bipolar disorder oprovided information to Spanish speaking therapists and resources via email to NP orecommended starting Lexapro oclose monitoring for hypomania ofollow up with patient in 1-2 weeks Consultation Example PERISCOPE INQUIRY Medical Assistant o21 week fetal loss ohusband calling secondary to concerns about wife s behavior: anxiety, tearfulness, some fears of her safety opatient has a new appointment with therapist one month away oprescribing provider out of office covering provider at different location PSYCHIATRIST RECOMMENDATION oprovided education to MA about how to talk directly to patient about her feelings, including imminent risk orecommended patient come into office for faceto-face evaluation within 2 days oconsider utilizing a low-dose benzodiazepine to aid with anxiety and insomnia oprovided community resources information Sustainability Sustainability Planning 1 2 3 4 CONTACT US: CHRISTINA L. WICHMAN, DO C W I CHM AN@M CW. EDU AnnualOperating Cost Projections MCWLeadership Strategy Development EngageAdditional Stakeholders Ensure Long Term Viability W W W.THE- PERI SCOPE- PR OJECT. ORG T H EPER I SCOPEPR OJECT@MCW. EDU Thank you! 6