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Mental Health Integration in Pediatric Primary Care: Engaging Families in Early Identification, Prevention, and Intervention DC Collaborative for Mental.

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Presentation on theme: "Mental Health Integration in Pediatric Primary Care: Engaging Families in Early Identification, Prevention, and Intervention DC Collaborative for Mental."— Presentation transcript:

1 Mental Health Integration in Pediatric Primary Care: Engaging Families in Early Identification, Prevention, and Intervention DC Collaborative for Mental Health in Pediatric Primary Care 1 National Federation of Families for Children’s Mental Health November 21, 2014

2 Thank you 2 We wish to extend our thanks and gratitude to our funders who make our work possible: – DC Department of Behavioral Health ( Partial funding for this project was provided by SAMHSA grant funds from the DC Children’s System of Care Expansion Implementation Project- The DC Gateway Project) – DC Department of Health (This project made possible through a sub- grant agreement with DC Department of Health Title V program. Notice of Grant Agreement # CHA.PSMB.CNMC.PGRM-C The views and opinions contained in this presentation do not necessarily reflect those of DC Department of Health or the US Department of Health and Human Services, and should not be construed as such.) – Howard and Geraldine Polinger Family Foundation

3 Learning Objectives 1)Identify steps taken to develop and sustain the Collaborative 2)Understand key components of the described initiatives 3)Describe family involvement in the Collaborative and its initiatives 4)Apply lessons learned to similar local efforts in their communities. 3

4 Agenda Introductions Background – Mental health in pediatric primary care – DC Collaborative for Mental Health in Pediatric Primary Care Projects & Initiatives – Annual, universal mental health screening – Pediatrician education/quality improvement – Resource guide – Behavioral health access project (DC MAP) – Mental health integration in primary care Family Involvement – Family voices – Family navigators Summary of Lessons Learned Questions and Wrap-Up 4

5 Introductions Brief introductions of presenters and audience 5

6 Background “20/20 Problem” 1-3 Young children (< 5) experience MH problems at rates similar to older children/adults. 4 50% of mental health conditions begin <

7 Background Problems unidentified or identified too late despite what we know about short- and long-term benefits of early identification. Access to MH and support services is low 3,6-7 ; many barriers that prevent families from seeking traditional care. 7

8 Why Primary Care? The “Primary Care Advantage:” Regular (frequent) contact with families Family-provider relationship (longitudinal, trusting) Behavioral health is already a common topic 8 8

9 Why Primary Care? Opportunity for: Early identification and prevention Reducing stigma Interdisciplinary collaboration/learning Improved outcomes for patients 9 Lesson Learned: Discussing MH is important regardless of outcome

10 Agenda Introductions Background – Mental health in pediatric primary care – DC Collaborative for Mental Health in Pediatric Primary Care Projects & Initiatives – Annual, universal mental health screening – Pediatrician education/quality improvement – Resource guide – Behavioral health access project (DC MAP) – Mental health integration in primary care Family Involvement – Family voices – Family navigators Summary of Lessons Learned Wrap-Up 10

11 History 11 Lessons Learned: Early involvement of key stakeholders Interdisciplinary, multi-agency (public- private), coordinated efforts

12 DC Collaborative for Mental Health in Pediatric Primary Care Aim: To improve the integration of mental health in pediatric primary care for children and adolescents in DC. Engage in initiatives that strive to be: – Collaborative & interdisciplinary – Culturally competent – Family-focused – Developmentally-sensitive (emphasis (focus on early childhood) 12

13 DC Collaborative for Mental Health in Pediatric Primary Care Working Group Advisory Board -American Academy of Pediatrics (DC Chapter) -Children’s National Health System -Children’s Law Center -DC Department of Behavioral Health -DC Department of Health -DC Department of Health Care Finance -Georgetown University (Partial Listing) -DC Behavioral Health Association -DC Public Schools -George Washington University -Health Services for Children with Special Needs (MCO) -Howard University -Mary’s Center -Strong Start DC -Total Family Care Coalition -Unity Health Care -Zero to Three Disciplines represented: -Advocacy -Education -Pediatrics -Policy -Psychiatry -Psychology -Social Work Funding Sources: -DC Department of Health Title V Block Grant Program -Howard and Geraldine Polinger Family Foundation Project Team 13

14 Activities – Initiatives Support for Practices Support for Families Integrated Services Policy- Advocacy Resource Guide Education and Training Behavioral Health Access Program Integrated Consultation Integrated Evaluation and Treatment Routine, Universal MH Screening Expert Resource Payment Reform Access to Services Family Navigators Coordinated Systems of Care Perinatal Depression and Anxiety Evaluation and Research 14

15 Agenda Introductions Background – Mental health in pediatric primary care – DC Collaborative for Mental Health in Pediatric Primary Care Projects & Initiatives Projects & Initiatives – Annual, universal mental health screening – Pediatrician education/quality improvement – Resource guide – Behavioral health access project (DC MAP) – Mental health integration in primary care Family Involvement – Family voices – Family navigators Summary of Lessons Learned Wrap-Up 15

16 Exercise: What do all these moms have in common? 16 “I was suffering from PPD. You can’t tell by looking, but I was self harming and trying to manage deep depression and intense rage.” “I was suffering from postpartum depression and severe anxiety. You can’t tell by looking, but I felt like a horrible mother. I had been suicidal a few months prior... just getting out of bed was painful and exhausting.” “I was suffering from the worst depression and anxiety I’d ever known…You can’t tell by looking, but I felt like I was drowning. I was never happy, worried about everything all the time, and wanted nothing more than to just disappear and never return” When this picture was taken… Source: “You Can’t Tell a Mom has Postpartum Depression by Looking” by Katherine Stone/Postpartum Progress

17 Annual, Universal Mental Health Screening Goal: Increase early identification of problems (improve outcomes). Rationale: o Pediatricians will miss a lot of problems without use of a tool 9 o Many parents will not raise concerns on their own 10 o Problems can be reliably identified early and brief screening in early childhood predicts outcomes in elementary school. 11 Process: o Parent/youth completes brief questionnaire at annual visit. o Scoring, discussion and referrals (as appropriate) by provider. o Screening is NOT diagnostic. 17

18 Mental Health Screening in DC July 2013: New DC Medicaid Managed Care Organization (MCO) contracts state primary care providers must use approved screening tool annually (all ages). September 2013: Primary tools selected: – 3-66 months: Ages and Stages Questionnaire: Social- Emotional (ASQ:SE) – 2-21 years: Strengths and Difficulties Questionnaire (SDQ) – years: Patient Health Questionnaire-9 (PHQ-9) – Received feedback from Community Advisory Board, including family representatives October 2014: Updated billing manual to help track screens and increased expectation that providers begin implementing. 18

19 Activity Work with a partner to match screening sample questions with the domains they belong to. 19

20 Concerns are Raised… Now What? In DC, most PCPs feel unable to usually meet the needs of children with mental health problems. 12 Lack of training, confidence, and knowledge = barriers to identification and management of mental health issues. 13 In DC, ~4 out of 5 providers said that their comfort level and knowledge in addressing mental health was worse for children < 5 years than for older children

21 Quality Improvement Learning Collaborative Model for multi-practice learning & measureable improvement Who? Pediatric practices (15) and providers (~130) What? 8 learning sessions (1 hour webinars) Monthly team leader conference calls Monthly practice team meetings Monthly chart audits to measure progress 3 PDSA cycles to facilitate change Received input from family navigators as learning sessions developed and implemented 21

22 Quality Improvement Learning Collaborative Where? In provider offices & on the web When? February – October 2014 Why? Receive support & MOC Credit (ABP, ABFM) Lessons Learned: Start small…then ramp up Lay groundwork such as office “screening” champions Provide support to PCPs Incentives 22

23 QI Learning Collaborative: Aims Between Feb and Oct 2014, providers will increase practice readiness to perform annual mental health screenings for culturally diverse patients % of annual well child visits where an approved screening tool is administered % of mental health screenings that have scored documentation of results % of "positive" mental health screens with an appropriate follow-up plan documented (addressed by provider and/or referred to care) % where administration of a screening tool is appropriately coded and/or billed 23

24 Project Map 2-Part Kick-Off: FebruaryMarchAprilMayJuneJulyAugustSeptOctober Team Leader Call: Tues 4/15 Team Leader Call: Tues 5/20 Team Leader Call: Tues 6/17 Team Leader Call: Tues 8/28 Team Leader Call: Tues 9/16 Part 1: Screening Overview Thurs 2/6 Part 1: Screening Overview Thurs 2/6 Team Leader Call & Learning Session #2: Tues 3/18 Team Leader Call & Learning Session #2: Tues 3/18 Learning Session #3: Thurs 5/15 Learning Session #3: Thurs 5/15 Learning Session #4: Thurs 6/5 Learning Session #4: Thurs 6/5 Learning Session #6: Thurs 8/7 Learning Session #6: Thurs 8/7 Team Leader Call & Learning Session #8 Tues 10/21 Practice Team Meeting PDSA Cycle Progress Report 1 (Feb - March) PDSA Cycle Progress Report 2 (April - May) PDSA Cycle Progress Report 3 (June-July) Mid-QI Balancing Survey Post-QI Balancing Survey Practice Readiness Inventory Part 2: QI101- Tues 3/4 Part 2: QI101- Tues 3/4 Baseline Chart Audits (30) (Covers 6 months pre-implementation period) Baseline Chart Audits (30) (Covers 6 months pre-implementation period) May Chart Audits (10) June Chart Audits (10) July Chart Audits (10) August Chart Audits (10) Sept Chart Audits (10) Sept Chart Audits (10) Oct Chart Audits (10) Team Leader Call & Learning Session #5: Tues 7/15 Learning Session #7: Thurs 9/4 Learning Session #7: Thurs 9/4 24

25 25 Learning Session #1 Learning Session #2 Learning Session #3 Learning Session #4 Early Childhood Learning Session #5 Learning Session #6 Early Childhood Learning Session #7 Learning Session #8 Screening Overview Implementation Screen Results: Partnering with Families on Screening Interpretation, Decision-Making, and Referrals Engaging Families Early Childhood Mental Health Overview Managing Mental Health Concerns Collaboratively Depression & Other Family Risk Factors Putting It All Together & Next Steps Lee Beers, MD & Matt Biel, MD Lee Beers, MD & Mark Minier, MD, FAAP Michele Dadson, PhD Bruno Anthony, PhD Bhavin Dave, MD Martine Solanges, MD & Kirsten Hawkins, MD Lisa Cullins, MD Lee Beers, MD & Larry Wissow, MD, MPH 2/6/143/25/145/15/146/5/147/15/14 8/7/14 9/4/1410/21/14 Goals: Understand purpose and basic fundamentals of routine MH screening Goals: Understand ways to prepare practices for screening and facilitate successful implementation with culturally diverse families Goals: Understand how to interpret and use screening results and how to access community referrals for culturally diverse families Goals: Understand ways to more effectively discuss MH and engage culturally diverse families in the process Goals: Understand basic issues pertaining to MH assessment and treatment for culturally diverse children < 5 Goals: Understand how to manage basic MH issues in the office for culturally diverse families and work collaboratively with providers in co-management Goals: Understand impact of depression/other risk factors on young child wellbeing and how to screen/refer for these issues Goals: Review and prepare for project end Content: Rationale for routine screening, overview of tools; begin discussing ways to engage culturally diverse families in screening Content: Review AAP Practice Readiness Inventory and discuss steps to prep for implementation (e.g., logistics, billing); discuss ways to engage families in screening Content: Review range of screening scores (e.g., at- risk, clinical), how to discuss and partner with families, and next steps (monitor, refer, manage), and discuss resources and referrals Content: Review ways to use screening as a jumping off point for engaging families in mental health discussions and for motivating change Content: Review key principles of young child assessment and treatment; Tips for talking with and engaging parents of young children about MH issues and common concerns Content: Review common concerns that can be managed in primary care and discuss ways to effectively engage parents in these efforts; Discuss strategies for effective co- management with outside MH providers Content: Provide info on family risk factors; discuss ways to screen (formally & informally) for and engage culturally diverse families in discussion of these issues; Review referrals and resources Content: Summarize and connect previous learning sessions; Discuss various collaborative care models and how practices can move forward with this work; Review sources of additional info and opportunities for learning

26 Early Improvement in DC Screening Practices 26

27 PDSA Activity Reminder of the steps (see worksheet) – Plan – Do – Study – Act 27

28 PDSA Cycle Example: Late to School PDSA Trial #1: Get up Earlier – No improvement Aims statement: Increase proportion of times arriving at school on time by improving AM processes and reducing negative parental interventions PDSA Trial #2: Eat Breakfast Last – Decreased time late to school from 60% to 40% PDSA Trial #3: Pick out clothes night before + targeted incentive (ice cream!) = On time every day! 28

29 Continual Improvement Learning Collaborative 2.0 Incorporating family navigators into screening process to assist with follow-up 29

30 DC Mental Health Resource Guide: DCHEALTHCHECK.NET 30

31 DC MAP (Mental health Access in Pediatrics) Goals: – Increase collaboration between PCPs and MH providers. – Promote mental health within primary care. – Improve identification, evaluation, and treatment – Promote the rational utilization of scarce specialty mental health resources for the most complex and high-risk children. Services provided: – Phone consultation with child MH experts – Brief, time-limited follow-up services – Mental health education and training – Resource guide maintenance – Medication reviews 31

32 32

33 MH Access Programs Started in MA in 2003 In MA, 96% increase in rate of primary care providers reporting that they are “usually able to meet the needs of psychiatric patients”. 14 Since adopted across > 25 states: nncpap.org Alaska Arkansas California Colorado Connecticut Delaware Florida Georgia Illinois Iowa Louisiana Maine Maryland Massachusetts Michigan Minnesota New Hampshire New Jersey New York North Carolina Ohio Oregon Pennsylvania Texas Virginia Washington Wisconsin Wyoming Vermont 33

34 DC MAP (Mental health Access in Pediatrics) FY14: DC Collaborative planning FY15: Launch program – RFP released by the Department of Behavioral Health – Behavioral Health System of Care Act – Care coordinator/family navigator proposed 34

35 Mental Health Integration in Primary Care Increasingly common Can assist with problems as they arise “Warm hand offs” Can catch families who might otherwise not see a MH clinician Decreases stigma Increased PCP learning and confidence 35

36 Agenda Introductions Background – Mental health in pediatric primary care – DC Collaborative for Mental Health in Pediatric Primary Care Projects & Initiatives – Annual, universal mental health screening – Pediatrician education/quality improvement – Resource guide – Behavioral health access project (DC MAP) – Mental health integration in primary care Family Involvement Family Involvement – Family voices – Family navigators Summary of Lessons Learned Wrap-Up 36

37 Integrating the Family Voice Community Advisory Board Parent focus groups (planned) Family navigators in primary care (beginning) Parent supports in the resource guide 37

38 Integrating the Family Voice What do you perceive as the major gaps in the identification and management of MH problems in primary care? What positive experiences have you had with pediatricians regarding mental health identification and management, and what would you want replicated by others? What are your suggestions for best engaging parents on advisory boards? 38

39 Family Navigators: Key Concepts for Working with Families in Primary Care Encourage parents to talk about MH issues: – Concerns – Evaluations, treatment (services, medication) – Questions or unmet needs (e.g., “my child has been attending therapy but I don’t feel like it’s helping”) Encourage open communication between PCP and MH team. Encourage open communication between PCP and MH team. – Bring medical records and be proactive about data-sharing. Help parents understand confidentiality – State-specific laws – Rationale 39

40 Family Navigators: Key Concepts for Working with Families in Primary Care Help parents understand: – role they play in treatment. – ways they can get more involved in their children’s care. Ensure that : – professionals understand that the family is part of the care team. – navigators have training in relevant topics so that they will be equipped to address families’ issues. Peer-to-peer support works because families can identify with their peer workers. 40

41 Lessons Learned Interdisciplinary, multi-agency (public-private), coordinated efforts Start small (pilot with a few practices, work out the kinks)…then ramp up Early involvement/awareness of key stakeholders (e.g., schools, MH providers) Lay groundwork in advance: Screening champions across the office 41

42 Lessons Learned Continued PCPs need support…including in-person) Discussing MH important regardless of the outcome Provide incentives (MOC, CME, payment, seeing improvement in outcomes) Facilitating more interaction b/w PCPs and MH providers 42

43 Group Discussion: Action Steps for Participants Are you involved or aware of pediatric primary care/mental health integration efforts in your community? Brainstorm ways you can get involved and encourage other parents to get involved in local efforts. – People you could contact? Relevant agencies? Ideas: – Parent Advisory Boards at pediatricians’ offices – Local chapters of American Academy of Pediatrics – Departments of Behavioral Health 43

44 Role Play: Engaging Pediatrician There are no formalized efforts to integrate primary care and mental health care in my community. What can I do as a parent to engage my pediatrician in one area, such as screening? – Discuss importance of routine, annual MH screening at well child visits using validated tools (can’t tell by looking). – Annual MH screening recommended by American Academy of Pediatrics Bright Futures. – Provide examples of screening tools: Ages and Stages Social Emotional, Strengths and Difficulties Questionnaire, Patient Health Questionnaire 9. 44

45 Thoughts—Questions? 45

46 Questions? Lee Beers: Leandra Godoy: Sarah Barclay Hoffman: Darcel Jackson: 46

47 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), Health and Health Care Among District of Columbia Youth, RAND Corporation, 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), Egger, HL & Angold, A (2006). Common behavioral and emotional disorders in preschool:: presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry., 47(3/4), Kessler, RC, Berglund, P, Demler, O, Jin, R, Merikangas, KR, Walters, EE (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6): DC Kids Count Data Snapshot: Children’s Mental Health in DC: The mismatch between need and treatment. May Thomas, C.R., & Holzer, C.E. (2006). The continuing shortage of child and adolescent psychiatrists. J. Am. Acad. Child Adolesc. Psychiatry, 45:9. 8. Young et al. (1998) Listening to Parents: A National Survey of Parents with Young Children. JAMA Pediatrics, 152(3), Sheldrick, Merchant, & Perrin, Identification of Developmental-Behavioral Problems in Primary Care: A Systematic Review. Pediatrics, 128(2), Ellingson, K. D., Briggs-Gowan, M. J., Carter, A. S., & Horwitz, S. M. (2004). Parent identification of early emerging child behavior problems: predictors of sharing parental concern with health providers. Arch Pediatr Adolesc Med, 158(8), Carter, AS & Briggs-Gowan, MG (2008). Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics, 121(5): 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 47


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