1. Progress Towards the Triple-Aim Behavioral Health and Care Coordination Integration Michael W. Yogman, MD, FAAP Susan Betjemann, LICSW Christopher Ortengren Yogman Pediatric Associates, Cambridge, MA MCAAP Annual Meeting, May 1, 2014

2. Acknowledgements This project was supported by a Harvard Pilgrim Quality Grant Thank you to the following for their help: Mt. Auburn Community IPA, Betsy Pollock, The Massachusetts Child Health Quality Coalition (Gina Rogers and Rich Antonelli), Mass DPH (Marianne Beach), MCPAP, Cambridge Health Alliance (Katherine Grimes), Sheila Donoyan and Lisa Hoey, the staff at Yogman Pediatrics and our Parent Advisory Group

3. Prevalence of Child Mental Health Disorders National Health Interview Survey 7.7% of < 18 yo have disabilities that limit activity. 4-fold increase from the 1960’s Chronic Mental Health Issues in Children Now Loom Larger Than Physical Problems.” Anita Slomski, Medical News & Perspectives, JAMA, July 2012 8% 20%

4. Prevalence of Child Mental Health Disorders Children 3-17 yo ADHD–6.8% Behavioral or conduct disorder–3.5% Anxiety–3.0% Depression–2.1% Autism spectrum–1.1% Tourette’s syndrome– 0.2% NSCH 2007 Adolescents 12-17 yo Illicit drug use disorder–4.7% Alcohol use disorder– 4.2% Cigarette dependence (past month)–2.8% NSDUH 2010-2011

5. Copyright © 2014 American Medical Association. All rights reserved. From: National Trends in the Mental Health Care of Children, Adolescents, and Adults by Office-Based Physicians JAMA Psychiatry. 2014;71(1):81-90. doi:10.1001/jamapsychiatry.2013.3074 Trends in Office-Based Medical Visits by Young People With Mental Disorder Diagnoses, 1995-2010Analysis was limited to young people (≤20 years). The odds ratios (ORs) and 95% CIs for the study period are for disruptive behavior disorders (OR, 2.31 [95% CI, 1.78-2.99]), mood disorders (OR, 1.92 [95% CI, 1.40-2.64]), anxiety disorders (OR, 2.72 [95% CI, 1.71-4.32]), psychoses and developmental disorders (OR, 2.27 [95% CI, 1.44-3.59]), and other mental disorders (OR, 1.17 [95% CI, 0.87-1.57]). Data are from the National Ambulatory Medical Care Survey. Figure Legend : Trends in Office Based Medical Visits by Young People With Mental Disorder Diagnoses, 1995-2010

7. Addressing the Triple-Aim -Experience of Care Patient Experience Parent Experience Surveys Parent Advisory Group Parent Stress Index Provider and Staff Experience Experience Surveys

8. Addressing the Triple-Aim -Quality of Care Quality Outcomes Team based coordinated care between pediatricians and social worker, “warm handoffs”, parent education, improved access to BH services, de-stigmatization

9. Addressing the Triple-Aim -Quality of Care Care Coordination Measurement Key Data Summary (September 2013 - March 2014) 284 recorded patient encounters 97 unique patients served 53 in office behavioral health therapy/treatment sessions 78 subspecialist visits prevented 37% patients referred to behavioral health subspecialists 44% of all patient encounters focused on behavioral health 25% of encounters involved care coordination for BH services 46% of encounters required further care coordination (follow up or referral)

10. Addressing the Triple-Aim -Quality of Care Patient Population Management Utilizing up-to-date registry lists for patient follow-up, targeted quality improvement, and medical cost data (1) ADD/ADHD (2) Autism/ASD (3) Complex Condition (4) Serious Emotional Disturbance (5) Comorbid Behavioral Health and Complex Condition (6) Early Intervention and IEP

11. Addressing the Triple-Aim -Cost Patient CategoryNumber of Patients identified Number of Patients with Claims Data in 2013 Average Cost per Patient per Month ADD / ADHD10241$271 Autism / ASD2611$762 Complex Condition 6625$862 SED8343$448 BH & CC comorbid 4821$1,167 Total Practice 971$168.72

12. Prevention Early Childhood Social emotional development, early identification and intervention Family Parent support and psycho-education Group Interventions Targeting both children and families Newborn, ADHD and Overweight groups

13. Child Psychiatry Consultation Massachusetts Child Psychiatry Access Project Cambridge Health Alliance Katherine E. Grimes, MD, MPH

14. Sustainability Payment for behavioral health care coordination Better reimbursement for evidenced based behavioral treatment rather than just psychopharmacology treatments Reimbursement for same-day care Reimbursement for post partum depression screening Reimbursement for non face-to-face care Training and supervision of parent partners and community health workers to provide care coordination

15. “It is easier to build strong children than repair broken men” -Frederick Douglass