Overview Why offer mental health services in primary care? What does primary care pediatric psychology look like? Establishing a primary care psychology program –Training issues –Business considerations –Coordinated vs. integrated care Training pediatricians to assess and treat child mental health problems
Unmet Needs for Parent Support & Guidance in Pediatric Care
Texas Childrens Needs Assessment 2006 TCPA currently owns 47 practices in Houston serving 300,000 children Pilot study to look at Primary Care Psychology Top five mental health concerns at five offices –ADHD related problems – differential dx –School problems and learning difficulties –Dx of depression –Developmental delay –Mental health follow up after referral
Why Address Behavior in Primary Care? PCPs are the health professionals most likely to come in contact with children & adolescents with behavioral & emotional problems Parents & children comfortable with PCP & office PCP often knows family well, for long time
Why Address Behavior in Primary Care? Non-stigmatizing service delivery Scarcity of community mental health services Promote mental health in children, adolescents, & families –Lack of services for children 0-6 Recognize early signs of psychosocial problems
When to Address Behavior in Primary Care? Parent seeking information Relatively discrete behavior Mild to moderate severity Recent onset No major psychopathology Family situation reasonably stable Pediatricians routinely do this already. What can Psychology meaningfully add to this?
How is it different from Healthy Steps? Referred patients – Healthy Steps is a universal approach for all patients. –Healthy Steps excellent program for guidance, screening Licensed mental health providers –Can bill for services, self supporting –Can diagnose disorders in the 15% of children who meet diagnostic criteria –Shared management of patients, not physician run. –Can also assist with screening and other tools for all patients, group parent information sessions etc.
Back to the Future Collaborative practice first introduced by Schroeder (1975, 2004) That practice involved: –Clinical Interventions –Teaching of Health Professions –Community Advocacy –Public Health Issues Not all practices can meet all of these goals Each group needs to determine which of these multiple roles Psychologists need to fill
What Does Primary Care Pediatric Psychology Look Like? Understanding pediatric offices Differences between primary & tertiary care What does it look like at Nemours? First impressions: Missing the bus
Understanding Pediatric Offices Majority of visits for infants & toddlers Each PCP may see up to 25-30 patients per day Variety of visits: well-child, sick, problem Each PCP has own style & ways of interacting with mental health
How is Primary Care Different from Tertiary Care? Philosophy of practice –punctuality less important –see more patients but spend less time with each – sick visits Need broad knowledge base – cannot specialize (I dont do that) – development – behavior Immediate access to Rx, some medical tests Flexibility is key!
Primary Care Pediatric Psychology: What Does it Look Like For Us? 4 sites 2-6 PCPs at each site Pediatric residency training at 3 sites Low income neighborhoods Racial and ethnic diversity Primarily Medicaid (90-95%) –Single insurer simplifies insurance issues in the carve out era
Primary Care Pediatric Psychology: First Impressions Weve been missing the bus! Wider range of symptoms and psychopathology –Subclinical/normative behavior –Severe psychopathology Missed diagnoses and misdiagnoses –GAD referred as sleep problem –Several cases of PDD missed at well-child visits
Establishing a Primary Care Psychology Program: The Nemours Experience Anecdotal evidence of PCP dissatisfaction with psychology services –Long wait lists –Infrequent communication from psychologists –Patients not following through with referrals to tertiary care site Pediatric needs assessment Funding sources Setting up services
Setting Up Primary Care Psychology Services Nemours Pediatrics: 8 sites in underserved areas Grant applications to the Nemours Foundation and to HRSA –January to May 2002 Start services in fall 2002 Provide direct services on-site, consultation and training Four sites in New Castle County, DE
Establishing a Primary Care Psychology Program: Training Considerations Few, if any, psychology residents have worked in a primary care setting Consider having resident shadow pediatricians Must be comfortable with babies & small children Primary care office is a smaller pond
Primary Care Training for Psychology Residents Similar issues to hospital-based training Learn to identify self as medical professional Must be appropriately assertive and directive with other medical professionals Develop understanding of pediatricians knowledge base and skills in developmental & behavioral realm Communicate information important to pediatricians clearly and with minimal jargon
Coordinated Care vs. Integrated Care In Health Psychology discussion of these issues –Separate records or a joint record? –All providers treated equal E.g. if a child comes to a pediatric appointment for a behavior problem do they go directly to Psychology (integrated) or see a Pediatrician (coordinated) first? Impact of Electronic Medical Record (EMR) –Improved, instant communication –Confidentiality issues that go both ways –Families need to be informed that the record is shared This is a continuum, not a dichotomy
Training Pediatricians: They Provide Most of the Front Line Mental Health Services. AAP Guidelines –Developmental Screening –Critical role for pediatricians is to counsel parents –Child mental health as a top priority in 2005 Yet, pediatricians do not necessarily have the time or the training to assess and treat child mental health problems effectively and efficiently
Nemours Primary Care Behavior Program: Training Modules Module I: Understanding Parent & Child Behavior Module II: Assessment Modules III & IV: Selective Brief Interventions in Primary Care W. Douglas Tynan, Ph.D., ABPP, Deborah Miller, Ph.D., & Jennifer Shroff Pendley, Ph.D.
Assessment in Primary Care –Use AAP materials –You ARE In pediatrics now –Intake Interview –DSM PC Identify non-normative behavior Assess severity of problems Establish diagnosis –Individualized Assessment ABC Analysis Facilitate treatment planning –Motivational Interviewing: Identify factors that mediate or exacerbate problems
Overview of Nemours Primary Care Behavior Program Course overview & objectives Teaching strategies –Didactics –Hand-outs –modeling Why address behavior in primary care? –Use of Bright Futures Mental Health Materials from the Academy of Pediatrics Causes of behavior problems Basic behavioral strategies Brief, targeted interventions Motivational interviewing
Interventions for Behavioral Problems often Seen in Primary Care: Preschool Tantrums & Oppositional Behavior –Example Toileting Problems Sleep Problems Fighting / Aggression with Peers Feeding Problems
The Nemours Primary Care Psychology Program: Some Initial Outcome Data Provider Satisfaction Survey Nemours Primary Care Psychology Program
Nemours Pediatric Provider Satisfaction Jan. 2004: Data to Guide Practice
Pediatric Psychology Program: Outcome data Calendar Year 2004 829 visits Calendar Year 2005 1072 visits Calendar Year 2006 871 visits Training Primary Care 2004 22 residents Training Primary Care 2005 27 residents and 3 PNP interns
Texas Childrens Provider Satisfaction 6 practices divided into 3 options: As usual, Fast Track Referral, Psychologists on site Increased satisfaction for both on site and Fast Track Physician ratings of improvement much higher for on site. Patients seen: 28% 0-5 year olds, 65% 6-12 year olds, 7% teens. Boys: Girls 2.5:1 This type of program appears to fit the needs of young children.
Results of Nemours Provider Satisfaction Survey Content with Psychology Service Do not place a high priority on Psychiatry services Want more parent education services Lack of confidence in own abilities to treat behavioral problems. –Indicates need for more help in pediatric training
Primary Care Program >90% Medicaid insured 54% show rate for appointments in 2003 63% show rate for appointments in 2005 –Typical inner-city rates < 50% 68% show rate for 2006 How does this compare with existing programs?
Resources Treating childrens psychosocial problems in primary care. B.G. Wildman & T. Stancin (Eds.), Information Age Publishing, 2004 Consulting with pediatricians: Psychological perspectives. Drotar, D. Plenum Press, 1995.
Role of Mental Health Providers: Empirically Supported Therapy Example, The Parent Child Conduct Clinic Provide parenting skills therapy in Behavior Modification Provide social skills training for children Emphasis on evidence based practice. Simply increasing service availability does not have meaningful impact.
Coordinate Pediatric/School/Mental Health Services Obtain informed consent for all parties to converse Send copies of reports with your impressions. Request that the school do evaluations for problems. Give input to the team meetings Encourage parents to work with the school Engage an advocate if there are problems www.picofdel.com
Treatment Approach IV: 18 Great Ideas for Management Parents are Shepherds, Not Engineers Reduce Delays, Externalize Time Externalize Important Information Externalize Motivation (Think win/win) Externalize Problem-Solving Use Immediate Feedback Increase Frequency of Consequences Increase Accountability to Others Use More Salient & Artificial Rewards
More of the Great Ideas (2) Change Rewards Periodically Touch More, Talk Less Act, Dont Yak Keep Your Sense of Humor Use Rewards Before Punishment Anticipate Problem Settings - Make A Plan Keep A Sense of Priorities Maintain a Disability Perspective Practice Forgiveness (Child, Self, Others)