1. Pregnancy Related Depression (PRD) Screening in the Pediatric Setting: Operational Considerations
Bridget Burnett, PsyD
Kathryn Jantz, MSW, MPH
Sue Williamson, JD
In collaboration with:
Colorado Department of Public Health and Environment (CDPHE)
Colorado SIM Office
ENSW/SIM Collaborative Learning Session – Golden, CO
June 2, 2017

2. Learning Objectives for Presentation
Summarize the literature review and key informant interviews around the operational challenges of performing the PRD screening within the pediatric setting
Identify findings on billing and coding for Medicaid and commercial payers for the PRD screening
Describe approaches and best practices used among pediatric practices (where to document within the EMR, consent forms, policies, and procedures)
Operational only-sue

3. Colorado Pregnancy Related Depression (PRD) Facts
According to the DSM, Pregnancy Related Depression is a form of Major Depression that occurs within four weeks of delivery
Prevalence: Ten percent of Colorado mothers experienced frequent PRD symptoms (2011) (1)
Significant impact on children: Infants of parents with PRD often have delayed cognitive and psychological development, delayed motorized skills, lower vocalizations, and increased resource use
Screening is reimbursed: Medicaid (federal and state) supports and reimburses screening by the child’s medical provider under the child’s Medicaid ID
CDPHE and others don’t use DSM diagnosis
Behavioral health clinicians are moving to PMADs. In setting up strong processes and procedures around PRD, practices are preparing for a more holistic, PMADs approach.
(1) Colorado Department of Public Health and Environment Pregnancy Risk Assessment Monitoring System (PRAMS)

4. American Academy of Pediatrics (AAP) Position
Includes “assessment and consideration of parental and family environmental factors that may affect children’s health”, maternal depression being one of these.
Include bullets about importance- Sue

5. Additional Recommendations
United States Preventive Services Task Force (USPSTF) – depression in general adult population including pregnant and postpartum women
Centers for Medicare and Medicaid (CMS) – identifies importance of PRD screening and encourages child’s provider to refer mothers for appropriate care

6. Policy Perspective
Encouraged to administer PRD screenings in a pediatric setting
SIM initiative – PRD screening is a Clinical Quality Measurement (CQM)
Medicaid and other payers reimburse PRD screening in pediatric setting

7. Mom is Not My Patient: Pediatric Worry List???
Do I need mom to sign consent form to administer PRD screen?
Where do I record the results in my EHR? In the child’s (patient’s) records?
Am I responsible for ensuring Mom has received appropriate referral to services?
To what extent can I release child’s records to outside party when it includes Mom’s information?
Do I have to let my risk management (malpractice) carrier know I’m doing this?
Is my risk/liability greater if I do nothing?
How do I know if Mom connected to the referral I made?

8. Findings: Notifications and Informed Consent
No clear consensus what type of notification a mother or father should receive about assessments or interventions directed at them within pediatric setting
Informed consent a construct for “treatment” although HIPAA defines it broadly
Gray area as to whether “treatment” defined broadly enough to include administration of PRD screening to mom
How to effectively and appropriately “close the loop” on referrals?

9. Recommendations: Notifications and Informed Consent
Consider revising standard forms to notify parents that mental health screening will occur
Consider notifying parents of the process for referring to other community or mental health providers
Consider written policies and procedures related to the maintenance and release of mental health related data
Obtain an ROI to coordinate the referral and “close the loop” with external systems
Ask the group whether they have done this

10. Findings: Liability
Treating adults not within traditional scope of pediatric practice
Absence of clear standard of care for pediatrician
Inference that policy recommendations serve as a proxy for standard of care
Case law/risk management: insufficient evidence that addressing maternal mental health outside the scope of pediatric practice
Seems reasonable that pediatricians may perform these activities
Operational Only

11. Emergency Protocols
Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child?

12. Recommendations: Liability
Limit liability by establishing carefully defined screening, documentation of results and referral policies and procedures

13. Findings: Privacy and Data Management
Guidelines around data management based on maintaining personal health information (PHI) for a single patient and releasing that information based on clearly defined rules
No consensus about how best to document screening results and follow-up related to mental health status of the parent of the patient
One legal analysis: presence of information in the child’s chart results in it becoming the child’s PHI
Typically behavioral health confidentiality held to higher standard by courts

14. Data Management Key Decisions
Where: Record information in the main EHR or in an area intended to have greater security?
What: What information is retained (screening score, follow-up plan, conversations at future visits)?
Release: How and when is the information released. Does it appear on your patient portal?
Kathryn- Operational only
Poll how many people put in their main EHR

15. Recommendations: Privacy and Data Management
Consider establishing clear written polices about data points provided or not provided when the child’s record is solicited by another entity (including another caregiver who may have no relation to the mother)

16. Findings: Billing and Coding
Private insurers have range of policies and coverage for PRD screening in practices
Colorado Medicaid (NEW!): 3 times a year
Billing and coding report

17. Emergency Protocols
Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child?

18. Identified Gaps Trainings for staff on PRD
Referral lists for all communities and clinics
Reimbursement that supports comprehensive services and prevention associated with screening in a pediatric perspective
Official guidance around policies and procedures on consent, and data management, privacy

19. Acknowledgements CDPHE Denver Public Health Colorado SIM
HealthTeamWorks
Project CLIMB Children’s Hospital Colorado