1. The MA Child Psychiatry Access Project
A Platform for Integrating Child Psychiatry in Primary Care
Barry Sarvet, MD
Chief, Division of Child Psychiatry
Baystate Health
SPCAP Annual Meeting
May 9, 2014

2. Disclosures Research Funding: SAMSHA, Baystate Health Foundation
Employer: Baystate Health

3. MCPAP Leadership Barry Sarvet, MD, Medical Director, Baystate Health
John Straus, MD, Executive Director, Massachusetts Behavioral Health Partnership
Marcy Ravech, Program Director, Massachusetts Behavioral Health Partnership
Site/Cluster Program Directors:
Charles Moore, MD, McLean Hospital SE
Mary Jeffers-Terry, APRN, UMass Med Ctr
Jeff Q. Bostic, MD, EdD, Mass General Hospital
Jefferson Prince, MD, North Shore Children’s Hospital
Sigalit Hoffman, MD, Tufts Medical Center
Barry Sarvet, MD, Baystate Medical Center

4. MCPAP is a system of regional children's mental health consultation teams designed to help primary care providers meet the needs of children with psychiatric problems.

5. 6 MCPAP “HUBS” * * * * * * * * * * * * Amanda Carveiro
Mass General Hospital
Lauren Hart, MPH
Leah Grant, MSW LICSW
Jeff Bostic, MD EdD
Betty Wang, MD
Elizabeth Pinsky, MD
Paul Hammerness, MD
UMass Memorial Med Ctr
Kelly Chabot
Deanna Pedro, LICSW
Danette Mucaria, LICSW
Mary Jeffers-Terry, CNS
Matthieu Bermingham, MD
William O’Brien, MSW
Northshore Children’s Hospital
Brianna Roy
Tracey Terrazzano, LICSW
Jennifer McAdoo, LMHC
Jefferson Prince, MD
Lisa D’Silva, MD
Michele Reardon, MD
Joseph DiPietro, PsyD * * *
Tufts Med Ctr
Children’s Hospital Boston
Rachael Roy Gorton
Alexis Hinchey Davis, LICSW
Sigalit Hoffman, MD
Neha Sharma, DO
Eric Goepfert MD
Mimi Thein, MD
Lauren Mckenna *
Baystate Med Ctr
Arlyn Perez
Jodi Devine, LICSW
Barry Sarvet, MD
Bruce Waslick, MD
Shadi Zaghloul, MD
Sara Brewer, MD
John Fanton, MD
Marjorie Williams-Kohl, CNS * * * * * * *
McLean Hospital/Brockton
Amanda Carveiro
Carla Fink, MSSA LICSW
Charles Moore, MD
Tracy Mullare MD
Mark Picciotto, PhD *

6. Child Psychiatry Workforce Issues
Estimated 1.6 child and adolescent psychiatrists per 1,000 children and youth with DSM IV rated severe
Overall rate of 8.6 child psychiatrists per 100,000 children and youth(range Alaska 3.1 to MA 21.3)
Poorly distributed throughout country
Inverse relationship between # of child psychiatrists and percentage of youth in poverty
No increase in number of child psychiatrists trained per year between 1995 and 2006(census~700)
Thomas and Holzer, JAACAP, 2006

8. Pediatrics and Mental Health
Costello E et al: Psychopathology in pediatric primary care: the new hidden morbidity, Pediatrics, 1988
routine care, pediatricians sensitivity=17%
Pediatricians prescribing 84.8% of the psychotropic meds in large national office-based practice survey (Goodwin et al, 2001)
Organized medicine gets behind mental health in mid-90’s to present
Bright Futures in Mental Health
AAP Mental Health Task Force
AACAP Initiatives 2005 through 2011
costello landmark article
mcaap mental health task force

9. “The Primary Care Advantage”: Suitability of Primary Care Providers for Mental Health
Patients and families often feel more comfortable and trusting of primary care providers
Primary care providers have the opportunity for prevention and screening
Experience coordinating care for children with multiple specialists and ancillary providers (medical home model)
Primary care providers know the developmental context of symptoms
Addressing psychiatric issues in primary care setting can reduce stigma

11. N=280
90% of pediatricians felt responsible for recognition but only 26% felt responsible for treating
46% lacked confidence in ability to recognize depression
10-14% felt adequate skill to treat depression
56-68% cited lack of time as limiting factor
38-56% cited lack of training limiting factor

12. 33% of parent respondents waited more than 1 year for an appt with a child mental health provider
50% reported that pediatrician never asked about child’s mental health
77% reported that pediatrician was not helpful in connecting them to resources

13. Child Psychiatrists and PCPs: Why is it so hard for us to work together?
Managed Care: Carving Out of Mental Health
Scarcity
Time-intensiveness of traditional CAP practice not matching up with high volume primary care operation
Confidentiality concerns
Stigma/Marginalization of Psychiatry from Mainstream Healthcare

14. MCPAP Goals
Improve access to treatment for children with psychiatric illness
Promote the inclusion of child psychiatry within the scope of primary care practice
Create functional primary care/specialist relationship between pcp’s and child and adolescent psychiatrists
Promote the rational utilization of scarce specialty resources for the most complex and high-risk children
Reduce stigma
pediatricians who say, “I won’t prescribe ssri’s--they should be prescribed by a child psychiatrist”
how do we do it?? restoring the functional relationship--it all comes from there.
notice... we don’t really do the comprehensive training
we don’t provide them with detailed practice guidelines

15. Program Information Dedicated teams deployed regionally across state
A state governmental program, through the Massachusetts Department of Mental Health, administered by the Medicaid managed care organization.
Serves all children and families in Massachusetts regardless of insurance status.
Serves all types of PCPs (MDs, PNPs, PAs)
Teams hosted by academic medical centers with existing relationships with pediatricians and family physicians.
Operating budgets of teams are fully funded, subject to reconciliation of third party reimbursement .

16. explain the color coding and the groupings
highlight the role of the care coordinator and all of the arrows going to her`

17. Operational Data 6 teams
423 practices with 1534 FTEs of primary care providers
92% of pediatric practices with panel size of 2000 or more in MA used MCPAP at least once in 2011
20,958 encounters in FY 2012
Over 1,460,000 children now covered
Over 98% of Commonwealth
Cost = $2.20 per child per year

18. Utilization – Encounters by Month
60% Commercially Insured – 40% Publicly Insured

19. Proportion of practices Proportion of all calls to MCPAP
15%
33%
Proportion of practices
Proportion of all calls to MCPAP 1% 5%
27%
66%
> 100 calls/practice
20-99 calls/practice
3-19 calls/practice
1-3 calls/practice
Variability in practices’ patterns of use of MCPAP
17%
35%
Van Cleave, J et al, AACAP Poster 1.37, 2012

20. Volume of Calls per Practice (n=248)
Year since enrollment
Van Cleave, J et al, AACAP Poster 1.37, 2012

21. Engagement Strategies
Be helpful on every call
Be in practice
Personalized, localized
Care coordination
Outreach/CME

22. MCPAP Encounter Types Activity FY2011 N = 20,619 Cumulative
FY05 – FY 11
N = 85,734
•Phone Consultation with PCP
41%
40%
•Care Coordination
30%
28%
•Face to Face Evaluation
11%
•Phone Member/Family
10%
•Follow Up Visit 2% 3%
•Other 5% 7%

23. Percentage of Encounters by Age

25. Types of Consultation Questions
Help!
Diagnostic question
Treatment planning
Unable to access MH resources
Need second opinion
Medication Questions:
-Selection
-Side Effects
-Interim manageme nt
Screening support
Therapy Questions:
-Selection
-Monitoring
-Linkages

26. Reason for contact (% of total calls)
FY 2011 N = 7,823
Cumulative April 2008 – June 2011* N = 22,761
Resources –Community Access
36%
37%
Diagnostic
33%
Medication Question
22%
24%
Medication Evaluation
19%
Parent Guidance 6%
Second Opinion 5% 3%
Follow Up 4% 1%
School Issues
Crisis 2%
Other
* Reason for contact field added in April of 2008

27. Outcome

28. MCPAP Follow-up Study Sarvet et al, Baystate Medical Center
Supported by AACAP Access Initiative Grant
Aims: Assess patient experience of MCPAP program
Did program meet the identified need of the child
Was child able to receive recommended services
Parent view of the role of their PCP
Design: Telephone survey of parents 1-3 months after their child received a MCPAP telephone encounter

29. 1148 consecutive calls to MCPAP from PCPs
Telephone survey administered to parents
Response rate of 50.5%
N=528

30. Parent Responses Yes No Aware that PCP Called 85.19 14.81
U-unknown
P-pending
Aware that PCP Called
85.19
14.81
Psychotherapy recommended
54.25
45.75
if Yes, was the service initiated
69.48
20.48
10.04-P
Psychiatric referral recommended
30.28
69.72
if Yes, was the service initatiated
78.42
13.67
7.91-P
Medications recommended
20.92
79.08
if Yes, was the medication prescribed
87.50
6.25
6.25-U
Return visit to PCP recommended
89.98
10.02
if Yes, was the return visit provided
93.46
2.91
3.63-U
Psychiatric medication prescribed by PCP
42.48
57.52

31. Overall Parent Perspective%
Scale 1 to 7: 1=not satisfied, 4=somewhat satisfied, 7=very satisfied

32. Scale 1 to 7: 1=not satisfied, 4=somewhat satisfied, 7=very satisfied
Perception of PCP %
Scale 1 to 7: 1=not satisfied, 4=somewhat satisfied, 7=very satisfied

33. AACAP Access Initiative Project
Promoting Best Practice in the Detection, Assessment, and Treatment of Adolescent Depression in the Primary Care Setting: Implementation of the GLAD-PC in Two
Large Primary Care Practices
Campaign for America’s Kids

34. Disease management project for Adolescent Depression with two large primary care practices
Utilizing GLAD-PC recommendations
Includes broad mental health screening at well-child visits with PSC-35
PCP’s trained in diagnostic assessment, treatment selection, initiation and monitoring of treatment
Enabling role of MCPAP: practical and psychological
Texas

35. Psychiatric consultation to Adult PCPs, Ob/Gyns, Adult Psychiatrists
Promotion of Screening for Perinatal Mood Disorders in Prenatal Care and Primary Care
Development and linkage to community- based resources
Provider education

36. Other MCPAP Initiatives
Early Childhood Mental Health: Developing capacity for Triple P (evidence based parenting program)
School MCPAP
Working within integrated care models

39. Texas
Vermont
Virginia
Washington
Wyoming
Wisconsin DC
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Illinois
Iowa
Louisiana
Maine
Maryland
Michigan
Massachuestts
Minnesota
Misouri
New Hampshire
New Mexico
New Jersey
New York
North Carolina
Ohio
Oregon
Pennsylvania

40. References
Sarvet B, Wegner L. Developing Effective Child Psychiatry Collaboration with Primary Care: Leadership and Management Strategies. Child Adolesc Psychiatr Clin N Am Jan;19(1):139-48
Sarvet B, Gold J, Straus J. Bridging the Divide between Child Psychiatry and Primary Care: The Use of Telephone Consultation within a Population-Based Collaborative System. Child Adolesc Psychiatr Clin N Am Jan;20(1):41-53.
Sarvet B, Gold J, Bostic JQ et al. Improving Access to Mental Health Care for Children: the Massachusetts Child Psychiatry Access Project. Pediatrics Dec; 126:
Rosie D. and Mental Health Screening: A Case Study in Providing Mental Health Screening at the Medicaid EPSDT Visit, TeenScreen National Center for Mental Health Checkups at Columbia University, Fall 2010
The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment In Primary Care, Wendy Holt, DMA Health Strategies, March 2010