Mental Health Screening in the Medical Home: Introduction

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Mental Health Screening in the Medical Home
Introduction

• Jane Meschan Foy, MD
• Department of Pediatrics
• Wake Forest University School of Medicine

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Prevalence of mental health problems in childhood

• 11 of children have a MH diagnosis evidence of
  functional impairment (SED)
• 16 of children have symptoms that do not rise to
  level of a diagnosis, but have functional
  impairment
• 9 have a diagnosis without current impairment
• 27-36 total may have need for MH services
• Great Smoky Mountain Study of Youth. Health
  Affairs, Fall, 1995

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Risk factors for mental illness children with
serious emotional disturbance are

• Twice as likely to be living in poverty (40 vs.
  20)
• 40 more likely to have a parent who has been
  arrested (17 vs. 12)
• 50 more likely to have a parent with a drug or
  alcohol problem (11 vs. 7)
• 3 times as likely to have a mother who is
  depressed (18 vs. 6)
• 25 more likely to have a parent who did not
  finish high school (42 vs. 32)

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Risk factors for mental illness (cont.)
children with serious emotional disturbance
are

• Nearly 3 times as likely to have a poor
  relationship with his/her parents (49 vs. 17)
• Nearly 2 times as likely to have witnessed
  physical violence between parents (13 vs. 8)
• Nearly 2 times as likely to have one or both
  parents unemployed (17 vs. 9)
• 50 more likely to come from a family other than
  one with two biological or adoptive parents (77
  vs. 50)

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Risk factors for mental illness (cont.)

• Children with 6 or more stress factors are 40
  times more likely to have SED than children
  without stress factors.
• Children with chronic medical illnesses are at
  higher risk for mental health disorders
  (including mild and moderate disorders).
• Adolescents tend to have the most significant
  health problems and the lowest utilization of
  healthcare services of any age group, esp. ethnic
  minorities, and are least likely to be insured.

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Consequences of mental illness

• Children with SED are more likely to
• be expelled from or drop out of school
• become pregnant
• be convicted of a crime
• use alcohol or other illicit drugs
• Children with mental illness are more likely to
  use medical services / emergency rooms
  (displaced utilization) their parents are also
  higher users of health services.
• Bernal, Hidden Morbidity in Pediatric Primary
  Care, Pediatric Annals 326, June,2003.

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• 70 of children in need of MH services are
  untreated.
• Surgeon Generals report www.surgeongeneral.gov
  

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Mental illness treatment sources

• Specialty MH system
• Child welfare and juvenile justice system
• Education (70 sole provider for 50)
• Health

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Barriers to treatment of mental illness in MH
specialty system

• Stigma
• Fragmentation / schism
• Cost
• Cultural biases / trust issues
• Absence of care coordination mechanisms
• Funding / reimbursement issues
• Shortage of mental health professionals generally

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Barriers to treatment of mental illnessin MH
specialty system (cont.)

• MH system reform targeting of public services
  to the severely ill
• Procedural requirements of public and private
  mental health programs
• Poor communication with primary care
• Non-parity of mental health benefits in insurance
  plans
• Adolescent-specific issues denial,
  confidentiality..

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Barriers to treatment of mental illness in child
welfare and juvenile justice system

• Adversarial relationship with family
• Under-funding
• Family disorganization
• Agency focus on non-MH aspects of care
• Discontinuity in custody
• Incomplete medical and mental health history
• Poor communication among agency, family, and
  healthcare providers

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Barriers to treatment of mental illnessin schools

• Focus on educational mission (e.g. testing,
  attendance)
• Confidentiality issues inhibiting exchange of
  information with healthcare providers
• Inadequacy of school funding
• Shortage of school-based mental health
  professionals and school nurses
• Reimbursement issues for school-employed
  personnel

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Barriers to treating mental illness in primary
care settings

• Comfort of primary care providers (other than
  uncomplicated ADHD /- anxiety, depression)
  deficits include
• Diagnostic skills / familiarity with DSM
• Giving bad news / concerns about labeling
• Collaborative experience with MH providers
  (public and private)
• Psychopharmacology (except ADHD)
• Non-pharmacologic treatment methods
• Coding and billing for MH disorders

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Barriers to treating mental illness in primary
care settings (cont.)

• Time limitations
• Access to psychiatry consultation
• Reimbursement issues, esp. for non-face-to-face
  elements of care
• Managed care requirements / limits
• Low utilization by adolescents
• Perceptions of scope of primary care
• By-pass through self-referral
• Perceived and actual confidentiality barriers
  that limit sharing of information

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Barriers to screening for MH problems in primary
care

• Concern about handling positive screens
  (diagnostic methods, referral sources, bad news,
  etc. see previous slides)
• Lack of familiarity with screening instruments
• Cost of instruments
• Variation in cultural norms of screening tools
• Time requirement
• Patient flow concerns

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Advantages of medical home for identifying and
serving children with MH problems

• Opportunity for prevention and early
  identification
• Relative absence of stigma
• Relationship with provider / trust
• Convenience, comfort, familiarity
• Coordination with medical services
• Cost efficiency

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Overcoming barriers in primary care delivery of
MH services

• Training / education (appropriate to stage of
  behavior change!)
• Advocacy with public and private insurers
• Local/regional resource directory
• Mixers, collaborative office rounds
• Access to psychiatry consultation, esp.
  psychopharmacology
• Referral brochure (AAP)
• Co-location model
• Introduction of screening instruments / coaching
  in use and interpretation

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Barriers to Mental Health Services for Children

• The Clinical Physicians
• Point of View

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The Barriers We See

• Lack of mental health personnel
• Lack of training
• Lack of time
• Lack of screening tools
• Services not available
• Inefficient processes
• Lack of communication
• Liability
• Costs exceed break-even

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Insufficient number of mental health personnel

• Not enough psychologists for the demand
• Not enough psychiatrists for the demand
• Not enough counselors for the demand

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Lack of Training

• Most primary care physicians do not see
  themselves as providers of mental health
  services, though that may have to change
• Its not our job . . .
• Most feel justified taking this position because
  they have had little training in this area of
  medicine

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Lack of time

• To do an adequate job for a child requires a
  large investment in time
• Even when the willingness is there, the time may
  not be
• Production quotas are a reality in many
  employment contracts

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Lack of screening tools

• Other than ADHD tools, good screening tools are
  difficult to procure
• Costs can be prohibitive
• Primary care physician often knows child the best
  and would be in best position to helpbut may not
  recognize certain types of problems

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Services not available

• Child often requires services not available in
  the community
• Waiting time can be very long
• Gate keeping mechanisms delay entry into programs
• Professionals in the community may not deal with
  particular types of problems

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Inefficient processes

• Mental health providers and organizations do not
  communicate with each other (huge problem)
• There is no bonafide case management process in
  effect
• Mental health records are judiciously guarded

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More Inefficiencies

• Primary care physicians are often asked to assume
  prescribing responsibility
• Children are returned to parents, and parents
  dont know the diagnosis
• PCP may not be familiar with the medication and
  its uses.

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Lack of Communication

• Physicians often expected to assume management of
  case with NO information
• Not inadequate information
• NO information
• No Master Plan developed
• Unmanageable plan

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More Lack

• Because communication among involved parties is
  poor
• Some services are needlessly duplicated.
• Some services never happen
• Some services arent needed, but they are done
  because they are covered.

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What are you looking for?
My keys.
Where did you lose them?
In the parking lot.
So why are you looking here?
THE LIGHTS BETTER HERE!
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Liability

• Willingness to help may be there, but insurance
  carriers discourage involvement.
• Were you trained to do this?
• Are you certified to do this?
• Why are you doing this?

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Costs exceed break-even

• Doing a good job takes time
• Doing a good job takes personnel
• Physician may even be willing to pro-bono his
  fees, but staff fees still must be met
• One 99215 does not equal four 99213s

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We want to help, but what can we do?
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Our tentative plan

• Add counselor in office
• Add case manager in office
• Why we think the case manager
• in office idea is workable
• Case manager more important
• initially but cost is an issue

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Barriers we have encountered

• Feasibility study
• Doesnt pay for itself
• Might pay for counselor alone
• Counselor alone will not get kids the help they
  really need.

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Circle of HOPE

• Circle of Hope
• 21.6 of kids could benefit
• 2.8 receiving help for SED
• Prefer help from pediatrician rather than MHP

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CATCH
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Mental Health, Behavioral Integrated Services
Pediatric offices are increasingly becoming a
place where children and families access
psychological services because surroundings are
familiar and there is no stigma associated with
visiting the pediatrician. The Youth Mental
Health Committee commissioned a feasibility study
to determine the implications of integrating
behavioral health services into Lakeside
Pediatrics. the study identified a need, however
funding to develop an implementation plan is
lacking. This proposal provides funding to the
committee for development of strategies to
integrate behavioral health services into the
pediatric practice, including mapping of local
resources, determining long-range
outcomes, identifying external funding
opportunities, and preparing grant applications.
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A Late Break through . . .

• Family Guidance collaboration
• In office case manager
• Procure services
• Coordinate services
• Prevent duplication
• Keeps all parties communicating
• In office counselor
• We provide space
• They provide personnel

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Mental health Screening and the Medical
HomeThe Bright Futures Model

• Joseph F. Hagan, Jr., MD, FAAP
• Co-Chair, AAP Bright Futures Steering Committee
  and PAC
• Primary Care Pediatrics
• Burlington, Vermont
• jhagan_at_aap.org

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Bright Futures Vision

• To promote the mental and emotional health and
  wellbeing of all children and adolescents
• A critical element and health
• Mental health-- the ability to
• Experience a range of emotions
• Possess positive self esteem
• Respect others
• Harbor a sense of security and trust in self and
  the world

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Bright Futuresunder construction

• is a set of principles, strategies and tools that
  are theory - based, evidence - driven, and
  systems - oriented, that can be used to improve
  the health and well-being of all children through
  culturally appropriate interventions that address
  the current and emerging health promotion needs
  at the policy, community, health systems and
  family levels.

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Bright Futures in Practice Mental Health

• Michael Jellinek, MD
• Bina Patel, MD
• Mary Froehle, PhD, eds.

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Bright Futures in Practice Mental Health

• Mental health promotion
• In a developmental context
• Mental health problems
• Specific issues
• Specific diagnoses

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Bright Futures in Practice Mental Health

• Three parts
• Developmental Chapters
• Infancy, early childhood, middle childhood,
  adolescence
• Mirrors Bright Futures Guidelines
• Bridge Topics
• Common mental health problems in childhood and
  adolescence
• Mental Health Tool Kit

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Screening or Surveillance?

• Most providers of primary pediatric care rely on
  surveillance
• Long term relationship
• Knowledge of child development
• Observation over time
• Does it work?
• NOPE!

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Surveillance?

• Ready.
• Fire!
• Aim.

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Screening

• Uses tools!
• Tools are tested
• Tools are validated
• Sensitivity and specificity

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Developmental Screening

• What tools do pediatricians use?
• Denver
• Low sensitivity and specificity
• Sort of the Denver
• No sensitivity and specifity
• Other screens
• PEDS
• Brighance
• Others all are proprietary

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Mental Health Screening
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Mental Health Screening

• What tools do pediatricians use?
• Any?
• None
• What were we trained to use?
• Probably none

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Mental Health Screening

• AAP ADHD Guidelines
• Diagnosis, 2001
• Treatment, 2003
• Diagnostic Guidelines
• DSM-IV criteria
• More than one environment
• Confers disability

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Mental Health Screening

• Vanderbilt ADHD Diagnostic Rating Scales
• Wolraich ML, Feurer ID, Hannah JN

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Mental Health Screening

• Pediatric Symptoms Checklist
• PSC
• Jellinek MS, Murphy JM, Little M, etal

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Mental Health Screening

• Center for Epidemiological Studies
  Depression Scale for Children
• CES-DC
• Faulstich ME, Carey MP, Ruggerio L

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Mental Health ScreeningAdditional Topics

• Edinburgh Postnatal Depression
• Included in BF-MH
• (2 question screen alternative)
• Anxiety Disorders
• Bipolar Disorder

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Essential library

• DSM-PC
• Bright Futures in Mental Health
• BF in MF Toolkit
• CPT 2004

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The argument for payment

• Psychosocial issues important in primary care
  settings
• A system is needed to help PCPs describe Mental
  Health in Primary Care settings
• Preventive activities need to be justified and
  reimbursed in primary care settings

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Pediatrics Collaborative Care Program

• Anjie Emanuel, MPH

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Pediatric Collaborative Care Program (PedsCare)

• 4 Year Cooperative Agreement with the AAP and
  MCHB
• Components of the grant mental health, oral
  health, child care and international activities

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PedsCare Mental Health Activities

• Publish Taskforce on the Family Report
• Develop a compendium of community based
  collaborative care and referral models
• Develop a training for pediatricians to improve
  mental health services for children and families
• Establish the pediatricians role in improving
  mental health services

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Next Steps

• Cross Functional Mental Health Work Group
• Mental Health Tool Kit
• Mental Health Training for Pediatricians

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AAPs Position

• January 2004 Board of Directors Meeting
• 04-05 Strategic Plan

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National Center for Medical Home Initiatives
Putting the Pieces Together

• Amy Brin, MA
• Manager, Training Initiatives

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How can the National Center help?

• Technical assistance
• Interdisciplinary training initiatives
• Screening initiatives
• Web site link to mentors

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Training Curriculum Accomplishments

• Developed national curriculum that is endorsed
  by MCHB, AAP, FV, and NACHRI
• Since 1999, trained 4,500 pediatricians, allied
  health care professionals, and family members
• Utilized in all 50 states Puerto Rico Guam
• Consists of 7 components in facilitator and
  participant versions
• Translated curriculum into Spanish

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Surveillance and Screening Curriculum What to
Expect?

• Outlines continuous surveillance proper
  screening techniques and their roles in medical
  homes
• Highlights recommended tools and resources to
  assist in integrating screening into practice
• Identifies proper follow-up strategies after
  screening tests are performed
• Offers difference screening tracks
  developmental hearing vision oral and mental
  health

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Surveillance and Screening Curriculum Mental
Health Track

• Mental health screening track provides practical
  framework for implementation
• Includes
• AAP recommendations
• Mental health screens to use in primary care
  setting PSC CDI Pediatric Intake Form
• Appropriate CPT codes for administering
  interpreting tests

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Surveillance and Screening Curriculum Where to
Get It?

• Contact Holly Noteboom at 800/433-9016, ext. 7081
  OR hnoteboom_at_aap.org
• Downloadable at
• www.medicalhomeinfo.org/training/materials/Screeni
  ng-fac-final.doc
• Curriculum is made available through the
  continued partnership between Shriners Hospitals
  for Children and the American Academy of
  Pediatrics.

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Because in the end
www.medicalhomeinfo.org