Integration of Pediatric Mental Health Services In Primary Care

1
Integration of Pediatric Mental Health Services
In Primary Care

• John V. Campo, MD
• University of Pittsburgh

2
National Comorbidity Study Seeing The Big
Picture

• Mental disorders highly prevalent
• Begin early in life
• 50 with onset by age 14 years
• 75 with onset by age 24 years
• Tend to be chronic
• Treatment often inadequate
• Public health challenge for psychiatry

3
The Good News...

• A few treatments for common pediatric mental
  disorders actually seem to work...
• A range of efficacious psychosocial and
  pharmacologic treatments exists for many mental
  disorders in children
• U.S. Surgeon general, 1999.

4
The Bad News...

• Most children with mental health needs receive no
  services
• Many receive inadequate services
• State of the art treatments for pediatric mental
  disorders are not being adequately translated or
  disseminated into clinical practice
• U.S. Surgeon general, 1999

5
Efficacy studies

• Conducted under ideal conditions
• High internal validity
• Certainty that study findings are true for the
  specific study population and setting
• Deviations from usual practice
• Exclusion of major comorbid conditions
• Elimination of participant choice/preferences
• Specialized providers, settings, and treatments
• Expectation of high treatment compliance
• Convenience sampling recruitment methods
• Free care

6
Efficacy studies (Cont.)Typical Characteristics

• Focus on relatively short term outcomes
• Relatively small sample sizes
• Greater study detail
• Homogeneous samples
• Randomization
• Standardized treatment protocols
• Control or placebo condition
• Blinding of subjects, providers, and evaluators
• Relatively frequent follow-up

7
Effectiveness studies

• Evaluate treatments under conditions
  approximating usual care
• Feasibility for community applications
• Representative patients/providers
• Conducted in community settings
• Emphasize external validity
• Certainty study findings are true for real world
  populations and settings (i.e., generalizability)
• Challenge for effectiveness research
• Standardize interventions while preserving usual
  care conditions

8
Effectiveness studies Typical Characteristics

• Focus on longer-term outcomes
• Less detail and less frequent follow-up
• Greater attention to cost
• Greater attention to comorbidity
• Potential heterogeneity of treatment
• Generally larger and more expensive

9
Hybrid studiesEfficacy and Effectiveness
Interface

• Optimize internal and external validity
• Efficacy research
• Threats to external validity
• High internal validity immaterial if findings
  cannot be applied
• Effectiveness research
• Threats to internal validity
• Poor internal validity diminishes
  generalizability

10
Current StatusPainful Realities

• Stigma for mental disorders persists
• Separate but not necessarily equal systems of
  care and reimbursement for physical and mental
  disorders
• Based on outdated models of illness
• Reify stigma
• Fragmentation of existing services
• True multidisciplinary care unusual
• Guild driven competition
• Poor disciplinary role definitions

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Why Focus on Primary Care?The Foundation of
Healthcare

• Health is a unitary concept
• MH in primary care challenges
• Stigma
• Separate systems of care
• Reimbursement carve-outs
• Provider unease/avoidance
• Resource management and cost control
• Leverages existing infrastructure
• Opportunities for prevention

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Why Focus on Primary Care?Public Health Relevance

• Practicality
• Youth make at least one yearly visit to PCC
• Familiarity and convenience
• Trust
• Parents view PCCs as resources
• Acknowledges reality
• Primary care the de facto MH system
• Most MH problems seen by PCCs
• Most MH drugs prescribed by PCCs

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A Public Health Perspective

• PRIMARY CARE
• OUTPATIENT SPECIALTY CARE
• INTERMEDIATE SPECIALTY CARE
• INPATIENT/RESIDENTIAL CARE

14
Need for Systemic Change Stepped Collaborative
Care

• Different levels of care delivered depending on
  illness severity, complexity, persistence, and
  response to intervention
• Primary care as the foundation
• Care manager directs traffic
• Outpatient referral and consultation
• Intermediate levels of care
• In-home services
• Partial hospitalization
• Residential treatment
• Acute inpatient
• Long-term residential treatment

15
Why Focus on Primary Care?Specialty Referral
Overrated

• Low recognition rates by PCCs
• Low MH specialty referral rate by PCCs
• Only one in four identified cases referred
• Limited access to specialty MH care
• Lack of child/adolescent psychiatrists
• Administrative/fiscal/geographic barriers
• Poor adherence with MH referral
• Only 1/3 ever see a MH specialist

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CARE-NET Primary Care PBRNPreliminary Findings

• N 110 children and adolescents
• At Risk for emotional disorder
• Screen positive ANX or DEP
• Parental concern about child ANX or DEP
• N 31 (28) receiving MH treatment
• N 38 (35) declined MH referral
• N 41 (37) facilitated MH referral
• 12 of 41 (29) got MH services by 6 months

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Services for Kids in Primary CareSKIP
Preliminary Findings (Kolko PI)

• N 138 children w/ disruptive behaviors
• Randomized by subject
• N 76 to on-site MH intervention
• 67 of 76 (88) received MH services
• N 62 to facilitated MH referral
• 22 of 62 (35) received MH services
• SKIP kids gt twice as likely to get MH Rx

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Why Focus on Primary Care?Physical and Mental
Health Overlap

• Functional Somatic Symptoms
• Abdominal pain 7 - 25
• 2 to 4 of pediatric visits
• Headaches 10 - 30
• 1 to 2 of pediatric visits
• Limb pain 5 - 20
• Chest pain 7 - 15
• High rates psychiatric comorbidity

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Pediatric RAP in Primary CarePsychiatric
Disorders Campo et al., 2004




.001 .05
Depressive Disorder
Anxiety Disorder
Internalizing Disorder
Externalizing Disorder
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Why Focus on Primary Care?Available Treatments
Overrated

• Inadequate primary care management
• Inadequate assessment
• Inadequate treatment intensity and f/u
• Limitations of community treatment
• Evidence based treatments scarce
• Often available in name only
• Need for travel
• Different mode of reimbursement
• Problems with communication

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Why Focus on Primary Care?Lack of Federal
Research

• Pediatric primary care research 0.1
• Only 2 of all pediatric research
• TOTAL 63 federally funded grants
• Pediatric MH primary care research 0.05
• 21 federally funded grants grants
• Pediatric primary care NIMH research 0.4
• 11 NIMH funded grants
• Horwitz et al., 2002 review of Computer
  Retrieval of
• Information on Scientific Projects (CRISP)
  database

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CARE-NET Child and Adolescent Research Network

• Rationale
• Practice based research network (PBRN) targeting
  pediatric mental disorders
• NIMH Funding
• Governance
• Collaborative between UPMC and CCP
• Website CARE-NETpgh.org

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CARE-NET Mission Statement

• A practice based research network
• dedicated to developing and evaluating
• methods and processes to improve
• quality of care for common pediatric
• mental disorders via collaboration
• between PCCs, MH specialists,
• researchers, and community
• stakeholders.

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Need for Systemic ChangeChronic Care Model

• Integrates MH professionals into primary care
• Educators, consultants, and clinicians
• Shifts focus to longitudinal perspective
• Mental disorders are chronic disorders
• Relevant to treatment safety monitoring
• Relies on multidisciplinary care teams
• Nonphysician care managers critical

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Chronic Care Model Goals

• A mutually understood and agreed upon care plan
• Patient and family skills and confidence
  necessary to manage the condition
• Ensure that the most appropriate treatments are
  available
• Accessible, continuous follow-up care

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Chronic Care Model Core Elements

• Organizational leadership team
• Decision support for PCCs
• Access to MH professionals and guidelines
• Delivery system design changes
• Care manager and a system to identify, track, and
  monitor affected individuals
• Clinical information systems
• Self-management support
• Promote patient understanding and activation
• Community resources
• Independent of health care providers

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On-Site MH Services in Primary Care Armstrong
Pediatrics - A Rural Model

• Large rural pediatric practice
• Over 12,000 covered pediatric lives
• Limited community based MH services
• Nurse Care Manager a key element
• Liaison between PCC and specialty MH
• Completes initial MH assessment and triage
• Initial patient and family education
• Ongoing case management
• Treatment support

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A MH Team Model in Primary CareA Collaborative
Venture

• CCP - Armstrong Pediatrics
• Family Counseling Center
• MH/MR for Armstrong County
• Western Psychiatric Institute Clinic
• CARE-NET and ACISR
• Community involvement

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A MH Team Model in Primary CareCollaborative
Care Team (CCT)

• Primary Care Clinician (PCC)
• Nurse Care Manager (NCM)
• Psychiatric Social Worker (SW)
• Pediatric Psychiatrist (PP)

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CCT RolesPrimary Care Clinician

• Identify psychosocial problem cases
• Establish initial diagnosis
• Treatment for less complex cases
• Medical evaluation as needed
• Ensure overall continuity of care

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CCT RolesNurse Care Manager

• Primary liaison between PCC and MH team
• Initial assessment and triage with PCC
• Initial patient and family education
• Active follow-up and outreach
• Ongoing case management
• Treatment support
• Monitoring of treatment adherence and outcomes
• Medication safety monitoring
• Counseling, support, self-management strategies

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CCT RolesPsychiatric Social Worker

• Intake assessment for in-practice referrals
• Patient and family education
• Specialty psychotherapeutic intervention
• Individual (CBT, self-management)
• Family
• Selected case management
• School liaison and support
• Liaison with PCCs

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CCT RolesPediatric Psychiatrist

• Team leadership
• NCM and PSW supervision and training
• PCC education
• Consultation for selected cases
• Co-manage selected cases with PCC
• Patient and family education

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Stepped Care ManagementFlow Chart
Case Identification
TRIAGE ASSESSMENT
ROUTINE CARE PCC CM
COLLABORATIVE PRIMARY CARE TEAM
SPECIALTY MH REFERRAL
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CHILD IDENTIFIED
TRIAGE
EMERGENCY ASSESSMENT

• ROUTINE CARE
• IMPAIRMENT
• Mild - Moderate
• COMPLEXITY
• Low
• PRIOR TREATMENT
• None/Past response
• TREATMENT NEEDS
• Psychoeducation
• Self-management
• Behavioral activation
• Medication

• COLLABORATIVE CARE
• IMPAIRMENT
• Moderate Severe
• COMPLEXITY
• Moderate
• Diagnostic uncertainty
• Comorbidity
• PRIOR TREATMENT
• None/Treatment failure
• TREATMENT NEEDS
• Brief psychotherapy
• Medication
• ? family support

• SPECIALTY CARE
• IMPAIRMENT
• Moderate Severe
• C0MPLEXITY
• Dangerousness
• Bipolar/Psychosis
• Alcohol/substances
• Legal issues
• Severe family problems
• Maltreatment
• PRIOR TREATMENT
• Prior psych hosp
• CC treatment failure
• TREATMENT NEEDS
• Intensive

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Practice Case Flow 2002
PCC Concerns 50 ADHD, Anx, Dep 40 Func
Somatic Sx 10 Other
Total Visits N 31,352
Compliance 91
TRIAGE REFERRALS N 789 (2.5)
ROUTINE CARE 65
COLLABORATIVE CARE TEAM 20
SPECIALTY MH REFERRAL 15
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Acknowledgments

• Dr. Hal Altman, Ms. Sheree Shafer, Ms. Jennifer
  Strohm, and their colleagues at the Armstrong and
  Natrona Heights practices of CCP
• Dr. David Shaeffer and the Family Counseling
  Center of Armstrong County
• Advanced Center for Interventions and Services
  Research for Early Onset Mood and Anxiety
  Disorders (Brent PI, MH 66371), especially Drs.
  David Brent, David Kolko, Robin Weersing, Kelly
  Kelleher, and Bill Gardner
• Drs. Frances Wren and David Raney for
  contributions to early program development