Childhood Mental Health: Strategies for rural people

1
Childhood Mental HealthStrategies for rural
people
2
Rural Challenge

• 1. Making the Diagnosis
• Requires team of family, school, primary care
  physician and patient.
• PCPs diagnose psycho-social problems in 19 of
  visits. (Koppelman, 2004)
• Specialty consult obtained for 50 of these
  cases.
• 2. Urgent Care
• Usually the primary care office or the ER.
• 3. Continuity and maintenance care.
• Requires integration of family, school, primary
  care physician, mental health specialty support.

3
Rural Need

• Rural Pediatric Mental Health Visits
• 5 of child ER visits are for MH (rural urban).
• 10 of psychiatric ER visits are children.
  (Hartley, 2005)
• Childhood mental health ER visits ?102. (Shah,
  2006)
• Only 1 in 5 children receive definitive care.
  (Rosenkranz, 2006)
• Rural adolescent rates of anxiety, depression,
  thought problems, attention problems,
  delinquency, substance abuse and aggressive
  behavior are equivalent. (Hartley, 1999)
• Suicide is higher in rural America. (Hartley,
  1999)
• Only 79 of Rural US Counties have mental health
  services. (Hartley, 1999)

4
Agricultural Workers NeedNeeds somewhat unique
to farming
Problem Strategy
Business Pressures Markets, regulatory, climatic ? business and family management resources.
Poor problem solving, rigidity, change. Build professional networks
Access to firearms. Crisis services.
Alcohol, prescription drug misuse. Access to recovery programs.
Lack of knowledge of mental health problems. Reducing stigma, education.
Source American Farm Bureau
5
Solutions Integrated Care (PCP)

• Mental Health Care in Primary Care
• Mental and physical health are indivisible.
• 50 of patients refuse referral. (Olfson, 1991)
• PCPs deal with mental symptoms as part of a
  larger, more general problem
• Mental symptoms are concentrated in patients who
  visit their PCP for other reasons.
• Mental health symptoms are imbedded in a matrix
  of physical symptoms.
• The Rural PCP remains stuck with difficult
  patients.
• Limited opportunity for passing the patient
  onto specialty care. (Farley, 1998)

6
Disease and Illness
(Stewart, 1995 Rosenthal, 2007)
Disease
Illness
Feelings Ideas Function Expectations
The Broken Part
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Bio-physiological MechanismPrimary Care Model of
Disease
Stress Trauma Predisposition Infection Inflammat
ion
Heterogeneous neuroendocrine-immune dysfunction
Aberrant central pain mechanism
Pain
Fatigue Depression/Anxiety Poor sleep Fatigue
Physical deconditioning
Mental stress
Sympathetic Activity
Trauma
Environmental stimuli
Poor posture
8
Why Primary Care? (PCP)

• Distress brings patients into the PCP Office
• An emotion that may arise out of physical or
  mental trigger.
• 10-20 of people visit a PCP for a mental health
  problem each year.
• 26 have a DSM diagnosis. (deGruy, 1996)
• 50 of high utilizers have significant distress.
• 8-15 of PCP Pediatric contacts are for
  psycho-social problems. (Costello, 1987)
• Team Care is inherent to Primary Care.
  (Rosenthal, 2001)

9
Why Primary Care? (PCP)

• Mind/Body Integration
• Americans accept the inter-relationship of mind
  and body more than clinicians. (Wolsko, 2004)
• 88 of patients accept management of mental
  illness by their primary care physician. (Smith,
  2003)
• Patients expect their PCP to facilitate referrals
  and consultations. (Rosenthal, 1991)
• Patients expect PCPs to continue participation in
  their care after referral. (Rosenthal, 1996)

10
Solutions Expand the Team

• Advance Practice Psychiatric Nurses
• Clinical outcomes of high quality.
• Both diagnosis and treatment (Merwin, 1995)
• Licensed with prescription authority in NYS.
• Their holistic framework is essential for rural
  practice.
• 9.6 of NYs APPNs practice in rural NY.
  (Hartley, 2004)
• 8 of NYS is considered rural.
• There are 40 APPNs in rural NYS as of 2004.
• Most training programs do not include rural
  experiences. (Hartley, 2004)

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Integrate Care Examples Chevy Version

• Bag Lunch Model
• Letchworth Family Medicine, Perry, NY
• Established in 1978 as a solo (fee-for-service)
  practice.
• Now has 3 Family Physicians and 2 NPs.
• Friday noon lunch in PCP office
• The physicians, NPs and nursing staff.
• Clinical psychologists, MHSWs from county mental
  health office and private practices in county.
• Agenda 1) referred cases, 2) problem cases, 3)
  medically complicated cases, 4) un-referrable
  cases.
• Enhanced number of referrals, fewer visits per
  referral, greater patient satisfaction, greater
  professional comfort. (Rosenthal, 1990)

12
Integrate Care Examples Buick Version

• Tount, Texas (Federally Qualified Health Center
  est 1993.)
• Step 1 Established grant funded Family violence
  intervention program.
• Step 2 Hired Clinical Psychologist (CP)
  initially supported by grant.
• Step 3 Weekly Office PCP, CP and Staff
  conferences focusing on patient care.
• Step 4 Referrals to CP expanded to other
  diagnoses.
• Step 5 Patient billings evolved to support CP.
• Step 6 Grant funding was no longer needed.
  (Farley, 1998)

13
Integrate Care Examples Cadillac Version

• Inter-professional Partners for Appalachian
  Children (IPAC)
• Assessment and comprehensive treatment of
  behavioral and developmental needs of children
  ages six and under
• 19 university and community health care
  organizations in Appalachian Ohio participate.
• Access is through PCPs and schools.
• Provider participants
• Primary physicians, psychologists, counselors,
  early child mental health professionals, nurses,
  educators, and hearing and speech-language
  pathologists from within the partnership.
• No matter what door you enter, someone is going
  to take a look at your childs broad
  developmental needs,
• http//www.oucom.ohiou.edu/ipac.

14
Integrate Care Examples Systems Approach

• 44 Child visits/yr/fp for psychosocial Issues.
• FP sees 102 patient visits/wk 46 weeks a
  year.(4,600 visits/year).
• 19 (890) of FP visits are patients lt19 yoa.
• 5 of pediatric visits are psychosocial.
• Swedish Sarcoma Model for non-common conditions.
• Regionalize systems approach.
• Connect specialty surgical centers to office
  based PCP practice.
• In-office Academic detailing.
• Regular single message teaching brochures.
• Improved outcomes and lowered recurrance rates by
  2/3rds. (Gustafson, 1994)

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Why doesnt the ideal just happen?Competing
Demands

• Competing demands confound PCP visits
• Most pts have psychosocial and physical
  co-morbidities.
• They present new problems at every visit
• Long problem lists interfere with providing
  prevention and treatment of chronic disease.
  (Jaen, 1994)
• The attention depression gets during a visit is
  less associated with the severity of the
  patients emotional symptoms than with the number
  of other problems the patient has. (Rost, 2000)

16
StrategiesBringing the PCP Into the Team

• 1. In-Office Training Treatment of Child
  Pscyho-social conditions
• 6 hours proved feasible and acceptable to all FPs
  in study.
• 93 FPs believed that learning were achieved.
• 82 felt more confident in care of complex
  patients. (Morriss, 2006)
• Specific diagnoses were not essential to
  management. (Clark, 2006)
• Lowers use of medications. (Salmon, 2006)

17
StrategiesBringing the PCP Into the Team

• 2. Re-imbursement
• Dual Diagnosis Medical management fee
• 5/month per patient per PCP. (Gold Choice)
• Saves 1m for every 1,000 enrollees. (Rosenthal,
  1996)
• 3. Specialty communication
• Tele-video
• NY Statewide Tele-psychiatry Task Force
  (www.hysarh.org)
• Electronic transmission of EMR note.
• Visits with urban based specialists as needed.
• Tailored specialty/PCP interaction according to
  patient needs and PCP participation.

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StrategiesBringing the PCP Into the Team

• 4. Guided Pharmacologic Care
• 85 of prescriptions for psychotropic meds in
  children are written by Pediatricians and Family
  Physicians. (Koppelman, 2004)
• Use of stimulants (i.e. Ritalin) for ADHD
• Use of selective serotonin reuptake inhibitors
  (SSRIs) for depression.
• Use of clomipramine fluvoxamine for
  obsessive-compulsive disorders. (Greenhill, 1999
  Emslie, 1999)
• 5. Support for Psychosocial Interventions.
• PCP encourages and facilitates family
  participation. (Dore, 2005)
• Combined medical and cognitive care works best.
  (March, 2004)

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StrategiesBringing the PCP Into the Team

• 6. Case Management
• Advanced Practice Psychiatric Nurses
• Mental Health Social Workers
• Special service agencies
• 7. School performance
• Semi-annual case conferences required.
• Each member of team may bill the equivalent of an
  office visit for each patient conference.

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Solutions Integrated Care (PCP)

• Key Feature Case Management at Multi-levels.
• Overall Costs are significantly less. (Baldwin,
  1993)
• Specialty and social services cost the same.
• Emergency and inpatient care costs were much
  lower.
• Outcomes measures better. (Schulberg, 1995
  Katon, 1995)
• Most of the data is from adult care.
• Clinical Care Pathways develop. (Bertram, 1996)
• Specialty consultation is distributed.
• Impact is expanded to more patients.
• European model of health care. (Rosenthal, 2000)

21
New York State AHEC System www.AHEC.buffalo.edu
AHECs Brooklyn AHEC, Brooklyn Bronx AHEC,
Bronx Catskill-Hudson AHEC, New Palz Central NY
AHEC, Cortland Erie Niagara AHEC,
Buffalo Hudson-Mohawk AHEC, Glens Falls
Manhattan/Staten Island AHEC Northern AHEC,
Potsdam Western New York Rural-AHEC, Warsaw
AHEC Districts
Regional Offices 1998 Statewide Office, UB 1999
Central Region Office, Upstate Med. Univ. 2000
Eastern Region Office, Albany Med. Col. 2000
NY Metropolitan Region Office,
The Institute for Urban Family Health
22
References

• Baldwin L, et al. The effect of coordinated
  multidisciplinary ambulatory care on service use,
  charges, quality of care, and patient
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  19931895-108.
• Bertram DA, Rosenthal TC. Implementation of an
  in-patient case management program in rural
  hospitals. J Rural Health. 1996 Winter
  1254-66.
• Clark, M. R. (2006). "Psychogenic disorders a
  pragmatic approach for formulation and
  treatment." Semin Neurol 26(3) 357-65.
• deGruy F. Mental Health Care in the Primary Care
  Setting. In Primary Care Americas Health in a
  new era. Institute of Medicine, Washingotn, DC.
  1996
• Dore M. Child and adolescent mental health. In G.
  Mallon and P. Hess (eds). Child Welfare for the
  twenty-first century A handbook of practices,
  policies and programs. New York Columbia
  University Press. P. 488-503.

23
References

• Emslie GJ, Walkup JT, Pliszka SR, Ernst M.
  Non-tricyclic antidepressants current trends in
  children and adolescents. J Am Acad Child
  Adolescent Psychiatry. 199938517-528.
• Farley T. Integrated primary care in rural areas.
  In Integrated Primary Care, Ed Blount A. WW
  Norton, New York, NY. 1998.
• Greenhill LL, Halperin JM, Abikoff H. Stimulant
  medications. J Am Acad Child Adolescent
  Psychiatry. 199938503-512.
• Gustafson P, Dreinhofer KE, Rydholm A. Soft
  tissue sarcoma should be treated at a tumor
  center a comparison of quality of surgery in 375
  patients. Acata Orthop Scand 19946547-50.
• Gustafson P. Soft tissue sarcoma. Epidemiology
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References

• Hartley D, Bird DC, Dempsey P. Rural Mental
  Health and Substance Abuse. In Ricketts TC
  (ed.). Rural Health in the United States. Oxford
  University Press. New York, NY. 1999.
• Hartley, D, et al. Are advanced practice
  psychiatric nurses a solution to rural mental
  health workforce shortages? Working paper 31.
  (muskie.usm.maine.edu/publications/rural/wp31.pdf.
  Accessed 8/27/07) April 2004.
• Hartley, D, et al. Mental health encounters in
  critical access hospitals emergency rooms a
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• Hartley, D., Ziller, E., Loux, S., Gale, J.,
  Lambert, D., Yousefian, A. E. (2007). Use of
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• Koppelman J. The provider system for childrens
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  2004.

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References

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• Mechanic D. Integrating mental health into a
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• Olfson M. Primary care patients who refuse
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• Rosenkranz, B. Mental Health Care Issuesfor
  Children and Youth, Childres Bureau/ACF/DHHS.
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References

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References

• Salmon, P., G. M. Humphris, et al. (2006). "Why
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Suicide Rates in Rural America

• NY Times article
• Social Isolation, Guns and a Culture of Suicide.
  February 13, 2005.
• Byline Fox Butterfield.
• Americans in small towns and rural areas are
  just as likely to die from gunfire as Americans
  in Major cities. The difference is in who does
  the shooting.