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Welcome to the 2019 Pediatric IBH Program Care Transformation Collaborative of RI

Join us for an overview of the Pediatric IBH Program, its benefits, and screening options for school-age children, adolescents, and new mothers. Explore the need for pediatric IBH and the prevalence rates of BH conditions in the pediatric population.

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Welcome to the 2019 Pediatric IBH Program Care Transformation Collaborative of RI

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  1. Welcome to the 2019 Pediatric IBH ProgramCare Transformation Collaborative of RI July 11, 2019 Liz Cantor, PhD, Pediatric IBH Practice Facilitator Susanne Campbell, RN, MS, PCMH CCE, Sr Project Director

  2. Agenda

  3. Pediatric IBH - Overview • Pediatric IBH and Adult IBH are different • Why Pediatric IBH? • Prevalence rates of BH conditions in pediatric population • Overview of the model and its benefits • Patient example • Introduce screening options under this program • School age children • Adolescents • New mothers

  4. Pediatric Primary Care  Adult Primary Care Because, e.g.: • Prevalence of medical and BH conditions is different in kids vs. adults • most common chronic condition in children is ASTHMA (8%); • about 25% of children have significant SLEEP problems; • only .24% of children under 20 have DIABETES vs. 9% of adults • Parents play a central role in the healthcare of their children, from decision-making to transportation to financial responsibility • Confidentiality with children and esp adolescents is a specific challenge • Pediatricians are more accustomed to thinking about prevention and early detection, compared to adult primary care physicians

  5. Why Pediatric IBH? • 1. Increase access to care • Only 20% of kids with MH disorder receive specialty care (nationally) • 2. Response to the shortage of child psychiatrists – we have no choice • 3. Improve physician comfort with mental health • While pediatricians increasingly are involved in mental health visits, 2/3 report they are not prepared/lack of training1 • 4. Improve provider satisfaction2 • 

  6. Why Pediatric IBH? (cont.) • 5. Cost & efficiency • Kids are generally physically healthy; mental health disorders cost the system more than medical disorders in children • With BHC in practice, medical provider has more time to spend on patients’ medical concerns (one study showed PCP could add 1 pt/session) 6. It works! (e.g. recent meta-analysis showed “The probability was 66% that a randomly selected youth would have a better outcome after receiving integrated medical-behavioral treatment than a randomly selected youth after receiving usual care.”) 3

  7. Prevalence of BH disorders in children • Per the CDC, about 20% of children are diagnosed with a mental health disorder • Only 20% of those diagnosed receive care from a MH provider • BUT 90% of all children receive regular medical care from a primary care provider • Per NIMH, 50% of all lifetime cases of mental illness begin by age 14 • Average time between symptom onset and intervention is 8-10 years • Suicide is the 3rd leading cause of death in teens, most of whom had an underlying mental illness

  8. www.cdc.gov/childrensmentalhealth/data.html

  9. Prevalence of Substance Use in (RI) Adolescents • ANY substance use is considered a problem/risk, not just a full disorder • The earlier teens start using substances, the greater their chances of continuing to use substances  • Per KIDS COUNT, in RI, in 2017 (reported in 2019): • 23% reported current ETOH consumption • 23% marijuana • 20% e-cigs • 11% binge drinking • 6% cigs • 5% OTC drugs • 4% Rx drugs

  10. Prevalence of Postpartum Depression in new mothers • Per the CDC, about 10-15% of new mothers nationally experience PPD symptoms; in RI (2012-2015), 11-14% reported sxs • Per NIMH, risk factors for PPD include: • Sxs of depression in the past • Family hx of depression • A stressful life event during pregnancy or shortly after giving birth (e.g. job loss) • Medical complications for baby or for mom • Mixed feelings about the pregnancy • Social isolation • Substance use problems

  11. What is Pediatric IBH? • It’s an approach to care whose most central characteristic is coordinated team-based care that is individualized to the patient; you are making a commitment, like with PCMH, to develop a care plan for each individual child based on his/her needs. • You are more effectively identifying problems/opportunities and connecting patients to treatment/resources to prevent conditions from getting worse.

  12. What is Pediatric IBH? • Central components: • Universal Screening (systematically identifying problems) • Triage and referral (systematically determining level of care and connecting patients to the care they need) • Brief treatment (systematically treating only those problems that have been shown to benefit from this model of intervention – mild to moderate) • Brief in session length – 30 minutes • Brief in treatment length – 1 to 6 sessions • Education of staff and patients on MH topics and IBH model

  13. A patient example • Universal Screening • 7 y.o. Billy in January for Annual Physical; mom completes PSC; results are significant for Attention Problems Subscale; mother notes transition to 1st grade has been very hard for him, not improving, he’s starting to hate himself and isolate because he feels like a failure; note in EHR indicates this has been an area to watch for a couple years; you rule out a sleep disorder, food allergies, or other medical conditions; explain possibility of an ADHD Dx and possibility of a medication trial, but you recommend she meet with the BHC first for further assessment, and she agrees. • Triage and referral • Through a 5 minute “warm hand-off” mother and Billy meet the BHC before they leave, and mother makes an appointment to return later that week • Brief treatment • Mother meets with BHC for brief assessment; clinician rules out other MH explanations (e.g. anxiety, learning disorder); provides ADHD education; plan to meet for 3-4 sessions for parent training to help manage the behavior at home, help her advocate at school; after several weeks, mother reports improvement at home, but ongoing struggles at school; BHC documents in EHR so you can see progress; mother returns to see you, you start a med trial…

  14. Review of Deliverables, Payment Structure, & Learning Collaborative Dates Susanne Campbell, RN, MS, PCMH CCE, Senior Project Director, CTC-RI

  15. Recommended Screeners • School-Age (5-11) • Pediatric Symptom Checklist (general social-emotional functioning) • Adolescence (12-17) • PHQ-A or PHQ-9M (Depression, adolescent version) • GAD-7 (Anxiety) • CRAFFT 2.1 (Alcohol and Substance Use) • New Mothers • Edinburgh Postnatal Depression Scale (EPDS) • Copies are in your orientation binder

  16. Pediatric Symptom Checklist - 35 • Purpose: Identify children at risk • Valid Population: Ages 3-17 (for this project, 4-11) • Completed by: Parent/caregiver • Scoring: Overall cutoff score AND subscale scores (next slide): • Attention Problems • Internalizing Problems • Externalizing Problems Sensitivity: 68% Specificity: 95%

  17. PSC-35 Scoring *Note: There are different cutoff scores for different language versions Go to MassGeneral website for more information

  18. PHQ-A (PHQ-9M) • Purpose: Establish provisional depression diagnosis as well as symptom severity • Population: Adolescents 12-17 • Completed by: Patient (self-report) • Validity: Detecting and monitoring depression in adolescents in primary care settings – not as much research as adult version, but still robust; valid for repeat administrations to track progress • Sensitivity: 73% Specificity: 94% • Scoring: next slide

  19. PHQ-A Scoring for Severity

  20. GAD7 • Purpose: Establish provisional anxiety disorder diagnosis as well as symptom severity • Population: Adolescents 12-17 • Completed by: Patient (self-report) • Validity: Detecting and monitoring anxiety in adolescents in primary care settings – not as much research as adult version, but still robust; valid for repeat administrations to track progress • Sensitivity: 97% Specificity: 100% (for scores indicating moderate severity or higher)4 • Scoring: next slide

  21. GAD7 Scoring

  22. CRAFFT 2.1(Car, Relax, Alone, Forget, Family/Friends, Trouble) • Purpose: Identify adolescents at risk for substance use disorders • Population: Adolescents 12-17 • Completed by: Patient (self-report); or Interview • Administration: First administer frequency questions (Part A) • If Part A = 0, complete only CAR question • If Part A > 1, complete all of Part B • Sensitivity: 79% (alcohol), 86% (drug use) • Scoring/Risk Level: next slide

  23. CRAFFT 2.1 Scoring

  24. Edinburgh Postnatal Depression Scale • Purpose: Identify new mothers at risk for depressive illness • Population: Postpartum mothers • Completed by: Patient (self-report) • Administration: 3 times before child is 6 months old • (at 3 of 4 visits: 1, 2, 4, 6 months) • Scoring: • Pay attention to Question 10 (thoughts of harming self) • Original cutoff “12 or 13” (1987); newer research suggests lower cutoff might be beneficial; use clinical judgment on patients whose scores are between 10-12.

  25. Resources:Screeners and Instructions NOTE: THESE ARE ALL AVAILABLE THROUGH CHADIS PSC (Pediatric Symptom Checklist) • Overview, forms, translations https://www.massgeneral.org/psychiatry/ PHQ-A (modified PHQ-9, or PHQ-9M) http://www.uacap.org/uploads/3/2/5/0/3250432/phq-a.pdf GAD-7https://www.phqscreeners.com/ CRAFFT 2.1https://crafft.org/wp-content/uploads/2018/04/CRAFFT-2.1_Selfadministered_2018-04-23.pdf; CRAFFT 2.1 Manual: https://crafft.org/wp-content/uploads/2018/08/FINAL-CRAFFT-2.1_provider_manual_with-CRAFFTN_2018-04-23.pdf EPDShttps://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf

  26. References • Horwitz, S., Storfer-Isser, A., Kerker, B., et al. (2015). Barriers to the identification and management of psychosocial problems: changes from 2004 to 2013. Acad Pediatr. 2015;15(6):613-620. • Hine, J., Grennan, A., Menousek, K., Robertson, et al. (2017). Physician Satisfaction With Integrated Behavioral Health in Pediatric Primary Care: Consistency Across Rural and Urban Settings. Journal of Primary Care & Community Health, Vol. 8(2) 89 –93. • Arsanow, J., Rozenman, M., Wiblin, J., Zeltzer, L. (2015). Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatrics; 169(10): 929-937. • Mossman, S., Luft, M., Schroeder, H. et al. (2017). The Generalized Anxiety Disorder 7-item (GAD-7) scale in adolescents with generalized anxiety disorder: Signal detection and validation. Annals of Clinical Psychiatry, Vol29(4): 227-234.

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