Mental health screenings In Primary Care A Legal Overview

1. Mental health screeningsIn Primary CareA Legal Overview Stamford Hospital Department of Pediatrics Grand Rounds - May 16, 2013 Jay Sicklick, Deputy Director Center for Children’s Advocacy Medical Legal Partnership Project (MLPP)

2. Overview & Goals • What does the law have to do with mental health screenings? • Medicaid as a foundation for screenings • Best practice vs. overburdening requirement • A Massachusetts case study ccamlpp

3. Case Study: Billy M. • 4 year old boy in primary care office for his well-care exam • Presents with no speech or language delays • Academically solid in pre-school setting • Psycho-educeval tests at above normal range But - conduct poor due to “behavioral issues” (mom called frequently to pick son up early) ccamlpp

4. Case Study: Billy M. • Mom shares that Billy has recently been described as using aggressive behavior and inappropriate language • Unbeknownst to you, Mom has history of bipolar disorder ccamlpp

5. Case Study: Billy M. • What is the PCP’s next step? • Tell the mom to wait and see what happens and call back? • Make a referral? To whom? • Conduct a brief validated screen for mental health red flags? • Why or Why Not? ccamlpp

6. Screening Tools • What behavioral/mental health screening tools do you utilize on a regular basis (if any) to screen patients (0-3 or above) in a well-care visit? ccamlpp

7. What If We Do Not Screen? • In any given year, more than 1 in 5 Connecticut children struggle with mental health or substance abuse • More than 50% do not receive treatment • 51% had - or were at risk of - court involvement, juvenile justice intervention, court referral for families with service needs Source: Andrea M. Spencer, PhD, Center for Children’s AdvocacyBlind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012) ccamlpp

8. Mental Heath Screening = Primary Care orMental Heath Screening ≠Primary Care? • Federal Medicaid Law • Early and Periodic Screening, Diagnosis and Treatment (EPSDT)* (Medicaid’s child health component) • EPSDT mandatory set of services and benefits for children under 21 enrolled in Medicaid • 1 in 3 U.S. children under 6 are eligible for Medicaid *Source: 42 U.S.C. § 1396d(r)(1) et seq. ccamlpp

9. EPSDT and Screening • EPSDT vital to ensure that young children receive appropriate health, mental health, and developmental services • Screening to detect physical and mental conditions must be covered at • established, periodic intervals (periodic screens) and • whenever a problem is suspected (inter-periodic screens). 42 U.S.C. § 1396d(r)(1) et seq. (emphasis added). ccamlpp

10. EPSDT Non-Compliance? Bring on the Lawsuits • Rosie D. v. Romney • Mass district court screening delivery system in primary care was woefully inadequate for state’s Medicaid children and lack of community-based mental health systems violated EPSDT • Ordered MASS Health (Medicaid Agency) to design comprehensive screening and referral system for children at risk insured through MASS • Compliance ensured through data collection (EPSDT numbers) Rosie D. v. Romney, 410 F. Supp. 2d 18 (2006). ccamlpp

11. Rosie D.Outcomes Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010); MassHealth Quarterly Screening Data: April-June 2011. ccamlpp

12. Positive Screen = Referrals Rosie D.Outcomes Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010). ccamlpp

13. Referrals = Intervention Rosie D.Outcomes Def.’s Report on Implementation (Jan. 1 2012). ccamlpp

14. Positive Screens = Referrals • Oregon Study utilized ASQ • ASQ compared to Pediatric Developmental Impression (PDI) • PDI on scale from typical–questionable–delayed • 224% increase in referral rate in a year • PDIs alone = 42% of referrals Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 Pediatrics 381 (2007). ccamlpp

15. Importance of Screening Instruments • PDIs missed children at risk • 67.5% of delayed cases only identified by ASQ • 45.1% of early intervention eligible children missed by PDI • Generally • 38% of 12 month cases missed by PDI • 23% of 24 month cases missed by PDI Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 Pediatrics 381 (2007). ccamlpp

16. Where Has It Lead? CCA Proposed Legislation 2011 Session of Connecticut GA • DSS to develop reimbursement strategies to provide support for PCPs to conduct screenings in primary care setting • DSS requested the convening of a task force rather than pursue legislative initiative ccamlpp

17. Where Has It Lead? • Behavioral Health Screening Task ForceExamination of delivery systems to ensure that screenings are promoted, supported and reimbursed in primary care. • Players • DSS • DCF • CT Chapter - AAP • CT Council of C&A Psychiatrists (CCCAP) • ACAP • DDS – Birth to Three • CHDI • CT Behavioral Health Partnership (CT-BHP) • School based health centers (SBHC) • Early Childcare Systems – Head Start • OPM • CHN – CT ccamlpp

18. Where Has It Lead? • BH Task Force met monthly Aug.2012 - Mar.2013 • Experts in-state and out-of-state (Mass e.g.) • Information obtained, recommendations provided • Mass Experience – PCC feedback • Not exceptionally burdensome, infrastructure working • MCPAP as a workable idea and resource ccamlpp

19. Where Has It Lead? Massachusetts Feedback • PCPs balked at screenings • Curriculum developed • Validated screens – in public domain • PCP’s found … • 50% already receiving BH treatment • 40% handled with practical advice – clinician training • 10% referred to “system” for BH treatment ccamlpp

20. Where Does It Lead? Task Force Recommendations (3/2013) • R/Q PCPs in MASS/HUSKY Program to perform annual behavioral health screens using validated instrument from ages 1 - 17 • Instruments used must be validated and recommended by AAP (and approved by DSS) • Providers will receive $18 per screen through DSS • DSS must maintain claims data and report quarterly • DSS to work with AAP to develop curriculum and trainings for PCPs ccamlpp

21. Where Does It Lead? Recommendations (continued) • DSS work with Behavioral Health experts (CT Council on Child & Adol. Psychiatrists and CHDI, etc.) to assist PCP’s on the “What to do Next” questions … • DSS shall participate in formation of child psychiatry access project in CT – if enacted by GA • Task force meets semi-annually to review data and revise recommendations etc. ccamlpp

22. Where Does It Lead? General Themes • Develop support to encourage PCPs to meet the challenge of conducting MH screens • Education to PCPs that reimbursement is available for those practices not already seeking or to those practices where reimbursement is not included (in bundled rate) • Support DSS’s Person Centered Medical Home (PCMH) initiative (resources) • Know that the threat of a lawsuit lurks in the background (a la Rosie D.) ccamlpp

23. Thoughts? ccamlpp

24. Questions? Center for Children’s AdvocacyMedical Legal Partnership ProjectAttorney Jay Sicklick 860-714-1412jsicklick@kidscounsel.org ccamlpp