DUVAL COUNTY HEALTH DEPARTMENT Maternal & Child Health Division JACKSONVILLE, FL

1. DUVAL COUNTY HEALTH DEPARTMENT Maternal & Child Health DivisionJACKSONVILLE, FL Integrating Behavioral Health Into Primary Care Donna Buchanan, MSW, LCSW Behavioral Health Services

2. Outline • Overview of Duval County Health Department • Community Profile • Mental Illness in Jacksonville, FL • Duval County Behavioral Health Services • Holistic Approach to Care Model • Medicaid Reform Challenges • Study of Maternal Depression • Future Program Plans

3. Overview of Duval County Health Department DCHD mission-“To lead continuous improvement in the health and environment of all people in Greater Jacksonville, Florida ” • Largest public health clinical program in Florida. 4th largest metropolitan area in the state.  21 health centers and clinics, 15 community based sites • Adolescent health Adult health • Communicable Diseases Dentistry • Immunizations Pediatrics • Psychiatry Women’s Health • Florida state and National Healthy Start Initiative are funded and implemented through Maternal and Child Health.

4. Overview of Duval County Health Department The focus is on addressing health disparities in communities that have higher rates of infant mortality, diabetes, heart disease and other issues. DCHD serves culturally diverse families and individuals of all ages.

5. Overview of Duval County Health Department As of 2007, the population of the greater Jacksonville area is over 1.2 million. 2005 Census Data: • White population 506,961 • Black population 240,117 • Hispanic population 43,604 • Asian population 28,646 • Persons of 2 or more races 12,689 • Other 19,739

6. Mental Illness in Jacksonville, Florida 62,000 residents with severe mental illness such as Schizophrenia 26% of children and adolescents in Duval County experience the signs and symptoms of a mental health disorder 1 in 4 adults suffer from diagnosable mental disorder 50% of all severe cases of mental illness manifest by age 14 and another 25% by age 24 11,000 Jacksonville adults with severe mental illness receive public assistance

7. Mental Illness in Jacksonville, Florida Mental healthcare resources are scarce in Jacksonville as are providers. Psychiatrists, Psychologists, LCSW, LMHC, LMFT’s The uninsured, the working uninsured and the poor find themselves unable to access mental health services because of the inability to pay.

8. Holistic Approach to Care Model As a result of the shortage of providers and services, Duval County Health Department Behavioral Health Services was formed in 2004 to provide counseling services to Medicaid clients in our health delivery system. Staff is composed of: • An adult and child psychiatrist • 2 LCSW’s, • 1 LMHC • 2 MSW’s. • A licensed professional is available 24 hours a day, 7 days a week for emergency or urgent services. Prior to that time we were focused on providing services to Healthy Start families especially in the area of postpartum depression. Program goals are to empower individuals and families in our community to become self-sufficient and able to deal with difficult life circumstances.

9. Holistic Approach to Care Model DCBHS provides services in 9 of the Health Departments area clinics. All are located in areas to serve high risk populations. Services are available to: • Children 6 years old + • Adolescents • Adults

10. Holistic Approach to Care Model Research indicates that 25 – 30% of clients that come for medical appointments have underlying behavioral health related disorders.

11. Holistic Approach to Care Model DCHD provided medical services to 28,764 Medicaid recipients in 2005. DCBHS provided 963 client sessions and generated $183,000 in revenue. Referrals generated by DCHD providers to mental health licensed providers and psychiatrists One stop shopping: • increases access to mental health treatment • reduces barriers to treatment as clients are seen in an already familiar environment.

12. Holistic Approach to Care Model DCHD provided Medicaid services in 2005 to: • 18,710 African Americans • 3,826 Caucasian • 2,303 identified minorities DCBHS has monthly behavioral health partners meetings to: • Conduct peer review • Training • Provide staff support The client’s prognosis for recovery and adherence to other medical treatment is increased by integrating behavioral health into primary care with our team approach. Monthly/Quarterly audits are conducted internally and externally.

13. Holistic Approach to Care Model  Treatment Interventions: • individual, family and group • brief solution focused • Cognitive behavioral • Reality/insight • Empowering young men and families to succeed; Child/parent rites of passage/skill group

14. SPECIALTY SERVICES Foster care children at our Kids N’ Care program are seen by a Pediatric Psychiatrist, licensed mental health counselor and a master’s level social worker. The goal of Kids ‘N Care is to be the premier health system for children in foster care and so far has provided care to over 5,000 children in Duval County. Last year 3,937 teens were seen at The Bridge Adolescent Health Center for Medical and Behavioral Health Services.

15. SPECIALTY SERVICES Last year 1,399 HIV/AIDS clients and their families were seen at our Boulevard Comprehensive Care Clinic (BCCC) for Medical and Behavioral Health services. • DCBHS links to services within the community that support the care and treatment of mentally ill people.

16. SPECIALTY SERVICES Behavioral Health staff are involved with the local child and adult mental health task force of N.E. Florida. • Assess community mental health needs • Make recommendations • Bring together stakeholders Community relations are also fostered with a local historical black college in a predominantly African American community. • Health fairs • Mental health month • Collaboration with student counseling center • Attending monthly professional support groups

17. BEHAVIORAL HEALTH PROGRAM OUTCOMES  Mothers reunited with their children – no longer living in violent home environments = stabilized families.  Healthy pregnancy = positive development of early mother & child relationships. Improved depression and postpartum depression scores; increased self-esteem.  High school diplomas, GED and employment obtained.  Client satisfaction surveys and feedback from referral sources indicate that individual mental health has improved which indicates that the overall health of the community have improved.

18. MEDICAID REFORM CHALLENGES  Impact to clients: • Confusion • Uncertainty • Provider/plan unknown • Clients frequently move to a new residence • Often times mail is not received by the client because of failure to notify the postal service of their new address.

19. MEDICAID REFORM CHALLENGES  Financial Impact: • delay in reimbursement from reform health plans • delay in client services due to providers needing notifications/authorization from managed care companies prior to providing services.

20. MEDICAID REFORM CHALLENGES  Impact to provider: • new requirements, guidelines and paperwork • obtain notification and pre-authorization upon admission to program • reauthorization after 250 units of service every 6 months • quarterly audits

21. Study of Maternal Depression In 2005, a candidate for Doctorate for Public Health in Community Health and Prevention, at Drexel University in Philadelphia, chose DCHD for her internship from the Bureau of Maternal and Child Health. Goals and Objectives of Internship = analyze and evaluate depression data on 195 pregnant and postpartum women enrolled in the Healthy Start program. Screening Tools: • Are you in danger of post partum depression? • Assess women at risk for PPD • Identifying support system or lack of • Stressful life events • Lack of income • Family History Edinburgh Postnatal Depression Scale: • 10 item questionnaire which screens women 6-8 weeks postpartum, as to how they have felt over the previous 7 days. • Range 0-30 • Score of 9-13 may indicate depression • Score of 14 and above is indicative of depression and the person should be followed by a clinical interview

22. Findings • Race: • African American 66% • Caucasian 32% • Other (Indian and Latino) 2% • Depression: • 113 women completed the Edinburgh • 38% of the women scored 13 or higher • Average score was 14 • Race and Depression: • Research indicates that African American women are more likely to have stressors in their lives which leads to depression but did not indicate any significant findings. • Both groups scored higher than 13 indicating that both groups are depressed. • White women scored slightly higher on the Edinburgh.

23. Findings • Age: average age was 22 (range 11-47 yrs of age) • Education: • 45% did not graduate from high school • 10% still in high school • Symptom Focus: • Depression 16.8% • Sexual abuse history 16% • Domestic violence 5% • History of depression (factor in PPD): 59% • Insurance: • Medicaid 67% • HMO (job, parent or spouse) 19%

24. Findings  Prenatal Care: • 92% received prenatal care • 6% received late prenatal care • 2% did not received care  Birth Outcomes on 135 women: • Birth weight ranged from 1 pound to 10.10 pounds with average weight of 6 pounds) • 14% premature births • 16% had very low to low-birth weights (under 2500 grams or 5 lb. 8 oz.) • 8 women had twins (weight ranging from 3.12 to 7.30 lbs.) • 2% miscarried • 5% infant deaths  Treatment completion: • Average length of sessions 3 • Completed with symptom improvement 40% • Could not be contacted for follow up 36% • Referred for additional services 12% • Declined further services 10%

25. Findings  Number of sessions and healthy birth outcomes.  Advocate for more finances and staff to provide counseling sessions before and after delivery to impact high infant mortality rates. • Women who declined services at 16.5%, scored the highest on the Edinburgh test. Women who completed the sessions at 13.29%, scored the lowest. Although this was not statistically significant it was concluded that those who declined services are more depressed. • The majority of the women indicated that they cannot financially support themselves alone.

26. Future Program Plans • The program is in the process of setting up more program evaluation with DCHD’s Health, Policy and Evaluation Research Department. • DCHD recently added on the Department of Institutional Medicine in 2006. • Medical and Behavioral Health Services are provided to inmates. • An additional need was identified to provide inmates and their families counseling to assist with the transition of inmates back to the community. • An additional licensed mental health professional is being hired to provide these services.