The MA Child Psychiatry Access Project

1. The MA Child Psychiatry Access Project A Platform for Integrating Child Psychiatry in Primary Care Barry Sarvet, MD Chief, Division of Child Psychiatry Baystate Health SPCAP AnnualMeeting May 9, 2014

2. Disclosures • Research Funding: SAMSHA, Baystate Health Foundation • Employer: Baystate Health

3. MCPAP Leadership • Barry Sarvet, MD, Medical Director, Baystate Health • John Straus, MD, Executive Director, Massachusetts Behavioral Health Partnership • Marcy Ravech, Program Director, Massachusetts Behavioral Health Partnership • Site/Cluster Program Directors: Charles Moore, MD, McLean Hospital SE Mary Jeffers-Terry, APRN, UMass Med Ctr Jeff Q. Bostic, MD, EdD, Mass General Hospital Jefferson Prince, MD, North Shore Children’s Hospital Sigalit Hoffman, MD, Tufts Medical Center Barry Sarvet, MD, Baystate Medical Center

4. MCPAP is a system of regional children's mental health consultation teams designed to help primary care providers meet the needs of children with psychiatric problems.

5. 6 MCPAP “HUBS” Mass General Hospital Lauren Hart, MPH Leah Grant, MSW LICSW Jeff Bostic, MD EdD Betty Wang, MD Elizabeth Pinsky, MD Paul Hammerness, MD UMass Memorial Med Ctr Kelly Chabot Deanna Pedro, LICSW Danette Mucaria, LICSW Mary Jeffers-Terry, CNS Matthieu Bermingham, MD William O’Brien, MSW Northshore Children’s Hospital Brianna Roy Tracey Terrazzano, LICSW Jennifer McAdoo, LMHC Jefferson Prince, MD Lisa D’Silva, MD Michele Reardon, MD Joseph DiPietro, PsyD * * * Tufts Med Ctr Children’s Hospital Boston Rachael Roy Gorton Alexis Hinchey Davis, LICSW Sigalit Hoffman, MD Neha Sharma, DO Eric Goepfert MD Mimi Thein, MD Lauren Mckenna * Baystate Med Ctr Arlyn Perez Jodi Devine, LICSW Barry Sarvet, MD Bruce Waslick, MD Shadi Zaghloul, MD Sara Brewer, MD John Fanton, MD Marjorie Williams-Kohl, CNS * * * * * * * McLean Hospital/Brockton Amanda Carveiro Carla Fink, MSSA LICSW Charles Moore, MD Tracy Mullare MD Mark Picciotto, PhD *

6. Child Psychiatry Workforce Issues • Estimated 1.6 child and adolescent psychiatrists per 1,000 children and youth with DSM IV rated severe • Overall rate of 8.6 child psychiatrists per 100,000 children and youth(range Alaska 3.1 to MA 21.3) • Poorly distributed throughout country • Inverse relationship between # of child psychiatrists and percentage of youth in poverty • No increase in number of child psychiatrists trained per year between 1995 and 2006(census~700) Thomas and Holzer, JAACAP, 2006

8. Pediatrics and Mental Health • Costello E et al: Psychopathology in pediatric primary care: the new hidden morbidity, Pediatrics, 1988 • routine care, pediatricians sensitivity=17% • Pediatricians prescribing 84.8% of the psychotropic meds in large national office-based practice survey (Goodwin et al, 2001) • Organized medicine gets behind mental health in mid-90’s to present • Bright Futures in Mental Health • AAP Mental Health Task Force • AACAP Initiatives 2005 through 2011

9. “The Primary Care Advantage”: Suitability of Primary Care Providers for Mental Health • Patients and families often feel more comfortable and trusting of primary care providers • Primary care providers have the opportunity for prevention and screening • Experience coordinating care for children with multiple specialists and ancillary providers (medical home model) • Primary care providers know the developmental context of symptoms • Addressing psychiatric issues in primary care setting can reduce stigma

11. N=280 • 90% of pediatricians felt responsible for recognition but only 26% felt responsible for treating • 46% lacked confidence in ability to recognize depression • 10-14% felt adequate skill to treat depression • 56-68% cited lack of time as limiting factor • 38-56% cited lack of training limiting factor

12. 33% of parent respondents waited more than 1 year for an appt with a child mental health provider • 50% reported that pediatrician never asked about child’s mental health • 77% reported that pediatrician was not helpful in connecting them to resources

13. Child Psychiatrists and PCPs: Why is it so hard for us to work together? • Managed Care: Carving Out of Mental Health • Scarcity • Time-intensiveness of traditional CAP practice not matching up with high volume primary care operation • Confidentiality concerns • Stigma/Marginalization of Psychiatry from Mainstream Healthcare

14. MCPAP Goals • Improve access to treatment for children with psychiatric illness • Promote the inclusion of child psychiatry within the scope of primary care practice • Create functional primary care/specialist relationship between pcp’s and child and adolescent psychiatrists • Promote the rational utilization of scarce specialty resources for the most complex and high-risk children • Reduce stigma

15. Program Information • Dedicated teams deployed regionally across state • A state governmental program, through the Massachusetts Department of Mental Health, administered by the Medicaid managed care organization. • Serves all children and families in Massachusetts regardless of insurance status. • Serves all types of PCPs (MDs, PNPs, PAs) • Teams hosted by academic medical centers with existing relationships with pediatricians and family physicians. • Operating budgets of teams are fully funded, subject to reconciliation of third party reimbursement .

17. Operational Data • 6 teams • 423 practices with 1534 FTEs of primary care providers • 92% of pediatric practices with panel size of 2000 or more in MA used MCPAP at least once in 2011 • 20,958 encounters in FY 2012 • Over 1,460,000 children now covered • Over 98% of Commonwealth • Cost = $2.20 per child per year

18. Utilization – Encounters by Month 60% Commercially Insured – 40% Publicly Insured

19. Variability in practices’ patterns of use of MCPAP Proportion of practices Proportion of all calls to MCPAP Van Cleave, J et al, AACAP Poster 1.37, 2012 15% > 100 calls/practice 66% 33% 20-99 calls/practice 35% 3-19 calls/practice 27% 1-3 calls/practice 17% 5% 1%

20. Volume of Calls per Practice (n=248) Year since enrollment Van Cleave, J et al, AACAP Poster 1.37, 2012

21. Engagement Strategies • Be helpful on every call • Be in practice • Personalized, localized • Care coordination • Outreach/CME

22. MCPAP Encounter Types

23. Percentage of Encounters by Age

25. Types of Consultation Questions Medication Questions: -Selection -Side Effects -Interim management Screening support Help! Diagnostic question Treatment planning Unable to access MH resources Need second opinion Therapy Questions: -Selection -Monitoring -Linkages

26. Reason for contact (% of total calls)

27. Outcome

28. MCPAP Follow-up Study Sarvet et al, Baystate Medical Center • Supported by AACAP Access Initiative Grant • Aims: Assess patient experience of MCPAP program • Did program meet the identified need of the child • Was child able to receive recommended services • Parent view of the role of their PCP • Design: Telephone survey of parents 1-3 months after their child received a MCPAP telephone encounter

29. 1148 consecutive calls to MCPAP from PCPs • Telephone survey administered to parents • Response rate of 50.5% • N=528

30. Parent Responses

31. Overall Parent Perspective % Scale 1 to 7: 1=not satisfied, 4=somewhat satisfied, 7=very satisfied

32. Perception of PCP % Scale 1 to 7: 1=not satisfied, 4=somewhat satisfied, 7=very satisfied

33. Promoting Best Practice in the Detection, Assessment, and Treatment of Adolescent Depression in the Primary Care Setting: Implementation of the GLAD-PC in Two Large Primary Care Practices AACAP Access Initiative Project Campaign for America’s Kids

34. Disease management project for Adolescent Depression with two large primary care practices • Utilizing GLAD-PC recommendations • Includes broad mental health screening at well-child visits with PSC-35 • PCP’s trained in diagnostic assessment, treatment selection, initiation and monitoring of treatment • Enabling role of MCPAP: practical and psychological Texas

35. Psychiatric consultation to Adult PCPs, Ob/Gyns, Adult Psychiatrists • Promotion of Screening for Perinatal Mood Disorders in Prenatal Care and Primary Care • Development and linkage to community-based resources • Provider education

36. Other MCPAP Initiatives • Early Childhood Mental Health: Developing capacity for Triple P (evidence based parenting program) • School MCPAP • Working within integrated care models

39. Alaska • Arkansas • California • Colorado • Connecticut • Delaware • Florida • Illinois • Iowa • Louisiana • Maine • Maryland • Michigan • Massachuestts • Minnesota • Misouri • Texas • Vermont • Virginia • Washington • Wyoming • Wisconsin • DC • New Hampshire • New Mexico • New Jersey • New York • North Carolina • Ohio • Oregon • Pennsylvania

40. References • Sarvet B, Wegner L. Developing Effective Child Psychiatry Collaboration with Primary Care: Leadership and Management Strategies. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):139-48 • Sarvet B, Gold J, Straus J. Bridging the Divide between Child Psychiatry and Primary Care: The Use of Telephone Consultation within a Population-Based Collaborative System. Child Adolesc Psychiatr Clin N Am. 2011 Jan;20(1):41-53. • Sarvet B, Gold J, Bostic JQ et al. Improving Access to Mental Health Care for Children: the Massachusetts Child Psychiatry Access Project. Pediatrics. 2010 Dec; 126: 1191-1200. • Rosie D. and Mental Health Screening: A Case Study in Providing Mental Health Screening at the Medicaid EPSDT Visit, TeenScreen National Center for Mental Health Checkups at Columbia University, Fall 2010 • The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment In Primary Care, Wendy Holt, DMA Health Strategies, March 2010