MENTAL HEALTH SCREENINGS
IN PRIMARY CARE
A 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)
Overview & Goals
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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
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Case Study: Billy M.
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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
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Psycho-educ eval tests at above normal range
But - conduct poor due to “behavioral issues”
(mom called frequently to pick son up early)
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Case Study: Billy M.
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Mom shares that Billy has recently been
described as using aggressive behavior
and inappropriate language
Unbeknownst to you, Mom has history of
bipolar disorder
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Case Study: Billy M.
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What is the PCP’s next step?
1.
2.
3.
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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?
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Screening Tools
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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?
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What If We Do Not Screen?
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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 Advocacy
Blind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012)
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Mental Heath Screening = Primary Care or
Mental Heath Screening ≠ Primary Care?
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Federal Medicaid Law
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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.
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EPSDT and Screening
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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
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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).
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EPSDT Non-Compliance?
Bring on the Lawsuits
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Rosie D. v. Romney
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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).
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Rosie D. Outcomes
Reported Mental Health Screenings at Well-Child Visits
80.00%
70.00%
67%
60.00%
58%
50.00%
Reported Mental Health
Screenings at Well-Child Visits
40.00%
30.00%
20.00%
10.00%
14.46%
0.00%
2008 Q1
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2009 Q4
2011 Q3
Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010);
MassHealth Quarterly Screening Data: April-June 2011.
Positive Screen = Referrals
Rosie D. Outcomes
60,000
50,000
50,535
Number of Children Screened
Positive for Mental Health
Disorders
40,000
30,000
20,000
10,000
0
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1,533
2008 Q1
2009 Q3
Teen Screen at Columbia
University, Rosie D. and Mental
Health Screening (2010).
Referrals = Intervention
Rosie D. Outcomes
5.00%
4.50%
4.70%
4.00%
3.50%
3.00%
3.50%
2.50%
Number of Youth Receiving
Any Remedy Service
2.00%
1.50%
1.00%
0.50%
0.00%
FY 2010
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FY 2011
Def.’s Report on Implementation
(Jan. 1 2012).
Positive Screens = Referrals
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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).
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Importance of Screening Instruments
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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).
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Where Has It Lead?
CCA Proposed Legislation
2011 Session of Connecticut GA
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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
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Where Has It Lead?
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Behavioral Health Screening Task Force
Examination of delivery systems to ensure that screenings are
promoted, supported and reimbursed in primary care.
Players
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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
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Where Has It Lead?
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BH Task Force met monthly
Aug.2012 - Mar.2013
Experts in-state and out-of-state (Mass e.g.)
Information obtained, recommendations provided
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Mass Experience – PCC feedback
Not exceptionally burdensome,
infrastructure working
MCPAP as a workable idea and resource
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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
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Where Does It Lead?
Task Force Recommendations (3/2013)
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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
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Where Does It Lead?
Recommendations (continued)
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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.
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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.)
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Thoughts?
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Questions?
Center for Children’s Advocacy
Medical Legal Partnership Project
Attorney Jay Sicklick
860-714-1412
jsicklick@kidscounsel.org
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