Mental Health Integration in Pediatric
Primary Care: Engaging Families in Early
Identification, Prevention, and Intervention
DC Collaborative for Mental Health in
Pediatric Primary Care
National Federation of
Families for Children’s
Mental Health
November 21, 2014
1
Thank you
• We wish to extend our thanks and gratitude to our
funders who make our work possible:
– DC Department of Behavioral Health (Partial funding for
this project was provided by SAMHSA grant funds from the DC Children’s System of Care
Expansion Implementation Project- The DC Gateway Project)
– DC Department of Health (This project made possible through a subgrant agreement with DC Department of Health Title V program. Notice of Grant
Agreement # CHA.PSMB.CNMC.PGRM-C.052013. The views and opinions contained in
this presentation do not necessarily reflect those of DC Department of Health or the US
Department of Health and Human Services, and should not be construed as such.)
– Howard and Geraldine Polinger Family
Foundation
2
Learning Objectives
1) Identify steps taken to develop and sustain the
Collaborative
2) Understand key components of the described
initiatives
3) Describe family involvement in the Collaborative
and its initiatives
4) Apply lessons learned to similar local efforts in their
communities.
3
Agenda
• Introductions
• Background
– Mental health in pediatric primary care
– DC Collaborative for Mental Health in Pediatric Primary Care
• Projects & Initiatives
–
–
–
–
–
Annual, universal mental health screening
Pediatrician education/quality improvement
Resource guide
Behavioral health access project (DC MAP)
Mental health integration in primary care
• Family Involvement
– Family voices
– Family navigators
• Summary of Lessons Learned
• Questions and Wrap-Up
4
Introductions
• Brief introductions of presenters and audience
5
Background
• “20/20 Problem”1-3
• Young children (< 5) experience MH problems at
rates similar to older children/adults.4
• 50% of mental health conditions begin < 14.5
6
Background
• Problems unidentified or identified too late despite what
we know about short- and long-term benefits of early
identification.
• Access to MH and support services is low3,6-7; many barriers
that prevent families from seeking traditional care.
7
Why Primary Care?
The “Primary Care Advantage:”
•
•
•
Regular (frequent) contact with families
Family-provider relationship (longitudinal, trusting)
Behavioral health is already a common topic8
8
Why Primary Care?
Opportunity for:
• Early identification and prevention
• Reducing stigma
• Interdisciplinary collaboration/learning
• Improved outcomes for patients
Lesson Learned:
 Discussing MH is important
regardless of outcome
9
Agenda
• Introductions
• Background
– Mental health in pediatric primary care
– DC Collaborative for Mental Health in Pediatric Primary Care
• Projects & Initiatives
–
–
–
–
–
Annual, universal mental health screening
Pediatrician education/quality improvement
Resource guide
Behavioral health access project (DC MAP)
Mental health integration in primary care
• Family Involvement
– Family voices
– Family navigators
• Summary of Lessons Learned
• Wrap-Up
10
History
Lessons Learned:
 Early involvement of key stakeholders
 Interdisciplinary, multi-agency (publicprivate), coordinated efforts
11
DC Collaborative for Mental Health in
Pediatric Primary Care
• Aim: To improve the integration of mental health in
pediatric primary care for children and adolescents in DC.
• Engage in initiatives that strive to be:
–
–
–
–
Collaborative & interdisciplinary
Culturally competent
Family-focused
Developmentally-sensitive
(focus on early childhood)
(emphasis
12
Working
Group
- American Academy
of Pediatrics (DC
Chapter)
- Children’s National
Health System
- Children’s Law
Center
- DC Department of
Behavioral Health
- DC Department of
Health
- DC Department of
Health Care
Finance
- Georgetown
University
DC Collaborative for
Mental Health in
Pediatric Primary Care
Project Team
Disciplines represented:
- Advocacy
- Education
- Pediatrics
- Policy
- Psychiatry
- Psychology
- Social Work
Funding Sources:
- DC Department of Health Title V Block Grant Program
- Howard and Geraldine Polinger Family Foundation
Advisory
Board
(Partial Listing)
-DC Behavioral Health
Association
-DC Public Schools
-George Washington
University
-Health Services for
Children with Special
Needs (MCO)
-Howard University
-Mary’s Center
-Strong Start DC
-Total Family Care
Coalition
-Unity Health Care
13-Zero to Three
Activities – Initiatives
Education
and
Training
Behavioral
Health
Access
Program
Integrated
Consultation
Integrated
Evaluation
and
Treatment
Resource
Guide
Family
Navigators
Support for
Practices
Support
for
Families
Integrated
Services
PolicyAdvocacy
Routine,
Universal
MH
Screening
Expert
Resource
Evaluation and Research
Coordinated
Systems of
Care
Perinatal
Depression
and Anxiety
Access to
Services
Payment
Reform
14
Agenda
• Introductions
• Background
– Mental health in pediatric primary care
– DC Collaborative for Mental Health in Pediatric Primary Care
• Projects & Initiatives
–
–
–
–
–
Annual, universal mental health screening
Pediatrician education/quality improvement
Resource guide
Behavioral health access project (DC MAP)
Mental health integration in primary care
• Family Involvement
– Family voices
– Family navigators
• Summary of Lessons Learned
• Wrap-Up
15
Exercise: What do all these moms have in
common?
“I was suffering from postpartum
depression and severe anxiety.
You can’t tell by looking, but I felt
like a horrible mother. I had been
suicidal a few months prior... just
getting out of bed was painful and
exhausting.”
“I was suffering from PPD. You
can’t tell by looking, but I was
self harming and trying to
manage deep depression and
intense rage.”
Source: “You Can’t Tell a Mom has
Postpartum Depression by Looking” by
Katherine Stone/Postpartum Progress
http://www.postpartumprogress.com
When this picture was taken…
“I was suffering from the
worst depression and anxiety
I’d ever known…You can’t tell
by looking, but I felt like I was
drowning. I was never happy,
worried about everything all
the time, and wanted nothing
more than to just disappear
and never return”
16
Annual, Universal
Mental Health Screening
• Goal: Increase early identification of problems
(improve outcomes).
• Rationale:
o Pediatricians will miss a lot of problems without use of a tool9
o Many parents will not raise concerns on their own10
o Problems can be reliably identified early and brief screening in
early childhood predicts outcomes in elementary school.11
• Process:
o Parent/youth completes brief questionnaire at annual visit.
o Scoring, discussion and referrals (as appropriate) by provider.
o Screening is NOT diagnostic.
17
Mental Health Screening in DC
• July 2013: New DC Medicaid Managed Care Organization (MCO)
contracts state primary care providers must use approved
screening tool annually (all ages).
• September 2013: Primary tools selected:
– 3-66 months: Ages and Stages Questionnaire: SocialEmotional (ASQ:SE)
– 2-21 years: Strengths and Difficulties Questionnaire (SDQ)
– 18-21 years: Patient Health Questionnaire-9 (PHQ-9)
– Received feedback from Community Advisory Board, including family
representatives
• October 2014: Updated billing manual to help track screens and
increased expectation that providers begin implementing.
18
Activity
• Work with a partner to match screening sample
questions with the domains they belong to.
19
Concerns are Raised…
Now What?
• In DC, most PCPs feel unable to usually meet the needs of
children with mental health problems.12
• Lack of training, confidence, and knowledge = barriers to
identification and management of mental health issues.13
• In DC, ~4 out of 5 providers said that their comfort level
and knowledge in addressing mental health was worse for
children < 5 years than for older children.12
20
Quality Improvement
Learning Collaborative
Model for multi-practice learning & measureable improvement
Who? Pediatric practices (15) and providers (~130)
 What?






8 learning sessions (1 hour webinars)
Monthly team leader conference calls
Monthly practice team meetings
Monthly chart audits to measure progress
3 PDSA cycles to facilitate change
Received input from family navigators as learning sessions
developed and implemented

21
Quality Improvement
Learning Collaborative
Where? In provider offices & on the web
 When? February – October 2014
 Why? Receive support & MOC Credit (ABP, ABFM)

Lessons Learned:
 Start small…then ramp up
 Lay groundwork such as office “screening” champions
 Provide support to PCPs
 Incentives
22
QI Learning Collaborative: Aims
Between Feb and Oct 2014, providers will increase
• practice readiness to perform annual mental health
screenings for culturally diverse patients
• % of annual well child visits where an approved screening
tool is administered
• % of mental health screenings that have scored
documentation of results
• % of "positive" mental health screens with an appropriate
follow-up plan documented (addressed by provider
and/or referred to care)
• % where administration of a screening tool is
appropriately coded and/or billed
23
Project Map
February
March
April
May
June
July
2-Part Kick-Off:
Team Leader
Part 1:
Part 2: Call & Learning
Screening QI101Session #2:
Overview Tues 3/4
Tues 3/18
Thurs 2/6
Team
Leader Call:
Tues 4/15
Team
Leader Call:
Tues 5/20
Learning
Session #3:
Thurs 5/15
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Baseline Chart Audits (30)
(Covers 6 months pre-implementation
period)
Learning
Session #4:
Thurs 6/5
Sept
Team
Leader Call:
Tues 8/28
Team
Leader Call:
Tues 9/16
Learning
Session #6:
Thurs 8/7
Learning
Session #7:
Thurs 9/4
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
Practice
Team
Meeting
May Chart
Audits
(10)
June
Chart
Audits
(10)
July Chart
Audits
(10)
August
Chart
Audits
(10)
Sept
Chart
Audits
(10)
Practice
Readiness
Inventory
PDSA Cycle
Progress Report 1
(Feb - March)
Team
Leader Call:
Tues 6/17
Team Leader
Call &
Learning
Session #5:
Tues 7/15
August
PDSA Cycle
Progress Report 2
(April - May)
October
Team Leader
Call &
Learning
Session #8
Tues 10/21
Practice
Team
Meeting
Oct Chart
Audits
(10)
Mid-QI
Balancing
Survey
Post-QI
Balancing
Survey
PDSA Cycle
Progress Report 3
(June-July)
Practice
Readiness
Inventory
24
Learning Session
#2
Learning Session
#3
Learning Session
#4
Early Childhood
Learning Session
#5
Learning Session
#6
Early Childhood
Learning Session
#7
Learning Session
#8
Screening
Overview
Implementation
Screen Results:
Partnering with
Families on
Screening
Interpretation,
Decision-Making,
and Referrals
Engaging
Families
Early Childhood
Mental Health
Overview
Managing
Mental Health
Concerns
Collaboratively
Depression &
Other Family
Risk Factors
Putting It All
Together & Next
Steps
Lee Beers, MD &
Matt Biel, MD
Lee Beers, MD &
Mark Minier, MD,
FAAP
Michele Dadson,
PhD
Bruno Anthony,
PhD
Bhavin Dave, MD
Martine Solanges,
MD & Kirsten
Hawkins, MD
Lisa Cullins, MD
Lee Beers, MD &
Larry Wissow,
MD, MPH
2/6/14
3/25/14
5/15/14
6/5/14
7/15/14
8/7/14
9/4/14
10/21/14
Goals:
Understand
purpose and basic
fundamentals of
routine MH
screening
Goals:
Understand ways
to prepare
practices for
screening and
facilitate
successful
implementation
with culturally
diverse families
Goals:
Understand how
to interpret and
use screening
results and how to
access community
referrals for
culturally diverse
families
Goals:
Understand ways
to more
effectively discuss
MH and engage
culturally diverse
families in the
process
Goals:
Understand basic
issues pertaining
to MH assessment
and treatment for
culturally diverse
children < 5
Goals:
Understand how
to manage basic
MH issues in the
office for
culturally diverse
families and work
collaboratively
with providers in
co-management
Goals:
Understand
impact of
depression/other
risk factors on
young child
wellbeing and
how to
screen/refer for
these issues
Goals: Review
and prepare for
project end
Content:
Rationale for
routine screening,
overview of tools;
begin discussing
ways to engage
culturally diverse
families in
screening
Content: Review
AAP Practice
Readiness
Inventory and
discuss steps to
prep for
implementation
(e.g., logistics,
billing); discuss
ways to engage
families in
screening
Content: Review
range of screening
scores (e.g., atrisk, clinical), how
to discuss and
partner with
families, and next
steps (monitor,
refer, manage),
and discuss
resources and
referrals
Content: Review
key principles of
young child
assessment and
treatment; Tips for
talking with and
engaging parents
of young children
about MH issues
and common
concerns
Content: Review
common concerns
that can be
managed in
primary care and
discuss ways to
effectively engage
parents in these
efforts; Discuss
strategies for
effective comanagement with
outside MH
providers
Content: Provide
info on family risk
factors; discuss
ways to screen
(formally &
informally) for
and engage
culturally diverse
families in
discussion of
these issues;
Review referrals
and resources
Content:
Summarize and
connect previous
learning sessions;
Discuss various
collaborative care
models and how
practices can
move forward
with this work;
Review sources of
additional info
and opportunities
for learning
Learning Session
#1
Content: Review
ways to use
screening as a
jumping off point
for engaging
families in mental
health discussions
and for motivating
change
25
Early Improvement
in DC Screening Practices
26
PDSA Activity
• Reminder of the steps (see worksheet)
–
–
–
–
Plan
Do
Study
Act
• http://www.youtube.com/watch?v=jsp-19o_5vU
27
PDSA Cycle Example: Late to School
• PDSA Trial #1: Get up Earlier
– No improvement
• Aims statement: Increase proportion of times
arriving at school on time by improving AM
processes and reducing negative parental
interventions
• PDSA Trial #2: Eat Breakfast Last
– Decreased time late to school from 60% to 40%
• PDSA Trial #3: Pick out clothes night before +
targeted incentive (ice cream!) = On time every day!
28
Continual Improvement
• Learning Collaborative 2.0
• Incorporating family navigators into screening
process to assist with follow-up
29
30
DCHEALTHCHECK.NET
DC Mental Health Resource Guide:
DC MAP
(Mental health Access in Pediatrics)
• Goals:
–
–
–
–
Increase collaboration between PCPs and MH providers.
Promote mental health within primary care.
Improve identification, evaluation, and treatment
Promote the rational utilization of scarce specialty mental health
resources for the most complex and high-risk children.
• Services provided:
–
–
–
–
–
Phone consultation with child MH experts
Brief, time-limited follow-up services
Mental health education and training
Resource guide maintenance
Medication reviews
31
32
MH Access Programs
• Started in MA in 2003
• In MA, 96% increase in rate of primary care providers
reporting that they are “usually able to meet the
needs of psychiatric patients”.14
• Since adopted across > 25 states: nncpap.org
Alaska
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Illinois
Iowa
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
New Hampshire
New Jersey
New York
North Carolina
Ohio
Oregon
Pennsylvania
Texas
Virginia
Washington
Wisconsin
Wyoming
Vermont
33
DC MAP
(Mental health Access in Pediatrics)
• FY14: DC Collaborative planning
• FY15: Launch program
– RFP released by the Department of Behavioral Health
– Behavioral Health System of Care Act
– Care coordinator/family navigator proposed
34
Mental Health Integration in Primary Care
•
•
•
•
Increasingly common
Can assist with problems as they arise
“Warm hand offs”
Can catch families who might otherwise not see a
MH clinician
• Decreases stigma
• Increased PCP learning and confidence
35
Agenda
• Introductions
• Background
– Mental health in pediatric primary care
– DC Collaborative for Mental Health in Pediatric Primary Care
• Projects & Initiatives
–
–
–
–
–
Annual, universal mental health screening
Pediatrician education/quality improvement
Resource guide
Behavioral health access project (DC MAP)
Mental health integration in primary care
• Family Involvement
– Family voices
– Family navigators
• Summary of Lessons Learned
• Wrap-Up
36
Integrating the Family Voice
• Community Advisory Board
• Parent focus groups (planned)
• Family navigators in primary care (beginning)
• Parent supports in the resource guide
37
Integrating the Family Voice
• What do you perceive as the major gaps in the
identification and management of MH
problems in primary care?
• What positive experiences have you had with
pediatricians regarding mental health
identification and management, and what
would you want replicated by others?
• What are your suggestions for best engaging
parents on advisory boards?
38
Family Navigators: Key Concepts for
Working with Families in Primary Care
• Encourage parents to talk about MH issues:
– Concerns
– Evaluations, treatment (services, medication)
– Questions or unmet needs (e.g., “my child has been attending
therapy but I don’t feel like it’s helping”)
• Encourage open communication between PCP and MH
team.
– Bring medical records and be proactive about data-sharing.
• Help parents understand confidentiality
– State-specific laws
– Rationale
39
Family Navigators: Key Concepts for
Working with Families in Primary Care
• Help parents understand:
– role they play in treatment.
– ways they can get more involved in their children’s care.
• Ensure that :
– professionals understand that the family is part of the care team.
– navigators have training in relevant topics so that they will be
equipped to address families’ issues.
• Peer-to-peer support works because families can identify
with their peer workers.
40
Lessons Learned
 Interdisciplinary, multi-agency (public-private),
coordinated efforts
 Start small (pilot with a few practices, work out the
kinks)…then ramp up
 Early involvement/awareness of key stakeholders (e.g.,
schools, MH providers)
 Lay groundwork in advance: Screening champions across
the office
41
Lessons Learned Continued
 PCPs need support…including in-person)
 Discussing MH important regardless of the outcome
 Provide incentives (MOC, CME, payment, seeing
improvement in outcomes)
 Facilitating more interaction b/w PCPs and MH providers
42
Group Discussion:
Action Steps for Participants
• Are you involved or aware of pediatric primary care/mental
health integration efforts in your community?
• Brainstorm ways you can get involved and encourage
other parents to get involved in local efforts.
– People you could contact? Relevant agencies?
• Ideas:
– Parent Advisory Boards at pediatricians’ offices
– Local chapters of American Academy of Pediatrics
– Departments of Behavioral Health
43
Role Play:
Engaging Pediatrician
• There are no formalized efforts to integrate primary
care and mental health care in my community. What
can I do as a parent to engage my pediatrician in one
area, such as screening?
– Discuss importance of routine, annual MH screening at well
child visits using validated tools (can’t tell by looking).
– Annual MH screening recommended by American Academy
of Pediatrics Bright Futures.
– Provide examples of screening tools: Ages and Stages Social
Emotional, Strengths and Difficulties Questionnaire, Patient
Health Questionnaire 9.
44
Thoughts—Questions?
45
Questions?
• Lee Beers: Lbeers@childrensnational.org
• Leandra Godoy: Lgodoy@childrensnational.org
• Sarah Barclay Hoffman: Sbhoffma@childrensnational.org
• Darcel Jackson: Dtjackso@childrensnational.org
46
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