Session A2b
October 11, 2013
Providing Care for Children and Adolescents
with Complex Medical, Psychological, and
Developmental Problems: A Collaborative Model
Mary Rineer, Ph.D.; Kathleen Shepherd Koljack, MD;
Michael J. Sannito, Ph.D.; and Danny W. Stout, Ph.D.
www.capesinc.org
Faculty Disclosure
We have not had any relevant financial
relationships during the past 12 months.
Learning Assessment
A learning assessment is required for CE credit.
Attention Presenters and Attendees:
Please incorporate audience interaction through a brief Question &
Answer period during or at the conclusion of your presentation.
This component MUST be done in lieu of a written pre- or post-test based
on your learning objectives to satisfy accreditation requirements.
Presentation Objectives
 Describe a model of collaborative multidisciplinary care
appropriate for complex cases.
 Describe the development and implementation of the
collaborative multidisciplinary model.
 Identify and discuss research models which can be
utilized with collaborative care and approaches to
measure and document benefits to patients.
 Describe both advantages and challenges of this model of
care and discuss solutions utilized for common challenges
when implementing the collaborative model.
The Agenda for Today’s Presentation
I. The Problem
II. The Collaborative Process
III. The Data
IV. The Future
I. The Problem
• Children and adolescents who present to Health Care
Providers with moderate to severe problems in two or
more areas of development pose a significant problem
for the Health Care Provider!
• The problem which this creates for the Health Care
Provider is created by a service delivery design which
does not encourage or establish a format for collaboration
among providers.
I. The Problem
• Half of “well-care” appointments in primary pediatrics
involve behavioral concerns. (Cassidy & Jellinek, 1998)
• Pediatricians may feel unprepared to accurately diagnose
behavioral problems and treat complex problems that may
necessitate both pharmacologic and behavioral
interventions. ( Williams, Klinepeter, Palms, Pulley, & Foy,
2004)
I. The Problem
• Health care providers
more readily identify and
treat attentiondeficit/hyperactivity
disorder than anxiety,
depression and conduct
disorder. ( Williams,
Klinepeter, Palms, Pulley,
& Foy, 2004)
Essentials of the Problem
Very complicated patients
Problems are interwoven-no clear referral pattern-doesn’t
fit the “medical model”
No clear format for addressing the problem
No common language-doctors don’t speak “Psychologist”
or “Occupational Therapist”
No “captain of the ship” for these patients
No algorithm
We need to build competency and comfort in our
pediatricians around these diagnoses
The Problem: An Ineffective Delivery System
In the past parent driven or based on referral of an HCP
(Health Care Provider)…
• Fragmented
• Variable outcomes
• Limited by perspective of the service provider
• Lack of awareness of available community resources
• Limited financial resources
• Limited communication between HCP in multiple fields
• Limited interaction between psychiatric services, regarding
outcomes of medication in a variety of settings
Benefits of CAPES Program
• Integrated
• Coordinated
• Consistent, evidenced-based outcomes
• Dynamic perspective of multiple service providers
• Awareness of available community resources
• Maximizing utilization of limited financial resources
• Consistent communication between HCP in multiple fields
• Consistent interaction between multiple providers and outcomes
observed in a variety of situations
• Integrated assessment of family dynamics related to the
child/adolescent
The Collaborative Process
• Recruiting Team Members to be part of the process:
• Start with individuals with whom you already have a practice
relationship.
• Emphasize the efficiency of the process that designs a treatment
plan and a way to implement it and follow progress.
III. The Data
• 10% to 20% of youths meet diagnostic criteria for a
mental health disorder, and many more are at risk for
escalating problems with long-term individual, family,
community, and societal implications (Kataoka, Zhang, &
Wells, 2002)
• Estimates are that 25% of the 150 million child visits per
year for primary health care (non-mental health and other
specialties) have a psychological problem associated with
the presenting problem (Woodwell, 2000)
III. The Data from CAPES
• It was hypothesized that the effectiveness of the CAPES
program would be manifested in significant lower post-test
scores on the Child Behavior Checklist.
• Initial nonparametric analysis using the Wilcoxon SignRank test found significant differences in the domains of
ADHD, OD and Conduct (p < 0.05), and marginal
significance for Affective (p = 0.06).
• This initial analysis did not account for the reason of
referral and utilized non-parametric tests of significance.
• Follow up tests accounting for referral reason and utilizing
the Student’s t-test were planned.
III. The Data from CAPES
• Follow up tests accounting for referral reason and utilizing
the Student’s t-test found significantly lower post-test
scores in all domains with the exception of Somatic,
meeting all statistical assumptions.
• Affective, t(17) = 3.80, p = .001
• Anxiety, t(17) = 3.02, p < .001
• ADHD, t(15) = 5.14, p < .001
• Oppositional Defiant, t(22) = 2.50, p < .001
• Conduct, t(17) = 4.01, p < .001
• Somatic (t(8) = 1.94, p = .088
Box & Whisker Plot
Pre_ADHD vs. Post_ADHD
Include condition: v24 = "X" and v25 <> 999 and v26 <> 999 and v27 > -100 and v27 < 100
13
12
11
10
9
8
7
6
5
Pre_ADHD
Post_ADHD
Mean
Mean±SE
Mean±1.96*SE
Box & Whisker Plot
Pre_Conduct vs. Post_Conduct
Include condition: v32 = "X" and v33 <> 999 and v34 <> 999 and v35 > -100 and v35 < 100
11
10
9
8
7
6
5
4
3
2
Pre_Conduct
Post_Conduct
Mean
Mean±SE
Mean±1.96*SE
IV. The Future
• Dynamic Long Term Results
• Service delivery model that maximizes the utilization of available
•
•
•
•
•
•
technology and expertise
Develop a hierarchy of family needs in order to optimize treatment
strategies which evolve as the child develops
Provide informational exchange between participants
Facilitate communication among parents and providers
Develop understanding of the service delivery system
Integrate decision making to enable a comprehensive and
collaborative series of recommendations
Develop standardized tools to communicate and document change
including: intake, case history, release of information and progress
updates and discharge reports
IV. Charting the Future
• CAPES Procedure Steps
• Intake Form
• Assessment Instruments
• Secure Website
• CAPES Team Notes and Care Recommendations
• Care Plan Sample
References
Williams, J., Klinepeter, K., Palmes, G., Pulley, A., & Foy, J.M.
(2004). Diagnosis and treatment of behavioral health disorders in
pediatric practice. Pediatrics, 114, 601-606.
doi: 10.1542/peds.2004-0090
Kataoka, S. H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental
health care among U.S children: Variation by ethnicity and
insurance status. American Journal of Psychiatry, 159, 1548-1555.
Woodwell, D.A., (2000). National Ambulatory Medical Care Survey: 1998 summary. Advance
Data From Vital and Health Statistics No. 315. Hyattsville, MD: National Center for Health
Statistics.
Cassidy, L.J., & Jellinek, M.S. (1998). Approaches to recognition and
management of childhood psychiatric disorders in pediatric
primary care. Pediatric Clinics of North America, 45, 1037-1052.
NAMI. Facts on Children’s Mental Health in America. (2005).
www.nimh.nih.gov.