1. No category

Integrated behavioral health in
pediatrics: From practicalities
of practice to policy change
March 23, 2015
Maya Bunik, MD, MSPH
Ayelet Talmi, PhD
Christopher Stille, MD, MPH
Cody Belzley
Maya Bunik, MD, MSPH
Associate Professor, Pediatrics
Ayelet Talmi, PhD
Associate Professor, Psychiatry and Pediatrics
GETTING STARTED,
PRACTICAL APPLICATIONS,
DISSEMINATION, & SYSTEMS
ISSUES
Maya Bunik, MD, MSPH
Ayelet Talmi, PhD
No financial disclosures or conflicts
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PROJECT CLIMB:
CONSULTATION LIAISON IN
MENTAL HEALTH AND
BEHAVIOR
INTEGRATING BEHAVIORAL HEALTH INTO PEDIATRIC
PRIMARY CARE
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CLIMB…how we started
• Partnership of Psychiatry and Pediatrics
• Initial Health Foundation funding
Started with:
• Developmental screening (>85% rates)
• Added pregnancy-related depression
screening
• Built foundation of collaboration and comanagement of two disciplines
• Planned for sustainability
with funds from ASQ &
Dept of Peds making it whole
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Generously Funded By:
with special thanks to Children’s Hospital Colorado Foundation and
Kathy Crawley and Jennie Dawe
• American Academy of Child and
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Adolescent Psychiatry
 Access Initiative Grant
Rose Community Foundation:
 Access to Mental Health Services
 CLIMB to Community
The Colorado Health Foundation
 Pediatric Resident Education
Caring for Colorado
Walton Family Foundation
 CLIMB to Community
Liberty Mutual
Denver Post Season to Share
Administration:
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Maya Bunik, MD, MSPH
Kelly Galloway, RN
Ayelet Talmi, PhD
Our Team
Pediatric Residents and Trainees:
Psychologists:
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Melissa Buchholz, PsyD
Emily Muther, PhD
Kate Margolis, PhD
Aurora Mental Health Clinician:
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Cathy Danuser, LPC
Psychiatrists:
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Leigh Anne Bakel, MD
Scott Canna, MD
Jacinta Cooper, MD
Michael DiMaria, MD
Thomas Flass, MD
Adam Green, MD
Danna Gunderson, MD
Kasey Henderson, MD
Ashley Jones, MD
Sita Kedia, MD
Gina Knapshaefer, MD
Courtney Lyle, MD
Catherine MacColl, MD
Jennifer McGuire, MD
Michelle Mills, MD
Amy Nash, MD
Rupa Narra, MD
Nicole Schlesinger, MD
Teri Schreiner, MD
Heather Wade, MD
And many more…
Kim Kelsay, MD
Celeste St. John-Larkin, MD
Postdoctoral Fellows: Shannon
Beckman, PhD, Steven Behling, PhD, Anna
Breuer, PsyD, Melissa Buchholz, PsyD,
Bridget Burnett, PsyD, Dena Dunn, PsyD,
Kendra Dunn, PsyD, Emily Fazio, PhD,
Barbara Gueldner, PhD, Rachel Herbst, PhD,
Jason Herndon, PhD, Jennifer Lovell, PhD,
Kate Margolis, PhD, Dailyn Martinez, PhD,
Christine McDunn, PhD, Brigitte McClellan,
PsyD, Brenda Nour, PhD, Sarah Patz, PhD, Psychology Interns: Megan Allen, MA, Caitlin
Conroy, MA, Tamie DeHay, MA, Barbara
Meg Picard, PsyD, Shawna Roberts, PsyD,
Kriston Schellinger, PhD, Casey Wolfington,
Gueldner, MA, Patrece Hairston, PsyM, Erin
PsyD
Hambrick, MA, Idalia Massa, MA, Jessican
Psychology Trainees: Dena Miller, MA, Keri
Linas, MA, Emma Peterson, MA, Jessica
Technow, MA, Crosby Troha, MA
Research Interns: Hamid Hadi, Traci Lien,
MD, Iman Mohamed, Cody Murphy, BA,
Molly Nowles, BA, Shagun Pawar, BA, Nick
Pesavento, Clare Rudman, Danica Taylor,
BA, Jen Trout, BA, Zeke Volkert, MD, Tyler
Weigang, MPH
Malmberg, MA, Alexis Quinoy, MA, Ryan
Roemer, MA, Justin Ross, MA, Cristina
Scatigno, MA, Tess Simpson, MA, Michelle
Spader, MA, Bethany Tavegia, MA, Crosby
Troha, MA, Brennan Young, MA, Jay
Willoughby, MA
CHC Faculty
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Mandy Allison, MD
Edwin Asturias, MD
Steve Berman, MD
Karen Call, MD
Mandy Dempsy, MD
Gretchen Domek, MD
Karen Dodd, PNP
Brandi Freedman, MD
David Fox, MD
Annie Gallagher, MD
Sita Kedia, MD
Allison Kempe, MD
Lindsey Lane, MD
Maureen Lennsen, PNP
Tai Lockspieser, MD
Dan Nicklas, MD
Steve Poole, MD
Bart Schmidt, MD
Chris Stille, MD
Christina Suh, MD
Meghan Trietz, MD
Shale Wong, MD
CHC Staff
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Liz Gonzales
Nicole Vallejo-Cruz
CLIMB Research Team
Ryan Asherin, BA
Mandi Millar, BA
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Iman Mohamed
Marianne Wamboldt, MD & Bob Brayden,
MD (original PIs)
Brian Stafford, MD, MPH (co-PI)
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Child Health Clinic
• Children’s Hospital Colorado
• Large Urban Primary Care
Teaching Clinic
• Low income= >90%
Medicaid/SCHIP
• 29,000 visits per year
• 60% of visits for zero to 3
years
• 56% Hispanic, 40% Spanish
Primary Language
• Pod based clinic design
• Dissemination to community
based clinics
Page 8
Program and Services
• Developmental Screening Initiative (Child)
• Pregnancy related depression (PRD) screening (Caregiver,
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Child, Family)
Healthy Steps for Young Children & MIECHV (Child, Caregiver,
Family)
Baby & Me at the CHC (Child, Caregiver, Family)
Case-based consultation (Child, Caregiver, Family)
Care coordination, triage, and referral (Child, Caregiver, Family)
Psychopharmacology consultations (Child)
Counseling and brief therapy services (Child, Caregiver, Family)
CLIMB to Community pilot (Child, Caregiver, Family)
Training and education (Providers/Health Professionals)
 Formal didactics
 Precepting trainees
 Collaborative care
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Clinician Identified Problem by Consultation
Type (%)
* Mothers of patients birth to 4 months were screened for pregnancy-related depression
CLIMB Initiatives
• Pregnancy-related depression
• Ages and Stages Developmental
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Screening
Healthy Steps for Young Children
Program
Baby and Me Group visits
Second Hand Smoke and Motivational
Interviewing
Trifecta for Breastfeeding Management
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Pregnancy-Related Depression
• Formal screening at well-child
visits from birth to four months
using Edinburgh Postnatal
Depression Scale (Cox et al.,
1987)
• Primary care services
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Training for providers
Psychoeducation
Support to mothers
Referral
Electronic medical record
• System changes
 Capacity building
• (Caregiver, Child, Family)
PRD data
• 89% of mothers seen for well child visits < 4
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months of age get screened
10% of mothers scored ≥10 on at least one
visit.
60 % by CLIMB provider only, 4%
(21/508)social worker (SW), 11 %
Those mothers who score high have more
clinic visits as part of their treatment
compared to those that do not (means 2.6
(1.1 sd), median 3.0 and 2.3 (1.1 sd),
median 2.0, respectively
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Developmental Screening and
Closing the Referral Loop
Talmi A, Bunik M Pediatrics 2014
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ASQ and EI Findings
• Developmental screening and referral is
necessary but not sufficient.
• Success of developmental screening
process depends on enhancing referral
completion.
• An intervention providing phone follow-up
and assistance with referral yielded
higher rates of referral and greater
provider knowledge of referral outcomes.
Talmi A, Bunik M Pediatrics 2014
Healthy Steps for Young Children
(www.healthysteps.org)
• Provide enhanced developmental services in
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pediatric primary care settings;
Focus on developing a close relationship between
the clinician and the family in order to address the
physical, socioemotional, and cognitive development
of babies and young children;
Currently used in 18 residency training programs
nationally
MIECHV funding to expand our program and develop
new sites across Colorado
Baby & Me at the CHC
(Child, Caregiver, Family)
Content analysis of well-child visits,
Healthy Steps vs. control (Buchholz & Talmi, 2012)
17%
Breast Feeding
70% *
11%
Postpartum depression
48%**
6%
How parent is feeling
75%**
3%
Child Care
23% *
56%
Home Safety
Temperament
90% *
0%
28% *
Promoting healthy eating
Healthy Steps
28%**
28%
Sleep
Daytime/Nighttime routines
Control
6%
63%**
0%
35%**
3%
Importance of Play
33%**
3%
Social Skills
38% *
8%
Language Development
35% *
0%
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
* ≤ 0.03
**≤ 0.01
Baby & Me at the CHC
(Child, Caregiver, Family)
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Bunik M et al. Pediatrics July 2013
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Methods: MI Intervention
The pediatric provider offers a MI session to
help make a plan for cessation or reduction.
If yes, trained provider meets family for 20
minute session. CLIMB providers are
primary counselors for the intervention.
If no, reasons for refusal are solicited.
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Results: Survey for
Satisfaction
• At the 1 week surveys, 81% (n=25/31)
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reported MI definitely worth their time.
81% (n=25/31) felt MI educator understood
their situation very or fairly well.
77% (n=24/31) found the quality of the MI
program excellent or good.
70% reported that most or almost all of the
of the participants needs were met
(n=21/30)
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Summary of SHS Findings
• The 'ONE Step' Quality Improvement
intervention was associated with a higher
quit rate (14%) compared to Colorado 2008
state data for low SES population (5%).
• Most parent/caregivers reported reductions
in smoking behaviors
• Addition of MI looks promising but need to
talk to families ‘treat it as an MI emergency’
Bunik M et al. Pediatrics July 2013
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Breastfeeding Management
Evaluation earlier is better and support
from an infant mental health specialist is
crucial
It’s Complicated
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Pregnancy-related depression
Paternal depression
Sleep expectations/deprivation
Sibling adjustment
Financial stress
Other family stressors
Transition to parenthood
Previous fertility or loss issues
Bunik M J Hum Lact 2014
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What We Do: The Trifecta Model
1. Comprehensive
functional
breastfeeding
assessment and
intervention:
• Physical exam
• Medical history
• Psychosocial history
• Pre-post feeding weights
• Assess latch
• Evaluate milk transfer
• Observe infant regulation
• Post hospitalization feeding
plan
• Evaluate baby growth and
milk supply
2. Psychosocial assessment
and support:
• Evaluate family adjustment
• Assess pregnancy-related
depression/Administer EPDS
• Acknowledge and support
partner’s involvement in
feeding routines
• Discuss sibling adjustment
• Self-care:
• “Baby out of the
building”
• Enjoyable activities
• Help with childcare
Community
Intervention
Family
Baby
Intervention
Breastfeeding Dyad
3. Follow-up
recommendations,
future planning, and
referrals:
• Communication with
medical home
• Discuss return to work
• Pumping
• Childcare
• Planning feeding and
sleep routines
• Community referrals if
needed:
• Fussy Baby
Network
• Mental health
referral
• Occupational
therapy
Lactation Consultant + Pediatrician + Psychologist
Bunik, Dunn, Talmi, & Watkins, 2012. Do not distribute without permission.
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Dissemination:
CLIMB to Community
• CLIMB to Community intends to implement and
evaluate the sustainability of integrated behavioral
health services in community-based pediatric
primary care practices serving publicly insured
children by disseminating the Project CLIMB model.
• Expansion of integrated behavioral health services
will improve the health outcomes for publicly
insured children ages 0-18 through increased
access to behavioral health services.
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Systems Isssues
• Maternal Infant Early Childhood Home
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Visitation (MIECHV) federal funding
State Innovations Model (SIM) - $65M
Office of Early Childhood
Regional Care Collaboratives
Behavioral Health Organizations
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Questions?
“I've learned that people will forget what you said, people will forget what
you did, but people will never forget how you made them feel.” Maya Angelou
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INTEGRATED BEHAVIORAL HEALTH: A FINAL
PIECE OF THE MEDICAL HOME PUZZLE
Christopher Stille, MD, MPH
Department of Pediatrics, UC Denver SOM/Children’s Hospital Colorado,
March 23, 2015
April 1, 2015
The Medical Home: definitions
• US MCHB definition:
A Medical Home provides
care which is:
• Accessible
• Family-Centered
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Culturally Effective
• Robert Frost definition:
“Home is the place where
when you go there, they
have to take you in.”
• My definition:
The medical place where
the buck stops.
Why focus on behavioral health services?
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We see this, many times, every day
4 year old boy for a 20 minute well child checkup
Previously healthy, few minor medical problems
Screen with PEDS: “behavioral problems”
Lives with mother (teen) and grandmother, father
incarcerated
Described as "a handful", "hard to manage" and "difficult"
since he started to walk. Referred for EI and behavioral
therapy in past
After 30 minutes of rambling history, they finally admit their
primary concern: he has injured two kittens that live in the
house and expresses no remorse over this practice. The
family is concerned for safety (his and theirs)
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Why does integrated care matter so
much?
• Accessible
• Family-Centered
• Continuous
• Comprehensive
• Coordinated
• Compassionate
• Culturally Effective
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Current challenges
• Challenges unique to
behavioral health that
are addressed by
integrated care:
Insurance “carveouts”
Stigma
Tradition of confidentiality
Lack of continuity
Interplay of physical and
behavioral health
• Lack of awareness of the
medical home as a source
of mental health care (and
other services)
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Accessible
Family-Centered
Continuous
Comprehensive
Coordinated
Compassionate
Culturally Effective
Typical Medical Care System
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Well-functioning Medical Home
High
Thinking about MH
services in the
context of a patientcentered medical
home:
Continuum
of Needs
Crisis and
emergency
services
Intervene with
specialty
mental health services
Intervene with
resources
of the practice
Low
Watchful
waiting
Child Mental Health: Opportunities for prevention
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But I’m just a primary care provider…?
• I see LOTS of behavioral health issues
• I think I am reasonably smart and caring
• I can’t do diagnostic interviews
• I can’t do therapy
• I can prescribe meds, but only so far…
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For the primary care team:
take a “Common Factors” approach
• Tending to the alliance you build with families is a
treatment in itself, and facilitates the impact of other
treatment you provide
• Clarifying concrete concerns and making it clear that you
are working toward addressing those concerns is also
therapeutic
• A relatively small repertoire of brief advice may help many
families while waiting for more definitive diagnosis and
treatment
From Wissow et al. Adm Policy Ment Health. Jul 2008;35(4):305-318
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Step 2: Make use of your integrated
behavioral health colleagues…
• After screening and identifying concerns, and clarifying
needs with patients and families, you are best prepared to
inform your behavioral health colleagues so they can get
a head start
• Later, you can best support what they do in followup visits
with the family
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What About A Virtual Team?
• Consult liaison model
• PCP as point of contact
• Phone consult with 30
minutes
• Single visit psychiatric
consult within 2 weeks
• Care coordination for “hard
cases”
• Funding secured to bring
modified program
statewide
• Open to all (MassHealth
and private payers)
And It Has Caught On….
National Network of Child Psychiatry Access Programs
(NNCPAP.org)
NNCPAP.org
 Alaska
 Massachusetts
 Vermont
 Arkansas
 Michigan
 Virginia
 California
 Minnesota
 Washington
 Colorado
 Missouri
 Washington, D.C.
 Connecticut
 Nebraska
 Wisconsin
 Delaware
 New Hampshire
 Wyoming
 Florida
 New Jersey
 Georgia
 New York
 Illinois
 North Carolina
 Iowa
 Ohio
 Louisiana
 Oregon
 Maine
 Pennsylvania
 Maryland
 Texas
CPAP vs. integrated care
• CPAP more accessible especially at a distance
• Few of the benefits of integrated care but much better
than the “status quo”
• Bridge to an integrated care model
• Complements integrated care
• Psychiatry available by phone if not available in person
• Coordination of psychiatry and psychology essential
• This is not telehealth… but telehealth is being explored as
a way to improve it in some states
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And then,
the State
Innovation
Model:
There is a
LOT going on
in Colorado.
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Colorado SIM grant: brand new
• Goal: 80% of people statewide have access to integrated
behavioral health
• Practice transformation
• Payment reform
• Measurement
• Challenge: aligning adult and child interests
• Pilot of a model like this ongoing in 8 practices using the
CLIMB model
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The policy argument
• Triple Aim (or just money):
• Moving from episodic payment to whole
person care
• Any divides hurt this
• Mental illness begins in childhood
• Early treatment saves money and improves
outcomes
• Children are not little adults
• Need different systems
• Need better measures
• Need different payment
April 1, 2015
Presentation Title
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Useful links
AAP Mental Health Task Force
http://www2.aap.org/commpeds/dochs/mentalhealth/mh1a.
html
National Network of Child Psychiatry Access
Programs
http://nncpap.org or
http://web.jhu.edu/pedmentalhealth/nncpap.html
Center for Mental Health Services in Pediatric
Primary Care
http://web.jhu.edu/pedmentalhealth/
My email: [email protected]
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Policy Change to Support Integrated Behavioral Health in Pediatrics
Cody Belzley
Vice President, Health & Strategic Initiatives
Colorado Children’s Campaign
Nonprofit, nonpartisan advocacy organization committed to realizing
every chance for every child in Colorado.
Grounding Data
Childhood Adversity and Developmental Delays
Children with Developmental Delays
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1 or 2
Source: Barth, et al.
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Number of Risk Factors
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Grounding Data
Many children who are identified as having a developmental
delay never receive intervention services
Initial Screenings
Further Evaluation
Services
Source: PolicyLab, The Children’s Hospital of Philadelphia
Understanding Your Policy Audience
• Most elected officials are not
health policy experts.
• Most elected officials are juggling
very full agendas.
• Medicaid Directors have a huge
job and limited capacity
Framing The Policy Discussion
• Children are Not Small Adults
• Whole Family Care Essential
• Focus on Prevention
• Focus on Community Settings
• Appropriate Evaluation
Policy Opportunities
Access and Delivery Models
• Meet families where they are – reduce stigma
• Primary care doctors offices
• Child care settings & schools
• Infrastructure for screening, referral & case management
• Standardized tools & protocol for screening
• Unified data collection
• Resources for families in crisis
• Statewide crisis support line
Policy Opportunities
Financing
• Paying for preventive services and non-medical supports
• Screening, referral, follow-up
• Case management, transportation, food
• Family care, not individual patient care
• Multi-generational care from same provider
• Appropriate metrics for evaluating and paying for care
• Process metrics, if not outcome metrics
Policy Opportunities
Workforce
• Addressing shortages in rural & underserved communities
• Recruiting and retaining providers in underserved places
• Telehealth and innovative models to serving remote
communities
• Professional development and training
• Supporting continued training opportunities and career ladders
for medical and education professionals
• Team-based approaches
• Scope of practice
Policy Strategies
• Educate and Engage Policy Makers
– Start with the basics
– Find personal connections to the issue
• Build Champions
– Invest time and resources in cultivating a few well-positioned
champions
• Form Partnerships & Nurture Coalitions
– Look for existing networks to leverage
– Build new groups only when necessary or at critical junctures
Policy Strategies
• Capitalize on Opportunities
– Be opportunistic over the short term
– Find places to build a pediatric mental health component into
existing work
• Create New Movements
– Be intentional and proactive over the long-term
– Build a multi-year agenda
More Info?
Cody Belzley
(303) 620-4560, [email protected]