Doug Lincoln, MD, MPH Erin Grady, PhD Audelia DeCosta, LCSW

Metropolitan Pediatrics

Learning Objectives By the end of this presentation and discussion you will be able to: Describe the changing epidemiology of behavioral health needs in pediatrics Identify alignment and variation between adult and pediatric models of integrated behavioral health Describe a public health model of integration and how we applied this model within our practice Identify opportunities and barriers for implementing behavioral health integration within a pediatric population

Shifting Epidemiology

Shifting Epidemiology The Doctor, Sir Luke Fildes, 1891

Shifting Epidemiology Centers for Disease Control

Shifting Epidemiology

The New Morbidity

The New Morbidity 10% to 11% of children and adolescents have both a mental health disorder and evidence of functional impairment US Department of Health and Human Services, Mental Health: A Report of the Surgeon General, 2000

The New Morbidity Half of all lifetime prevalence of mental health disorders in adults present before the age of 14 US Department of Health and Human Services, Mental Health: A Report of the Surgeon General, 2000

The New Morbidity Specialty mental health care for children falls far short of need, particularly among children in rural areas and lower SES Thomas CR, Holzer CE III. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9): 1023 1031.

The New Morbidity American Academy of Child and Adolescent Psychiatry, Workforce Maps By State

The New Morbidity HRSA, The Mental and Emotional Well-Being of Children: A Portrait of States and the Nation, 2007

The New Morbidity

Oregon Healthy Teens, 2017

Oregon Healthy Teens, 2017 8.7% of 8 th graders and 6.8% of 11 th graders report 1 or more attempts in the past 12 months

Where Are They Being Seen? Luoma JB et al. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909-916.

Oregon Healthy Teens, 2017

Adverse Childhood Experiences (ACEs)

ACEs Impact Children Across Incomes

Room For Improved Screening Do pediatricians ask about adverse childhood experiences in pediatric primary care? Kerker et al. Acad Pediatr. 2016 Mar; 16(2): 154 160.

A Call To Action

A Call To Action 2009: Establish a practice environment that normalizes integration of mental health and incorporates medical home principles for the care of children with mental health concerns as for children and youth with other special health care need - The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care

A Call To Action

Integrating Behavioral Health in a Pediatric Primary Care Setting Evolution of our model

A Brief History BH was integrated in 2011 Started with 1 pediatric psychologist at 1 site Over the next 5 years, BH team gradually expanded to include 1 pediatric psychologist and 1 pediatric clinical social worker at all 4 sites The BH team also includes care managers and patient service coordinators

Continuum of Behavioral Health for Primary Care Established partnerships with community BH clinics and providers BH on-site but referral based fee for service BH integrated in care team across levels of care Referral based Consultative Co-located Integrated To learn more about six levels of collaboration/integration, visit SAMHSA Center for Integrated Health Systems. Improved collaboration

Pediatric Primary Care Without Integrated Behavioral Health BH support provided by PCPs, primarily in Well Child Visits, Screenings, and Patient Education Tier III Tier II: Patients with At-Risk or Clinical concerns are referred out PCPs may provide medical interventions for some BH concerns Tier I: All Patients PCPs administer screening + provide patient education

The Co-Located Model Inefficient use of resources What if kids can improve with less intensive intervention? Many can. And we often have access to them when problems first arise. Tier III: Pediatric Psychologists provide intensive interventions to patients with diagnosed behavioral problems & mental illness based on referral Tier II Tier I Does not capitalize on opportunity for prevention/promotion Assumes pathology

Current definition of Integrated Behavioral Health BH providers practice alongside PCPs Emphasis on penetration or quantity how many patients can we touch? Psychoeducation Tier II heavy model Tier III Tier II: SOME Underlying assumption: all patients require/benefit from brief same day consultation Identified as at-risk in screening Helps to address barriers to BH contact get face time with BH provider + reduce stigma BH providers have no/limited scheduled appts so available for brief (usually 30 min.), same day visits Proactive Tier I

Current definition of Integrated Behavioral Health We lose patients/ motivation from Tier II to referral With no Tier III (planned follow up), families face waitlists & gaps in service for most in need With this emphasis on penetration, are we valuing quantity over quality? BH care can feel disjointed Care planning? Tier III Tier II: SOME Identified as at-risk in screening Tier I Without follow up (for some), how are we enhancing care from the screen-refer model? Why aren t we shaping what is happening here?

Current definition of Integrated Behavioral Health 13 y/o with depression + ED who is cutting waitlists for DBT Tier III Waitlists, waitlists, waitlists Functional Abdominal Pain 14 y/o with depression and suicidal ideation with open DHS case Patients with distrust of BH + motivated PCP Tier II: SOME Identified as at-risk in screening 4 year old with medical trauma due to brain cancer Patient with cystic fibrosis & medical phobia needs injections/draws Tier I

Challenges In Implementation of Tier II Heavy Model We treat systems, not just kids: Assessment Outside providers (medical, behavioral health Family Child or Youth Educational Services Social Service Agencies (DHS)

Challenges In Implementation of Tier II Heavy Model We treat systems, not just kids: Assessment Intervention Family Other agencies: School, mental health, DHS Child Just as child behavioral health problems are created in systems, they require system involvement to heal

Challenges In Implementation of Tier II Heavy Model 1. Not sensitive to unique aspects of practice in a pediatric setting We treat systems, not just kids: parents, family, school, DHS, foster care, juvenile justice Assessment and intervention require systems Building rapport often takes time 2. Misses opportunity for impact (true population reach) at Tier I Patient education Program development PCP education and consultation 3. Assumes all patients have Tier II needs, and that this level of service can meet their need Some needs can be adequately addressed at Tier I To be effective, some require more (Tier III) in time-limited fashion

If I see a Tier III patient at Tier II, I am ineffective. If I see a Tier I patient at Tier II, I am not efficient with my resources. That being said: We don t have ALL the resources, and we acknowledge that we can t do EVERYTHING. (There is still an appropriate time to refer out) Here is what we think we can do well.

Redefining Integrated BH in Pediatric Primary Care We hope to create a model that: Is sensitive to the unique aspects of delivering BH in a pediatric setting Emphasizes population reach and matching level of resource to level of need Maximizes resources and opportunity for prevention and promotion in this setting

A Public Health Model in Pediatrics Tier III: FEW Brief, EBP intervention Care coordination Tier II: SOME Identified as At-Risk in Screening Assessment/triage Same day/week consultation Tier I: ALL Prevention + Promotion programming Universal Screening

A Public Health Model in Pediatrics Medical Type I Diabetes, Cancer, Cystic Fibrosis Asthma Action Plan Obesity intervention for at-risk ADHD med management Tier III: Few Tier II: Some At-Risk Behavioral Brief, solution focused interventions (2-12 sessions) Care Coordination for high-risk In-house treatment for few (medically complex patients) Address at-risk for common BH concerns (anxiety, depression, behavior, ADHD) Same day consultation Assessment/triage Referrals Immunizations Developmental Screening Well Child Tier I: All Prevention + Promotion BH Education & Promotion Programming (Resilience) PCP education Care planning Universal Screening

Who We Are and What We Do Across Tiers LCSW Pediatric Psychologist PCP education + Care team Program Development Community/ referral partnerships Tier III: Few Brief, EBP intervention Care coordination Tier II: Some Identified as At-Risk in Screening Assessment/triage Same day/week consultation Tier I: All Prevention + Promotion programming Universal Screening PCP education + Care team Program Development Education behavioral health blog Parent workshops

Who We Are and What We Do Across Tiers LCSW Pediatric Psychologist Brief, same-day consultation Assessment + triage Connect patient to resources High-risk families Tier III: Few Brief, EBP intervention Care coordination Tier II: Some Identified as At-Risk in Screening Assessment/triage Same day/week consultation Brief, same-day consultation Assessment + triage ADHD assessment Tier I: All Prevention + Promotion programming Universal Screening

Who We Are and What We Do Across Tiers LCSW Care Coordination School Therapist DHS Tier III: Few Brief, EBP intervention Care coordination Tier II: Some Identified as At-Risk in Screening Assessment/triage Same day/week consultation Pediatric Psychologist Brief, solution-focused interventions Medical needs Medical trauma/phobia Functional Abdominal Pain Parent Child Interaction Therapy Tier I: All Prevention + Promotion programming Universal Screening

Who We Are and What We Do Across Tiers Medical Assistants Patient Services Coordinator Advice Nurse Care manager Tier III: Few Brief, EBP intervention Care coordination Tier II: Some Identified as At-Risk in Screening Assessment/triage Same day/week consultation Decision point Decision point Tier I: All Prevention + Promotion programming Universal Screening

Benefits Of This Model Prevention and promotion focused Incorporates data-based decision making Tiers patients to ensure intensity of intervention and resources match identified need Maximizes resources More consistent with base rates of mental illness Meets unique needs of pediatric populations

Tier I For Depression Screening PHQ-2 (11-19) at all visits PHQ-9 (11-19) at all well child visits Promotion Resiliency curriculum PCP education and consultation Care Team meetings, pre-visit planning Patient Education BH Blog, handouts Tier I: All Prevention + Promotion programming Universal Screening

PHQ-2 and PHQ-9

Resiliency Curriculum

Physician Education And Training

Education: Behavioral Health Blog

Tier II for Depression Tier II: SOME Identified as At-Risk in Screening Assessment/Triage Moods & Feelings Questionnaire Risk/Suicide Assessment, Safety Planning Brief, same-day consultation (Evidence-Based Practice EBP) Psychoeducation on Depression/CBT for depression Behavioral Activation (BASEs) Possible referral to community provider

Moods And Feelings Questionnaire 59

Suicide And Risk Assessment 60

Safety Planning

Pscyhoeducation

BASEs (Behavioral Activation)

Tier III For Depression Tier III: Few Intensive, Specialty Care coordination Brief, solution-focused intervention (~3 sessions) (EBP) Psychoeducation on depression/cbt for depression Behavioral Activation Cognitive Restructuring Ongoing assessment/progress monitoring Match patient to community therapist (if indicated) Refer patient back to PCP for medication management (if indicated) Bridging the gap for high-risk patients who aren t connected to resources, yet Care coordination

Cognitive Restructuring University of WA

Challenges and Opportunities Financial sustainability Payment models often not aligned to care models Carve-outs introduce barriers around credentialing, claims, co-pays Tension between open access and reimbursed visits Balance between PMPM and visit-based reimbursement

Challenges and Opportunities What gets measured, gets managed Unanticipated patient/family demand

Challenges and Opportunities Next steps for us: Continue to develop tier I assessment and intervention: universal ACEs screening Standardization of workflows Building on workforce strengths and differences across clinic sites Development of brief solution focused treatment protocols that center on active components of EBPs

Take Aways Children are a unique population with unique needs Mental health needs of many children are underidentified and go unmet A tiered, population-based model has the largest reach and impact Increasing well-defined tier III interventions in primary care settings increases timely access to care Funding models should meet the needs of the population and be tied to meaningful measurement

Questions?