# Presentation: 576222

## Mental Health Screening in the Medical Home: Introduction

- Jane Meschan Foy, MD
- Department of Pediatrics
- Wake Forest University School of Medicine

## 
11% of children have a MH diagnosis + evidence of functional impairment (“SED”)
16% of children have symptoms that do not rise to level of a diagnosis, but have functional impairment
9% have a diagnosis without current impairment
27-36% total may have need for MH services

* Great Smoky Mountain Study of Youth.  Health Affairs, Fall, 1995

- 11% of children have a MH diagnosis + evidence of functional impairment (“SED”)
- 16% of children have symptoms that do not rise to level of a diagnosis, but have functional impairment
- 9% have a diagnosis without current impairment
- 27-36% total may have need for MH services
- * Great Smoky Mountain Study of Youth.  *Health Affairs*, Fall, 1995

- Prevalence of mental health problems in childhood*

## Twice as likely to be living in poverty (40% vs. 20%)
40% more likely to have a parent who has been arrested (17% vs. 12%)
50% more likely to have a parent with a drug or alcohol problem (11% vs. 7%)
3 times as likely to have a mother who is depressed (18% vs. 6%)
25% more likely to have a parent who did not finish high school (42% vs. 32%)

- 40% more likely to have a parent who has been arrested (17% vs. 12%)
- 50% more likely to have a parent with a drug or alcohol problem (11% vs. 7%)
- 3 times as likely to have a mother who is depressed (18% vs. 6%)
- 25% more likely to have a parent who did not finish high school (42% vs. 32%)

- Risk factors for mental illness:	children with serious emotional disturbance are...

## Nearly 3 times as likely to have a poor relationship with his/her parents (49% vs. 17%)
Nearly 2 times as likely to have witnessed physical violence between parents (13% vs. 8%)
Nearly 2 times as likely to have one or both parents unemployed (17% vs. 9%)
50% more likely to come from a family other than one with two biological or adoptive parents (77% vs. 50%)

- Nearly 2 times as likely to have witnessed physical violence between parents (13% vs. 8%)
- Nearly 2 times as likely to have one or both parents unemployed (17% vs. 9%)
- 50% more likely to come from a family other than one with two biological or adoptive parents (77% vs. 50%)

- Risk factors for mental illness (cont.) :children with serious emotional disturbance are...

## Children with 6 or more stress factors are 40 times more likely to have SED than children without stress factors.
Children with chronic medical illnesses are at higher risk for mental health disorders (including mild and moderate disorders).
Adolescents tend to have the most significant health problems and the lowest utilization of healthcare services of any age group, esp. ethnic minorities, and are least likely to be insured.

- Children with chronic medical illnesses are at higher risk for mental health disorders (including mild and moderate disorders).
- Adolescents tend to have the most significant health problems and the lowest utilization of healthcare services of any age group, esp. ethnic minorities, and are least likely to be insured.

- Risk factors for mental illness (cont.)

## Children with SED are more likely to... 
be expelled from or drop out of school
become pregnant
be convicted of a crime
use alcohol or other illicit drugs
Children with mental illness are more likely to use medical services / emergency rooms (“displaced utilization”); their parents are also higher users of health services.*

*Bernal, Hidden Morbidity in Pediatric Primary Care, Pediatric Annals 32:6, June,2003. 

**be expelled from or drop out of school**
**become pregnant**
**be convicted of a crime**
**use alcohol or other illicit drugs**
**Children with mental illness are more likely to use medical services / emergency rooms (“displaced utilization”); their parents are also higher users of health services.***
- *Bernal, Hidden Morbidity in Pediatric Primary Care, *Pediatric Annals* 32:6, June,2003.

- Consequences of mental illness

-    * *
***70% of children in need of MH services are untreated.****
- *Surgeon General’s report: _[www.](http://www.surgeongeneral.gov/)__[surgeongeneral](http://www.surgeongeneral.gov/)__[.](http://www.surgeongeneral.gov/)__[gov](http://www.surgeongeneral.gov/)_

## 	Specialty MH system

	Child welfare and juvenile justice 	system

	Education (70%; sole provider for 50%)

	Health

- 	Child welfare and juvenile justice 	system
- 	Education (70%; sole provider for 50%)
- 	Health

- Mental illness treatment sources

## Stigma 
Fragmentation / schism
Cost 
Cultural biases / trust issues
Absence of care coordination mechanisms 
Funding / reimbursement issues  
Shortage of mental health professionals generally

- Fragmentation / schism
- Cost
- Cultural biases / trust issues
- Absence of care coordination mechanisms
- Funding / reimbursement issues
- Shortage of mental health professionals generally

- Barriers to treatment of mental illness
- in MH specialty system

## MH system reform: targeting of  public services to the severely ill
Procedural requirements of public and private mental health programs
Poor communication with primary care
Non-parity of mental health benefits in insurance plans
Adolescent-specific issues: denial, confidentiality..... 

- Procedural requirements of public and private mental health programs
- Poor communication with primary care
- Non-parity of mental health benefits in insurance plans
- Adolescent-specific issues: denial, confidentiality.....

- Barriers to treatment of mental illnessin MH specialty system (cont.)

## Adversarial relationship with family
Under-funding
Family disorganization
Agency focus on non-MH aspects of care
Discontinuity in custody
Incomplete medical and mental health history
Poor communication among agency, family, and healthcare providers

- Under-funding
- Family disorganization
- Agency focus on non-MH aspects of care
- Discontinuity in custody
- Incomplete medical and mental health history
- Poor communication among agency, family, and healthcare providers

- Barriers to treatment of mental illness in
-  child welfare and juvenile justice system

## Focus on educational mission (e.g. testing, attendance) 
Confidentiality issues inhibiting exchange of information with healthcare providers
Inadequacy of school funding
Shortage of school-based mental health professionals and school nurses
Reimbursement issues for school-employed personnel

- Confidentiality issues inhibiting exchange of information with healthcare providers
- Inadequacy of school funding
- Shortage of school-based mental health professionals and school nurses
- Reimbursement issues for school-employed personnel

- Barriers to treatment of mental illnessin schools

## Comfort of primary care providers (other than uncomplicated ADHD +/- anxiety, depression); deficits include:
Diagnostic skills / familiarity with DSM
Giving “bad” news / concerns about labeling
Collaborative experience with MH providers (public and private)
Psychopharmacology (except ADHD)
Non-pharmacologic treatment methods
Coding and billing for MH disorders

- Diagnostic skills / familiarity with DSM
- Giving “bad” news / concerns about labeling
- Collaborative experience with MH providers (public and private)
- Psychopharmacology (except ADHD)
- Non-pharmacologic treatment methods
- Coding and billing for MH disorders

- Barriers to treating mental illness in primary care settings

## Time limitations
Access to psychiatry consultation 
Reimbursement issues, esp. for non-face-to-face elements of care 
Managed care requirements / limits
Low utilization by adolescents
Perceptions of scope of primary care
By-pass through self-referral		
Perceived and actual confidentiality barriers that limit sharing of information

- Access to psychiatry consultation
- Reimbursement issues, esp. for non-face-to-face elements of care
- Managed care requirements / limits
- Low utilization by adolescents
- Perceptions of scope of primary care
- By-pass through self-referral
- Perceived and actual confidentiality barriers that limit sharing of information

- Barriers to treating mental illness in
- primary care settings (cont.)

## 
Concern about handling positive screens (diagnostic methods, referral sources, bad news, etc.... see previous slides)
Lack of familiarity with screening instruments
Cost of instruments
Variation in cultural norms of screening tools
Time requirement
Patient flow concerns

- Concern about handling positive screens (diagnostic methods, referral sources, bad news, etc.... see previous slides)
- Lack of familiarity with screening instruments
- Cost of instruments
- Variation in cultural norms of screening tools
- Time requirement
- Patient flow concerns

- Barriers to screening for MH problems in primary care

## 
Opportunity for prevention and early identification
Relative absence of stigma
Relationship with provider / trust
Convenience, comfort, familiarity
Coordination with medical services
Cost efficiency

- Opportunity for prevention and early identification
- Relative absence of stigma
- Relationship with provider / trust
- Convenience, comfort, familiarity
- Coordination with medical services
- Cost efficiency

- Advantages of medical home for identifying
- and serving children with MH problems

## Training / education (appropriate to stage of  behavior change!)
Advocacy with public and private insurers
Local/regional resource directory
“Mixers,” collaborative office rounds
Access to psychiatry consultation, esp. psychopharmacology
Referral brochure (AAP)
“Co-location” model
Introduction of screening instruments / coaching in use and interpretation

- Advocacy with public and private insurers
- Local/regional resource directory
- “Mixers,” collaborative office rounds
- Access to psychiatry consultation, esp. psychopharmacology
- Referral brochure (AAP)
- “Co-location” model
- Introduction of screening instruments / coaching in use and interpretation

- Overcoming barriers in primary care
- delivery of MH services

## Barriers to Mental Health Services for Children

- The Clinical Physician’s
- Point of View

## The Barriers We See

- Lack of mental health personnel
- Lack of training
- Lack of time
- Lack of screening tools
- Services not available
- Inefficient processes
- Lack of communication
- Liability
- Costs exceed break-even

## Not enough psychologists for the demand
Not enough psychiatrists for the demand
Not enough counselors for the demand

- Not enough psychiatrists for the demand
- Not enough counselors for the demand

- Insufficient number of mental health personnel

## Most primary care physicians do not see themselves as providers of mental health services, though that may have to change
“It’s not our job . . . “
Most feel justified taking this position because they have had little training in this area of medicine

- “It’s not our job . . . “
- Most feel justified taking this position because they have had little training in this area of medicine

- Lack of Training

## Lack of time	

- To do an adequate job for a child requires a large investment in time
- Even when the willingness is there, the time may not be
- Production quotas are a reality in many employment contracts

## Other than ADHD tools, good screening tools are difficult to procure	
Costs can be prohibitive
Primary care physician often knows child the best and would be in best position to help—but may not recognize certain types of problems

- Costs can be prohibitive
- Primary care physician often knows child the best and would be in best position to help—but may not recognize certain types of problems

- Lack of screening tools

## Child often requires services not available in the community
Waiting time can be very long
Gate keeping mechanisms delay entry into programs
Professionals in the community may not deal with particular types of problems

- Waiting time can be very long
- Gate keeping mechanisms delay entry into programs
- Professionals in the community may not deal with particular types of problems

- Services not available

## Mental health providers and organizations do not communicate with each other (huge problem)
There is no bonafide case management process in effect
Mental health records are judiciously guarded

- There is no bonafide case management process in effect
- Mental health records are judiciously guarded

- Inefficient processes

## Primary care physicians are often asked to assume prescribing responsibility
Children are returned to parents, and parents don’t know the diagnosis
PCP may not be familiar with the medication and its uses.

- Children are returned to parents, and parents don’t know the diagnosis
- PCP may not be familiar with the medication and its uses.

- More Inefficiencies

## Lack of Communication

- Physicians often expected to assume management of case with NO information
- Not inadequate information
- NO information
- No Master Plan developed
- Unmanageable plan

## Because communication among involved parties is poor:
Some services are needlessly duplicated.
Some services never happen

Some services aren’t needed, but they are done because they are covered.

- Some services are needlessly duplicated.
- Some services never happen
- Some services aren’t needed, but they are done because they are covered.

- More Lack...

## What are you looking for?

- Where did you lose them?

- My keys.

- In the parking lot.

- So why are you looking here?

**THE LIGHT’’S BETTER HERE!**

## Willingness to help may be there, but insurance carriers discourage involvement.
Were you trained to do this?
Are you certified to do this?
Why are you doing this?

- Were you trained to do this?
- Are you certified to do this?
- Why are you doing this?

- Liability

## Doing a good job takes time
Doing a good job takes personnel
Physician may even be willing to “pro-bono” his fees, but staff fees still must be met
One 99215 does not equal four 99213s

- Doing a good job takes personnel
- Physician may even be willing to “pro-bono” his fees, but staff fees still must be met
- One 99215 does not equal four 99213s

- Costs exceed break-even

## We want to help, but what can we do?

## Our tentative plan

- Add *counselor* in office
- Add *case manager* in office
- Why we think the case manager
- in office idea is workable
- Case manager more important
-     initially but cost is an issue

## Barriers we have encountered

- Feasibility study
- Doesn’t pay for itself
- Might pay for counselor alone
- Counselor alone will not get kids the help they really need.

## Circle of HOPE

- Circle of Hope
- 21.6% of kids could benefit
- 2.8% receiving help for SED
- Prefer help from pediatrician rather than MHP

## CATCH

## Mental Health, Behavioral Integrated Services	

- access psychological services because surroundings are familiar and there is
- no stigma associated with visiting the pediatrician.
- The Youth Mental Health Committee commissioned a feasibility study to
- determine the implications of integrating behavioral health services into
- Lakeside Pediatrics. the study identified a need, however funding to
- develop an implementation plan is lacking.
- This proposal provides funding to the committee for development of
- strategies to integrate behavioral health services into the pediatric practice,
- including mapping of local resources, determining long-range outcomes,
- identifying external funding opportunities, and preparing grant applications.

- Mental Health, Behavioral Integrated Services

## A Late Break through . . .

- Family Guidance collaboration
- In office case manager
- Procure services
- Coordinate services
- Prevent duplication
- Keeps all parties communicating
- In office counselor
- We provide space
- They provide personnel

## Mental health Screening and the Medical Home:The Bright Futures Model

- Joseph F. Hagan, Jr., MD, FAAP
- Co-Chair,  AAP Bright Futures Steering Committee and PAC
- Primary Care Pediatrics
- Burlington, Vermont
- jhagan@aap.org

## To promote the mental and emotional health and wellbeing of all children and adolescents
A critical element and health
Mental health-- the ability to: 
Experience a range of emotions
Possess positive self esteem
Respect others
Harbor a sense of security and trust in self and the world

- A critical element and health
- Mental health-- the ability to:
- Experience a range of emotions
- Possess positive self esteem
- Respect others
- Harbor a sense of security and trust in self and the world

- Bright Futures Vision

## Bright Futures...under construction...

- is a set of ***principles, strategies***** *****and tools*** that are theory - based, evidence - driven, and systems - oriented, that can be ***used to*** ***improve ***the health and well-being of all children through ***culturally*** ***appropriate interventions*** that address the current and emerging ***health promotion*** needs at the policy, community, health systems** **and family levels.

## Bright Futures in Practice: Mental Health

- Michael Jellinek, MD
- Bina Patel, MD
- Mary Froehle, PhD, eds.

## Mental health promotion
In a developmental context
Mental health problems
Specific issues
Specific diagnoses

- In a developmental context
- Mental health problems
- Specific issues
- Specific diagnoses

*Bright Futures in Practice: Mental Health*

## Three parts
Developmental Chapters
Infancy, early childhood, middle childhood, adolescence
Mirrors Bright Futures Guidelines
Bridge Topics
Common mental health problems in childhood and adolescence
Mental Health Tool Kit

- Developmental Chapters
- Infancy, early childhood, middle childhood, adolescence
- Mirrors *Bright Futures Guidelines*
- Bridge Topics
- Common mental health problems in childhood and adolescence
- Mental Health Tool Kit

*Bright Futures in Practice: Mental Health*

## Most providers of primary pediatric care rely on surveillance
Long term relationship
Knowledge of child development
Observation over time
Does it work?
NOPE!

- Long term relationship
- Knowledge of child development
- Observation over time
- Does it work?
- NOPE!

- Screening or Surveillance?

##  Surveillance?

- Ready....
- ...............Fire!
- ...........................Aim.

## Uses tools!
Tools are tested
Tools are validated
Sensitivity and specificity

- Tools are tested
- Tools are validated
- Sensitivity and specificity

- Screening

## What tools do pediatricians use?
Denver
Low sensitivity and specificity
“Sort of the Denver”
No sensitivity and specifity
Other screens
PEDS
Brighance
Others – all are proprietary

- Denver
- Low sensitivity and specificity
- “Sort of the Denver”
- No sensitivity and specifity
- Other screens
- PEDS
- Brighance
- Others – all are proprietary

- Developmental Screening

## Mental Health Screening

## What tools do pediatricians use?
Any?
None
What were we trained to use?
Probably none

- Any?
- None
- What were we trained to use?
- Probably none

- Mental Health Screening

## AAP ADHD Guidelines
Diagnosis, 2001
Treatment, 2003
Diagnostic Guidelines
DSM-IV criteria
More than one environment
Confers disability

- Diagnosis, 2001
- Treatment, 2003
- Diagnostic Guidelines
- DSM-IV criteria
- More than one environment
- Confers disability

- Mental Health Screening

## Mental Health Screening

- Vanderbilt ADHD Diagnostic Rating Scales
- Wolraich ML, Feurer ID, Hannah JN

## Slide 53

## Slide 54

## Pediatric Symptoms Checklist
PSC
Jellinek MS, Murphy JM, Little M, etal

- PSC
- Jellinek MS, Murphy JM, Little M, etal

- Mental Health Screening

## Slide 56

## Slide 57

## Center for Epidemiological Studies                         		Depression Scale for Children
CES-DC
Faulstich ME, Carey MP, Ruggerio L

- CES-DC
- Faulstich ME, Carey MP, Ruggerio L

- Mental Health Screening

## Edinburgh Postnatal Depression
Included in BF-MH
(2 question screen alternative)
Anxiety Disorders
Bipolar Disorder

- Included in **BF-MH**
- (2 question screen alternative)
- Anxiety Disorders
- Bipolar Disorder

- Mental Health ScreeningAdditional Topics

## DSM-PC
Bright Futures in Mental Health
BF in MF Toolkit 
CPT 2004

- Bright Futures in Mental Health
- BF in MF Toolkit
- CPT 2004

- Essential library

## Psychosocial issues important in primary care settings
A system is needed to help PCP’s describe Mental Health in Primary Care settings
Preventive  activities need to be justified and reimbursed in primary care settings

- A system is needed to help PCP’s describe Mental Health in Primary Care settings
- Preventive  activities need to be justified and reimbursed in primary care settings

- The argument for payment

## Slide 63

## Pediatrics Collaborative Care Program 	

- Anjie Emanuel, MPH

## 4 Year Cooperative Agreement with the AAP and MCHB

Components of the grant: mental health, oral health, child care and international activities

- Components of the grant: mental health, oral health, child care and international activities

- Pediatric Collaborative Care Program (PedsCare)

## Publish Taskforce on the Family Report
Develop a compendium of community based collaborative care and referral models
Develop a training for pediatricians to improve mental health services for children and families
Establish the pediatrician’s role in improving mental health services

- Develop a compendium of community based collaborative care and referral models
- Develop a training for pediatricians to improve mental health services for children and families
- Establish the pediatrician’s role in improving mental health services

- PedsCare Mental Health Activities

## Next Steps		

- Cross Functional Mental Health Work Group
- Mental Health Tool Kit
- Mental Health Training for Pediatricians

## January 2004 Board of Director’s Meeting

04-05 Strategic Plan

- 04-05 Strategic Plan

- AAP’s Position

## National Center for Medical Home Initiatives:   Putting the Pieces Together

*Amy Brin, MA*
*Manager, Training Initiatives*

## Slide 70

## How can the National Center help?

**Technical assistance**
**Interdisciplinary training initiatives**
**Screening initiatives**
**Web site link to mentors**

- Training Curriculum Accomplishments

** ****Developed national curriculum that is endorsed by MCHB, AAP, FV, and NACHRI**
** ****Since 1999, trained 4,500 pediatricians, allied health care professionals, and family members**
**Utilized in all 50 states; Puerto Rico & Guam**
** ****Consists of 7 components in facilitator and participant versions**
** ****Translated curriculum into Spanish**

**Notes:**
Discusses the accomplishments resulting from the development of the training curriculum.

## Surveillance and Screening Curriculum: What to Expect?

- Outlines continuous surveillance; proper screening techniques; and their roles in medical homes
- Highlights recommended tools and resources to assist in integrating screening into practice
- Identifies proper follow-up strategies after screening tests are performed
- Offers difference screening tracks: developmental; hearing; vision; oral and mental health

## Mental health screening track: provides practical framework for implementation

Includes:
AAP recommendations
Mental health screens to use in primary care setting: PSC; CDI; Pediatric Intake Form  
Appropriate CPT codes for administering & interpreting tests

**Mental health screening track**: provides practical framework for implementation
**Includes:**
- AAP recommendations
- Mental health screens to use in primary care setting: *PSC; CDI; Pediatric Intake Form  *
- Appropriate CPT codes for administering & interpreting tests

- Surveillance and Screening Curriculum:
- Mental Health Track

## Surveillance and Screening Curriculum:  Where to Get It?

**Contact Holly Noteboom** at 800/433-9016, ext. 7081 **OR**   _[hnoteboom@aap.org](mailto:hnoteboom@aap.org)_
**Downloadable at:**
- _[www.medicalhomeinfo.org/training/materials/Screening-fac-final.doc](http://www.medicalhomeinfo.org/training/materials/Screening-fac-final.doc)_
*Curriculum is made available through the continued partnership between Shriners Hospitals for Children and the American Academy of Pediatrics.*

## Because in the end...

- _www.medicalhomeinfo.org_* *