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BHIP: Behavioral Health Integration Program at Montefiore- Across the Pediatric Lifespan

Rahil D. Briggs, PsyDAssociate Professor of Pediatrics, Albert Einstein College of Medicine

Director, Pediatric Behavioral Health Services, Montefiore Medical Group.

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Healthy Steps at Montefiore 2006-present

• Co-location and integration of mental health specialists in pediatric primary care

– Universal screening, assessment, treatment, and referral of infant mental health/development and caregiver mental health

– Adverse Childhood Experiences (ACES)

– Ages and Stages Questionnaires: Social Emotional (ASQ:SE)

– Patient Health Questionnaire ( PHQ-9)

– Provider education

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Healthy Steps at Montefiore

• First time mothers and their children and partners enrolled either prenatally or before the child is 2 months old

• Co-management of well child visits

• “Baby and Me” group

• Home visits

• Adult mental health services

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Healthy Steps Program Evaluation

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Design

• Quasi-experimental longitudinal follow up of children enrolled in a Healthy Steps (HS) program at their primary care pediatric setting and a comparison group (CG) from a matched clinic who met enrollment criteria, but did not receive the intervention

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Objective and Method

• Determine the relationship between maternal ACES and maternal report on the ASQ:SE at 36 months

• General linear model and logistic regression (LR) analyses

• Adjusted for baseline differences between HS and CG and between study completers and drop-outs

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Results – Impact of Intervention on 36 month ASQ:SE scores

90.4

28.3

44.5

28.2

0

10

20

30

40

50

60

70

80

90

100

ASQ:SE mean score p<.001

CG Children of motherswith 1 or more ACES

CG children of motherswith no ACES

HS Children of motherswith 1 or more ACES

HS Children of motherswith no ACES

Briggs, et al. (2014). Healthy Steps as a Moderator: The Impact of Maternal Trauma on Child Social-

Emotional Development. Clinical Practice in Pediatric Psychology (2, 2), 166–175

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Behavioral Health Integration Program

Behavioral Health

Pediatric Primary

Care

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Our model (present future)

• 300,000 patients (90,000 pediatric)

• 21 sites

• Healthy Steps 0-5, innovative Child and Adolescent programming (CAP), Collaborative Care Initiative model for adults

• Universal life span behavioral health screening

• Family assessments

• Integrated care at each site (hubs and satellites)

• Challenges

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CAP Study Objectives

• Understand the feasibility of implementing integrated behavioral health services on a large scale in pediatric clinics with a particularly vulnerable population

• Understand the effectiveness of CAP in improving the mental and physical health Montefiore’s pediatric patients

• Understand the effectiveness of CAP in reducing health care utilization and costs

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Outcome measures

• Primary outcomes: – Mental health symptoms – measured using PSC-17

• 4-month follow-up administered by research assistants

• Only among primary sample: patients at BOPS clinics with positive PSC-17

• Better Health

– Medical service utilization – sick visits and ED utilization• Lower Costs

– Steroid prescriptions for asthma – as a proxy for asthma control• Better Health

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Outcome measures

• Secondary outcomes:

– Patient satisfaction • two questions modified from the Strengths and Difficulties Questionnaire

– Provider satisfaction • Online survey (comfort with behavioral health issues and satisfaction with the

mental health care provided)

– Process measures – measuring success of implementation• % of patients referred to mental health providers

• % of patients referred who came to the first mental health visit

• number of days between referral and the first mental health visit

• number of mental health visits patients attended

• number of patients who successfully completed treatment

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BHIP Conclusions

• It is feasible and efficacious to integrate pediatric behavioral health into primary care pediatrics/family medicine settings

• HS as a moderator between ACES in parents and SE development in children

• Early data from CAP:

– Sept-Nov 2014: 19.6% of children presenting for HCM were referred to BHIP (N=833 referrals)

– at least 55% of those children came in for separate visits with the BHIP provider.

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Acknowledgements

• Andrew Racine

• Judy Aschner

• Peter Belamarich

• BHIP and Healthy Steps providers

• MMG provider and practice teams, MMC leadership

• Supporters (Altman Foundation, Center for Medicaid and Medicare

Innovation, Child Welfare Fund, Edith Glick Shoolman Children’s Foundation, Grinberg Family Foundation, Marks Family Foundation, NYC Children’s Mental Health under 5 Initiative, Price Family Foundation, Stavros Niarchos Foundation, Tiger Foundation)

Rahil Briggs, PsyDDirector, Pediatric Behavioral Health Services

Research Evaluation Team

Miguelina German, PhD

Director of Quality

Elizabeth Altschuler, PhD

Pediatric Psychologist

Diane Bloomfield, MD, FAAP

Medical Director, FCC

Nicole Brown, MD, MPH, MHS

Attending Physician, FCC

Silvie Colman, PhD

Health Economist

Lauren Haliczer, MA

Lab Manager

Teresa Hsu-Walklet, PhD

Senior Psychologist

Michael Rinke, MD, PhD

Assistant Medical Director

of Pediatric Quality

Clinical Team, Healthy Steps (Birth-5 years)

Rebecca Schrag Hershberg, PhD

Director of Training, Healthy Steps

Laura Krug, LCSW

Senior Healthy Steps Specialist

Polina Umylny, PhD

Senior Healthy Steps Specialist

Elizabeth Altschuler, PhD

Healthy Steps Specialist

Loring Bartlett, PsyD

Healthy Steps Specialist

Kate Cuno, PsyD

Healthy Steps Specialist

Elizabeth Ward, PhD

Healthy Steps Specialist

Carina Wind, LMSW

Healthy Steps Specialist

Miguelina German, PhD

Clinical Director, Parental Mental Health

Desiree Castillo, PhD

Parental Mental Health Specialist

Micheal Dowling, PhD

Parental Mental Health Specialist

Clinical Team, Child & Adolescent Psychiatry

Audrey Walker, MD

Division Chief, Child and Adolescent Psychiatry

Jason Herrick, MD

Pediatric Psychiatrist

Uchenwa Okoli, MD

Pediatric Psychiatrist

Darryl Smith, MD

Pediatric Psychiatrist

Susan Weinstein, MD

Pediatric Psychiatrist

Clinical Team, Child & Adolescent Psychology

Miguelina German, PhD

Director of Training, Child and Adolescent

Carla Cirilli, PsyD

Senior Psychologist

Dana Crawford, PhD

Senior Psychologist

Teresa Hsu-Walklet, PhD

Senior Psychologist

Elizabeth Merrill, PsyD

Senior Psychologist

Elizabeth Altschuler, PhD

Pediatric Psychologist

Martha Bennett, PsyD

Pediatric Psychologist

Desiree Castillo, PhD

Pediatric Psychologist

Kate Cuno, PsyD

Pediatric Psychologist

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