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

“The Doctor”, Sir Luke Fildes, 1891

Shifting Epidemiology

Centers for Disease Control

Shifting Epidemiology

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

The New Morbidity

Oregon Healthy Teens, 2017

Oregon Healthy Teens, 2017

Oregon Healthy Teens, 2017

8.7% of 8th graders and 6.8% of 11th 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)

Adverse Childhood Experiences (ACEs)

ACEs Impact Children Across Incomes

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.

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

Referral based

Consultative Co-located Integrated

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

To learn more about six levels of collaboration/integration, visit SAMHSA

Center for Integrated Health Systems.

Improved

collaboration

Tier III

Tier II:

Tier I:

All Patients

PCPs administer screening + provide patient education

Pediatric Primary Care Without Integrated Behavioral Health

BH support provided by PCPs,

primarily in Well Child Visits,

Screenings, and Patient

Education

Patients with At-Risk or Clinical

concerns are referred out

PCPs may provide medical

interventions for some BH

concerns

The Co-Located Model

Tier III:

Pediatric Psychologists provide

intensive interventions to patients

with diagnosed behavioral problems

& mental illness

based on referral

Tier II

Tier I

Assumes pathology

Inefficient use of

resources

Does not “capitalize”

on opportunity for

prevention/promotion

What if kids can improve with less intensive intervention? Many can. And we often have access to them when problems first arise.

Current definition of “Integrated” Behavioral Health

BH providers practice

alongside PCPs

BH providers have

no/limited scheduled

appts so available for

brief (usually 30 min.),

same day visits

Helps to address

barriers to BH

contact—get face time

with BH provider +

reduce stigma Tier III

Tier II:

SOME

Identified as at-risk in screening

Tier I

Emphasis on

penetration or quantity–

how many patients can

we “touch”?

Underlying assumption: all patients require/benefit from brief same day consultation Proactive Psychoeducation

Tier II heavy model

Current definition of “Integrated” Behavioral Health

We lose patients/

motivation from Tier II to

referral

Without follow up (for

some), how are we

enhancing care from the

screen-refer model?

BH care can feel

disjointed

With no Tier III (planned follow

up), families face waitlists &

gaps in service for most in

need

Care

planning?

Why aren’t we

shaping what is

happening

here?

Tier III

Tier II:

SOME

Identified as at-risk in screening

Tier I

With this emphasis on

penetration, are we

valuing quantity over

quality?

Current definition of “Integrated” Behavioral Health

13 y/o with depression + ED

who is cutting– waitlists for

DBT

Waitlists, waitlists,

waitlists

Patients with

distrust of BH +

motivated PCP

4 year old with medical trauma

due to brain cancer

Patient with cystic

fibrosis & medical

phobia needs

injections/draws

Tier III

Tier II:

SOME

Identified as at-risk in screening

Tier I

14 y/o with depression

and suicidal ideation

with open DHS case

Functional Abdominal

Pain

Child or Youth

Family

Educational Services

Social Service Agencies

(DHS)

Outside providers (medical,

behavioral health

Challenges In Implementation of Tier II Heavy Model

We treat systems,

not just kids:

• Assessment

We treat systems,

not just kids:

• Assessment

• Intervention

Child

Family

Other agencies: School,

mental health, DHS

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

Challenges In Implementation of Tier II Heavy Model

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

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

Tier III: Few

Tier II: Some

At-Risk

Tier I: All

Prevention + Promotion

Medical

• Type I Diabetes, Cancer,

Cystic Fibrosis

• Asthma Action Plan

• Obesity intervention for at-risk

• ADHD med management

• Immunizations

• Developmental

Screening

• Well Child

• BH Education & Promotion

Programming (Resilience)

• PCP education

• Care planning

• Universal Screening

• Address at-risk for common BH

concerns (anxiety, depression,

behavior, ADHD)

• Same day consultation

• Assessment/triage

• Referrals

• Brief, solution focused

interventions (2-12 sessions)

• Care Coordination for high-risk

• In-house treatment for few

(medically complex patients)

Behavioral

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

Who We Are and What We Do Across Tiers

LCSW

• PCP education + Care team

• Program

Development

• Community/

referral

partnerships

• PCP education + Care team

• Program

Development

• Education– behavioral health

blog

• Parent workshops

Pediatric Psychologist

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

LCSW

• Brief, same-day consultation

• Assessment + triage

• Connect patient to resources

• High-risk families

• Brief, same-day consultation

• Assessment + triage

• ADHD assessment

Pediatric Psychologist

Who We Are and What We Do Across Tiers

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

LCSW

• Care Coordination

• School

• Therapist

• DHS

• Brief, solution-focused

interventions

• Medical needs

• Medical trauma/phobia

• Functional Abdominal Pain

• Parent Child Interaction Therapy

Pediatric Psychologist

Who We Are and What We Do Across Tiers

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

Decision point

Decision point

Who We Are and What We Do Across Tiers

Patient Services

Coordinator

Care manager

Medical

Assistants

Advice Nurse

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

• 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

Tier I For Depression

PHQ-2 and PHQ-9

Resiliency Curriculum

Physician Education And Training

Education: Behavioral Health Blog

Tier II for Depression

• 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

Tier II: SOME

Identified as At-Risk in Screening

Moods And Feelings Questionnaire

59

Suicide And Risk Assessment

60

Safety Planning

Pscyhoeducation

BASEs (Behavioral Activation)

• 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

Tier III: Few

Intensive, Specialty

Care coordination

Tier III For Depression

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 under-identified 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?