Session #C1a October 5, 2012 Resource Link: A Replicable Model for Integrating Behavioral Health and Pediatric Primary Health Care Margie Getz, MA, MPHIL, Resource Link Program Evaluator Kay Saving, MD, Medical Director, Children’s Hospital of Illinois Lourdes Delgado-Serrano, MD, Child Psychiatrist, University of Illinois College of Medicine Michael Wells, MS, Children’s Service Line Coordinator, Resource Link Director, OSF HealthCare Collaborative Family Healthcare Association 14th Annual Conference October 4-6, 2012 Austin, Texas U.S.A. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. Objectives • Describe major components of the Resource Link program • Recognize evidence basis in support of the development of the Resource Link program. • Discuss the process through which the Resource Link program was replicated • Discuss general outcome results of Resource Link program evaluation. Resource Link A Resource Center for Child and Adolescent Mental Health October 5, 2012 Illinois Mean Center of Population SFMC Total Service Area Source: United States Census Bureau, 2010 Resource Link • Responds to the lack of child psychiatrists and other barriers in the child and adolescent mental health system by helping equip the primary care provider to treat mental illness effectively. • Is a replicable, flexible model based on an external centralized hub that provides a coordinated system of care, easily accessible to the primary care practice. Background and Evidence Basis • 20% US children and teens meet diagnostic criteria for MH disorder with impaired functioning • An additional 15% of US children and teens have impaired MH functioning, not meeting criteria for disorder • 50% of US adults with MH disorders had symptoms at 14 yrs of age • Children living in rural areas have decreased access to services. Source: National Institute of Mental Health, 2010 and HRSA, 2011 Background and Evidence Basis • System level barriers (lack of training/effective screening, limited access to referral networks, time restrictions, inadequate communication/involvement among providers, poor organizational and financial incentives for primary care providers) • Patient level barriers (lack of awareness; lack of trust in and ability to traverse the system; transportation; insurance/health care coverage; stigma) 2004 Assessment Findings (Child and Adolescent Mental Health System – Peoria, IL) • Too few child psychiatrists • Long waits for counseling and other mental health services • Greatest impact on families with no insurance or publicly funded healthcare • Many families see primary care physician for mental health concerns • Lack of communication between mental health providers and primary care provider Findings (Continued) Primary Care Practices lack • Training on mental illness • Knowledge about the local mental health system • Time for care coordination • Financial flexibility to hire MH staff Possible Models • • • • Education/Training only Consultation Resource Link: A Center for Co-location Behavioral Health Shared Care Resource Link External, centralized hub • Office-based physician training • Psychiatric consultation • Care coordination – screening/assessment, referral and follow up Addresses system and patient level barriers Care Coordination Care coordinator contacts parent for telephone or in-person screening within 24 hours of physician referral. Screening includes: •Depression screening •Assessment of risk of harm to self or others •Strengths/needs inventory Referral for diagnostic evaluation: •Psychological evaluation •Psychiatric evaluation •Diagnostic interview •Other evaluation Yes More in-depth screening necessary? No Referral for mental health and other social services Follow up for 60-90days with patient, physician and service providers to ensure patient engagement and progress and effective communication among providers Provider Training • Modeled after ICAAP “academic detailing” model • Modules – – – – Attention Deficit Hyperactivity Disorder Depressive Disorder Anxiety Disorder Bipolar Disorder • Flexible Format – Time and Location • To meet the needs of the practice – Physicians, nurses, office staff • Components of Training Module – Diagnostic Criteria • Signs and Symptoms – Diagnostic Tools • ADHD Questionnaires • Depression Rating Scale – Diagnostic Interview • Treatment Options – Evidence-based • Pharmacotherapy • Psychotherapy – – – – Individual Family Group Cognitive-Behavioral • Healthy Life Styles – Diet – Exercise – Sleep Hygiene • Training Manual – Educational components – Tool Kit • Diagnostic Tools • Research Data • Helpful Websites Case Consultation Primary care physician completes pre-consultation questionnaire to provide psychiatrist with patient background and specific consultation questions. 15 to 20 minute telephone conversation between primary care physician and child psychiatrist regarding specific case issues (diagnosis, medication, etc) Is psychiatrist able to give recommendations based on information provided in the consultation session? No Yes No Are psychiatrist and primary care physician confident that the case can be managed effectively by the primary care physician? Yes Care coordinator assists by working to find a child psychiatrist who will take the patient. Follow-up consultation sessions are scheduled as needed. Psychiatrist provides in-person evaluation of the patient And Sends the primary care physician a written report with recommendations Case Examples Case #1 – Female – Age 5 – Oppositional/Aggressive Behaviors Case #2 – Male – Age 17 – Depressive Symptoms Geographic Coverage Illinois Mean Center of Population Population under 18 = 66,000 Geographic Coverage Illinois Mean Center of Population Population under 18 = 131,907 Expansion/Replication Assessment • Physician Survey • Focus Groups (parents, mental health providers, social service providers, educators) East/West Assessment Findings • 20% of patient visits relate to mental health • Primary care physicians often are the sole medical provider for many of their patients with mental illness • 100% of physicians would access care coordination • 84% of physicians would access consultation/training • System characteristics: scarce resources, fragmented delivery system Utilization: Total Patients 800 700 600 500 400 300 200 100 0 2006 2007 2008 2009 2010 2011 2012 (Projected) Resource Link Patient Demographics Gender Age 17% 25% 39% 2 to 5 F M 6 to 12 13 to 18 61% 58% 2% Presenting Issue 1% Autism Behavior Medical 38% Mood Other 57% 2% Resource Link Services Services Provided 10% 0% Case Coordination 6% Psych Consult Combo of CC and PC 84% Financial Resource Link Revenue 25% 65% 10% Fee for Service Grants OSF HealthCare Financial Resource Link Expenses 8% 12% Staff Contracts Other 80% Outcome Analysis - Methods • Satisfaction – Patient Survey – Physician Survey – Community Provider Survey • Functional – Physician Survey – Parent Survey Resource Link Process Evaluation (August 2005 – July 2006) Parent Survey: Satisfaction 9% N = 55 Satisfied Dissatisfied Parent Survey: Child Better 91% 24% N = 55 Child Better No Change 76% Resource Link Process Evaluation (August 2005 – July 2006) Physician Survey: Satisfaction N = 20 Neutral 17% Sat/Very Sat 83% Physician Survey: Patient Improvement Not Improved 19% Physician Survey: Patient Improvement % of Patients 100% 90% 91% Reduction of Emotional Symptoms Reduction of Behavioral Symptoms 83% 77% Improved Family Functioning Improved School Performance 80% 74% 60% 40% 20% 0% Area of Improvement Improved Overall Health N = 20 Patient Improved 81% Resource Link Outcome Evaluation (October 2011 – September 2012) Parent Survey: Satisfaction 4% N = 24 Satisfied Dissatisfied 96% Parent Survey: Child Better 13% N = 23 Child Better No Change 87% Survey Time Frame: 10/1/11 – 9/7/12 33 Resource Link Outcome Evaluation (October 2011 – September 2012) Physician Survey: Satisfaction Neutral 4% Physician Survey: Patient Improvement N = 77 Not Improved 8% Sat/Very Sat 96% N = 59 Patient Improved 92% Physician Survey: Patient Improvement % of Patients 100% 93% 86% 80% Reduction of Emotional Symptoms Reduction of Behavioral Symptoms Improved Family Functioning 87% 82% 80% 60% 40% 20% 0% Improved School Improved Overall Performance Health Area of Improvement Physician Survey Time Frame: 10/1/11 – 9/7/12 34 Sustainability Value Proposition – Community (Local participation in assessment and through advisory group ensures program meets community needs) – HealthCare System (high value for relatively low cost) • • • • Wide geographic coverage Replicable in urban and rural areas Physician satisfaction Aligned with relevant concepts in health care (ACO, population health management and care coordination) • Proactive patient care leads to improved outcomes Future Plans • Further Expansion (Northern Illinois) • Incorporate use of technology – Telepsychiatry – Web-based learning and tool kits • Improve consistency of – Provider to provider communication – Routine screening – Addition of subspecialty referrals Acknowledgements • Illinois Chapter of the American Academy of Pediatrics • Illinois Children’s Healthcare Foundation • Heart of Illinois United Way • St Mary Medical Center Auxiliary Foundation • Galesburg Community Foundation • University of Illinois College of Medicine at Peoria References 1. (2007). AAP Chapter action tool kit, Strategies for system change in children’s mental health-a chapter action kit. Mental health concerns in primary care: A clinician’s toolkit. 2. (2009). Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. Pediatrics, 123, 3. (2010). A guide to building collaborative mental health care partnerships in pediatric primary care. American Academy of Child and Adolescent Psychiatry. 4. Gabel, S. (2010). Journal of pediatrics. The Integration of mental health into pediatric practice: Pediatricians and child and adolescent psychiatrists working together in new models of care, 157(5), 848-851. 5. Meschan-Foy, J. (2010). Enhancing pediatric mental health care: Strategies for preparing a primary care practice. Pediatrics, 125(3), 6. Jensen, P. S. (2011). Overlooked and underserved: "action signs" for identifying children with unmet mental health needs. Pediatrics, 128(5). 7. (2011). The Health and Well-Being of Children in Rural Areas: A portrait of the Nation 2007. U.S. Department of Health and Human Services Health Resources and Services Administration. For further information, contact Mike Wells [email protected] (309) 671-7532 Questions? Children’s Hospital of Illinois Peoria, IL Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!