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!
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