network for early childhood tele-education (kki-nect

Kennedy Krieger Institute Network for Early Childhood Tele-Education

(KKI-NECT)

A Learning Collaborative for Behavioral, Emotional, and Developmental Disorders

in Early Childhood

Joyce Harrison, MD and Mary Leppert, MB BCH

Maryland Rural Health AssociationOctober 5, 2017

ACCREDITATION

CREDIT DESIGNATION STATEMENTThe Johns Hopkins University School of Medicine designates this live teleconference for amaximum of 52 AMA PRA Category 1 Credits™. Physicians should claim only the creditcommensurate with the extent of their participation in the activity.

POLICY ON SPEAKER AND PROVIDER DISCLOSUREIt is the policy of the Johns Hopkins University School of Medicine that the speaker and providerglobally disclose conflicts of interest. The Johns Hopkins University School of Medicine OCME hasestablished policies in place that will identify and resolve all conflicts of interest prior to thiseducational activity. Detailed disclosure will be made in the instructional materials.

ACCREDITATION STATEMENTThis activity has been planned and implemented in accordance with theaccreditation requirements and policies of the Accreditation Council for ContinuingMedical Education (ACCME) through the joint providership of Johns HopkinsUniversity School of Medicine and Kennedy Krieger Institute. The Johns HopkinsUniversity School of Medicine is accredited by the ACCME to provide continuingmedical education for physicians.

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As a provider approved by the Accreditation Council for Continuing Medical Education (ACCME), it is the policyof the Johns Hopkins University School of Medicine Office of Continuing Medical Education (OCME) to requiresigned disclosure of the existence of financial relationships with industry from any individual in a position tocontrol the content of a CME activity sponsored by OCME. Members of the Planning Committee are requiredto disclose all relationships regardless of their relevance to the content of the activity. Speakers are required todisclose only those relationships that are relevant to their specific presentation. The following relationships havebeen reported for this activity:

No speaker has indicated that they have any financial interests or relationships with a commercialentity whose products or services are relevant to the content of their presentation(s).

No planner has indicated that they have any financial interests or relationships with a commercialentity.

Note: Grants to investigators at the Johns Hopkins University are negotiated and administered by the institutionwhich receives the grants, typically through the Office of Research Administration. Individual investigators whoparticipate in the sponsored project(s) are not directly compensated by the sponsor, but may receive salary orother support from the institution to support their effort on the project(s).

No speaker has indicated that she will discuss “off-label” uses of medications.

FULL DISCLOSURE POLICY AFFECTING CME ACTIVITIES

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ACKNOWLEDGMENTS

We wish to acknowledge the following companies/company that have/hasprovided or pledged an educational grant in support of this Activity.

HEALTH RESOURCE AND SERVICES ADMINISTRATIONGrant No. H2ARH30299

Please note that the commercial support received is solely for the educationalcomponent of the activity and will not be used to provide food and beverage.

The Physician Payments Sunshine Act was enacted by Congress to increase public awareness offinancial relationships between drug and medical device manufacturers and physicians. Incompliance with the requirements of this Act, the commercial supporter/s of this activity mayrequire the Johns Hopkins University School of Medicine to report certain professionalinformation (such as name, address, National Provider Identifier (NPI), and State License number)of physician attendees who receive complimentary food and beverage in conjunction with a CMEactivity. The commercial supporter is required to submit the collected data to the Centers forMedicare and Medicaid Services which will then publish the data on its website.

Goal of KKI-NECT

• To increase the capacity and confidence of primary pediatric providers to identify and manage behavioral, emotional, and developmental (B/E/D) disorders in early childhood within the Medical Home

Learning Objectives

Upon completion of this module, the learner will be able to:

1. Describe the frequency of co-morbid behavioral, emotional, and developmental disorders in young children in the state of Maryland

2. List 2 patient and 2 provider barriers to accessing care for behavioral, emotional, and developmental disorders

3. Describe the “Project ECHO” model

4. Describe one finding from the first KKI-NECT cohort

Prevalence of Behavioral, Emotional, and Developmental Disorders in U.S. Children

• Developmental disorders: 15.04% (Boyle 2008)

• Behavioral and Emotional Disorders: 11-20% (Weitzman 2015)

• Behavioral, emotional, and developmental disorders frequently co-occur

• Behavioral disorders can mask underlying developmental or emotional disorders

Diagnostic Overshadowing

• Behavioral problems in early childhood may mask underlying trauma, mental health, or developmental disorders

• Angry outbursts/tantrums in a 3-year-old may be driven by trauma, developmental delay, or autism, or may be typical toddler behavior

Consequences of Missed or Untreated Disorders of Early Childhood

• Inappropriate service provision• Ineffective services• Social failure• Academic underachievement• Grade retention• School failure

When B/E/D disorders are addressed late, are inaccurately diagnosed, or are overlooked, issues potentially remedied in childhood become untreatable or irreversible in adulthood

Poll #1

Approximately what percentage of children with a developmental disorder also have a mental health/behavioral disorder?

A. 5-20%

B. 25-40%

C. 45-60%

D. 65-80%

National Evidence of Need

• 25-40% of children with a developmental disorder also have mental health/behavioral diagnoses (The 2007 National Survey of Children’s Health)

• An estimated 30-50% of children with cognitive delays have mental health disorders

• 75-85% of children with autism spectrum disorders have behavioral disorders (Shedrick, 2011, 2012)

HRSA Designated Mental Health Provider Shortage Areas

National Survey of Children’s Health (NSCH): Maryland

• 38% of MD parents reported concerns about their child’s development

• 12.4% of MD children ages 0-17 had a behavioral, emotional, or developmental disorder

• 19.7% of MD children ages 0-17 had special health care needs (SHCN)– 20% of those children with SHCN were under age 5

Poll #2

All of the following are barriers to specialty care for B/E/D disorders EXCEPT…

A. Abundance of specialists

B. Cost of missed work

C. Distance

D. Waitlists

• 72% of caregivers said children reported needing to see a specialist in the last 12 months

• 50% of those who reported needing to see a specialist had to travel over 100 miles to do so

• Parents identified a need for professionals trained in developmental disabilities, particularly on the Eastern Shore and in Western Maryland

Maryland Center of Developmental Disabilities Survey (2011-2013)

• Paucity of specialists

• Waitlists

• Distance

• Cost of missed work

• Time involved in coordinating care

• Cost of travel/lodging

Patient Barriers

• 2009 AAP survey of fellows: 48% said additional training in development and behavior would have been beneficial

• Only 31% reported being comfortable managing developmental and behavioral disorders without a specialist

Provider Barriers

Previous Efforts

• KKI Telemedicine Program– Tele-consultation program at Atlantic General

• Maryland’s Behavioral Health Integration to Primary Practice (BHIPP)– Phone consultation program to enrolled pediatric

providers across the state

• Race to the Top Early Learning Challenge Grant – Phone consultation for 0-5 year olds– Learning collaboratives

Previous Efforts

• Developmental Screening Grant– Provided 1:1 screening guidance to community

practitioners which increased compliance with AAP screening recommendations

• Maryland AAP Emotional Health Committee

• KKI Preschool Interdisciplinary Clinic (PIC)– Started in 2013, PIC sees complex children from birth to 5 – PIC team includes developmental pediatricians, child

psychiatrist, behavior psychologists, speech and language pathologists, genetic counselor

Lessons Learned

• Developmental Screening Efforts– Primary care providers still have trouble referring

children who failed screens

• BHIPP– 26% of providers expressed interest in training on

consultation or developmental screening– 52-64% expressed interest in training surrounding

developmental or autism spectrum disorders– 30% expressed interest in training on behavioral

and emotional health screening

• As many as 40% of children with behavioral disorders have developmental co-morbidities

• In BHIPP consult calls about behavioral issues in ages 0-5…– 30% of the consults had known or suspected developmental

concerns– 15% had known or suspected trauma/adverse experience as

comorbid underlying conditions

• In the KKI Preschool Interdisciplinary Clinic– 35% have comorbidities – Comorbid developmental and emotional diagnoses identified

5X more often– Etiologic evaluations done 10X more often

Lessons Learned

• Providing remote consultation—neither optimal nor efficient

• Waitlists for telehealth and clinical care remain long

• Time to move knowledge, not patients

• Increase quality care for children with behavioral, emotional, and developmental disorders within the medical home by guided practice and mentorship by KKI experts using the ECHO model

Lessons Learned

• The first teleECHO clinic was developed in 2003 in New Mexico to respond to the growing health crisis hepatitis C

• Since then, Project ECHO has expanded to cover over 45 other complex conditions at academic medical centers across the US and around the globe

Project ECHO

• Project ECHO® (Extension for Community Healthcare Outcomes) is a movement to de-monopolize knowledge and amplify the capacity to provide best practice care for underserved people all over the world

• The Project ECHO model is not “telemedicine” where the specialist assumes the care of the patient

• It is a guided practice model where the primary care clinician retains responsibility for managing the patient, operating with increasing independence as their skills and self-efficacy grow

• The Project ECHO model uses a combination of multi-point videoconferencing technology, case-based learning, promotion of best practices, and the monitoring of outcomes to create and support professional communities of learning and practice

Project ECHO

• https://www.youtube.com/watch?v=VAMaHP-tEwk

Project ECHO

KKI-NECT Community Partners

KKI-NECT teleECHO Clinics

• Weekly or bi-weekly (1 hour) tele-education sessions– Introductions/Announcements– Case Discussion (submitted in advance and de-identified)– 15-20 minute didactic from the KKI B/E/D Curriculum

• autism spectrum disorder• psychotropic medication needs• obsessive compulsive behavior• sexually acting out behaviors• aggression• anxiety • exposure to adverse events • Parent/child relational issues

• oppositional behavior • speech and language delay • global developmental delay• motor delay • sleep disruption• hyperactivity/ADHD • feeding issues

Needs Assessment Survey

Participating clinicians identified the following topics as being very helpful or extremely helpful to their practice:

And We’re Off!

• 14 sessions from 3/15/17 to 6/21/17– 76 total attendees; 9 unique clinicians at 5 sites

• 4 sessions from 7/5/17 to 7/26/17– 17 total attendees; 6 unique clinicians at 4 sites

• Miles saved (round-trip travel between presenting spoke and KKI): 3,896 total across all 13 case presentations

Pilots

• Program– Attendees– CME hours– Miles aaved

• Satisfaction– Team process– Patient care

• Clinical– Topics covered– Age of patients– Spoke diagnoses– Hub diagnoses– Medication use– Co-morbidity rates

Evaluation Measures

Poll #3

True or False:

You do not have to do anything to receive your CME.

CME

18 1-hour sessions

79.5 CME Credits Earned

100% of respondents agreed (23.6%) or strongly agreed (76.3%) to the question “Were the learning objectives met?”

Overview of Preschool Developmental and Behavioral Health

Medicate a Three Year Old? An Introduction to Early Childhood Psychiatric/Behavior Health Medication Assessment

Asking about Preschool Trauma and Adverse Childhood Events

The Child Who Does Not TalkSpeech & Language Disorders and Differential Diagnosis

Is This Really ADHD?Diagnosing ADHD in Preschoolers

My Child Won’t ListenDisruptive Behavior in Preschoolers

Treatment of ElopementOffice Based Interventions

Medical Management of Preschool ADHD, Part I

Medical Management of Preschool ADHD, II

Beyond the M-CHATScreening for Autism in Preschoolers, Part 1

Is This Really Autism?Differential Diagnosis of Autism

Next Steps for ASD DiagnosisOffice-Based Interventions

Early Intervention in Autism

Should I Medicate This Child with ASD?Brief Overview of Medication

The Anxious ChildDifferential Diagnosis of Anxiety Disorders

Nonmedical Interventions for Anxiety

KKI-NECT’s 16 Week Introductory Series

• “This fantastic program should go to the guidance counselors. They are the primary source of behavioral and mental health referral.”

• “This has been an excellent experience for me so far, and I am so blessed and thankful that you all came knocking at my door!”

• “This curriculum should be a requirement for any advance practice pediatric nurses.”

• “ When you asked me to participate I was worried I wouldn’t be able to commit to an hour a week. It is now the hour I most look forward to in my work week”

Evaluation

• 100% of participants either agreed or strongly agreed

– Improved their knowledge/skills in the evaluation of developmental concerns

– Improved their knowledge/skills in the treatment of developmental concerns

– Improved their knowledge/skills in the treatment of behavioral concerns

– Learned best practice care in developmental concerns

– Learned best practice care in behavioral concerns

Pre-Post EvaluationsKnowledge, Skills, and Practice

• 100% agreed or strongly agreed that they would…

– Participate again in the future

– Recommend to professional colleagues

Pre-Post Evaluations: Satisfaction

Mean Difference

Std. Deviation

Std. Error Mean

T Sig. (2-tailed)

Knowledge/Skills - Evaluation of Behavioral Concerns 1.400 0.548 0.245 2.45 0.005

Knowledge/Skills -Treatment of Behavioral Concerns 1.200 0.837 0.374 2.45 0.033

Confidence - Identifying Temper Tantrums 0.800 0.447 0.200 5.72 0.016

Confidence - Identifying Anxiety 1.400 0.894 0.400 3.21 0.025

Confidence - Identifying Psychotropic Med Needs 1.400 0.548 0.245 2.45 0.005

Confidence - Identifying Exposure to ACEs 1.200 0.837 0.374 3.21 0.033

Confidence - Identifying Parent-Child Relational Issues 1.000 0.707 0.316 2.45 0.034

Retrospective Pre-Post Evaluations: Knowledge, Skills, and Practice

• Diversity of cohort

• Diversity of hub team

• Desire to commit long term

• Dedication of hub participants

• Dedication of HRSA sponsors

Lessons Learned

• Expansion of current HRSA grant beyond Maryland to surrounding states

• Maryland Center of Excellence in Developmental Disabilities grants in North and South Dakota and the US Virgin Islands

• India ?

• Sustainability/Funding

Future Directions

Poll #1

Approximately what percentage of children with a developmental disorder also have a mental health/behavioral disorder?

A. 5-20%

B. 25-40%

C. 45-60%

D. 65-80%

Poll #2

All of the following are barriers to specialty care for B/E/D disorders EXCEPT…

A. Abundance of specialists

B. Cost of missed work

C. Distance

D. Waitlists

Poll #3

True or False:

You do not have to do anything to receive your CME.

Learning Objectives

Upon completion of this module, the learner will be able to:

1. Describe the frequency of co-morbid behavioral, emotional, and developmental disorders in young children in the state of Maryland

2. List 2 patient and 2 provider barriers to accessing care for behavioral, emotional, and developmental disorders

3. Describe the “Project ECHO” model

4. Describe one finding from the first KKI-NECT cohort