early childhood behavioral health integration in primary...

Early Childhood Behavioral Health Integration in

Primary Care SettingsAyelet Talmi, PhD & Melissa Buchholz, PsyD

WebinarMarch 1, 2016

Presenters

Ayelet Talmi, PhD and Melissa Buchholz, PsyD

Financial DisclosuresNo relevant financial relationships with any

commercial interests.

Why primary care?

121,000,000 visits (< 15 years old ) 64,000,000 visits(< 4 years old) Type of insurance

60% private insurance Routine infant/child well-child check

34,000,000 visits/year* Reasons for visit

Well-child checks (routine, health supervision) Sick visits (acute) Treatment of chronic conditions

* 11 recommended visits in the first 4 years (7 in the first year)

Early Childhood Behavioral Health IntegrationScreening Developmental Pregnancy related depression (PRD) Psychosocial/EnvironmentalCase-based consultation/Intervention Typical developmental concerns (feeding, sleeping, milestones) Behavioral concerns (tantrums, adjustment, adversity) Family factors Counseling and brief therapy servicesPrevention/Health Promotion/Intervention Group-based (Centering Pregnancy/Parenting, well-child, Baby & Me) Healthy Steps for Young Children, Reach out and ReadCare coordination/Systems of Care Identification, triage Referral, closing the loop Community connection (Bright by Three, home visitation)

CORNET Study: Collaborative Care Levels

Exclusive Referral: mental health/behavioral care is referred out to local resources

Traditional Care: mental health/behavioral care is provided by the pediatrician based on the providers comfort level and available resources; i.e., some conditions treated and more complex conditions referred to local resources

Phone Consultation Model: pediatric behavioral/mental health specialist is available for phone consultation during the visit, which provides guidance in evaluation and triage of these issues.

Enhanced Care: pediatric behavioral/mental health specialist has an office in the pediatric clinic setting that allows for easy referral, but requires a return visit to see the specialist

Integrated / Collaborative Care Co-location of developmental, behavioral, and mental health consultants, or direct service providers available for consultation at the time of identification by the pediatric provider without the need for a return visit

Pediatric Residency Survey In Mental Health in Primary Care PRISM_PC

6

Bunik, M., Talmi, A., Stafford, B., Beaty, B., Kempe, A., Dhepyasuwan, N., & Serwint, J. R. (2013). Pediatric Residency Integrated Survey of Mental Health in Primary Care: A National CORNET Study. Academic Pediatrics, 13(6), 551-557. (PMID: 24238682)

Chart1

0.22

0.13

0.1

0.02

0.53

Distribution of Programs

Sheet1

Program TypeDistribution of Programs

Enhanced 22%22%

Integrated 13%13%

Exclusive Referral 10%10%

Phone Consultation 2%2%

Traditional 53%53%

To resize chart data range, drag lower right corner of range.

Generously Funded By:with special thanks to Childrens Hospital Colorado Foundation and Kathy Crawley and Jennie Dawe American Academy of Child and

Adolescent Psychiatry Access Initiative Grant

Rose Community Foundation: Access to Mental Health Services CLIMB to Community

The Colorado Health Foundation Pediatric Resident Education

Caring for Colorado Walton Family Foundation CLIMB to Community

Liberty Mutual Denver Post Season to Share Community First Foundation BHIPP:0-5

Child Health Clinic Childrens Hospital Colorado Large urban primary care teaching clinic Low income= >90% Medicaid/SCHIP 29,000 visits per year 60% of visits for zero to 3 years 56% Hispanic, 40% Spanish Primary Language Pod based clinic design Dissemination to community based clinics

Page 8

Our TeamAdministration:

Maya Bunik, MD, MSPH Kelly Galloway, RN Ayelet Talmi, PhD

Psychologists: Melissa Buchholz, PsyD Kate Margolis, PhD Emily Muther, PhD

Aurora Mental Health Clinician: Cathy Danuser, LPC

Psychiatrists: Kim Kelsay, MD Celeste St. John Larkin, MD

Postdoctoral Fellows: Shannon Beckman, PhD, Steven Behling, PhD, Anna Breuer, PsyD, Melissa Buchholz, PsyD, Bridget Burnett, PsyD, Shaleah Dardar, MD, MSW, Dena Dunn, PsyD, Kendra Dunn, PsyD, Emily Fazio, PhD, Collette Fischer, PhD, Barbara Gueldner, PhD, Rachel Herbst, PhD, Jason Herndon, PhD, Marcia Kearns, PhD, Jennifer Lovell, PhD, Kate Margolis, PhD, Dailyn Martinez, PhD, Brigitte McClellan, PsyD, Christine McDunn, PhD, Brenda Nour, PhD, Julie Pajek, PhD, Sarah Patz, PhD, Meg Picard, PsyD, Shawna Roberts, PsyD, Kriston Schellinger, PhD, Casey Wolfington, PsyD

Psychology Trainees: Dena Miller, MA, Keri Linas, MA, Emma Peterson, MA, Jessica Technow, MA, Crosby Troha, MA

Previous PIs and Collaborators: Bob Brayden, MD, Mary Navin, RN, Brian Stafford, MD, MPH, Marianne

Pediatric Residents and Trainees: Leigh Anne Bakel, MD Scott Canna, MD Jacinta Cooper, MD Michael DiMaria, MD Thomas Flass, MD Adam Green, MD Danna Gunderson, MD Kasey Henderson, MD Ashley Jones, MD Sita Kedia, MD Gina Knapshaefer, MD Courtney Lyle, MD Catherine MacColl, MD Jennifer McGuire, MD Michelle Mills, MD Amy Nash, MD Rupa Narra, MD Nicole Schlesinger, MD Teri Schreiner, MD Heather Wade, MD And many more

Psychology Interns: Megan Allen, MA, Caitlin Conroy, MA, Tamie DeHay, MA, Barbara Gueldner, MA, Patrece Hairston, PsyM, Erin Hambrick, MA, Idalia Massa, MA, Jessican Malmberg, MA, Angelica Montalvo-Santiago, MA, Alexis Quinoy, MA, Ryan Roemer, MA, Justin Ross, MA, Cristina Scatigno, MA, Tess Simpson, MA, Michelle Spader, MA, Bethany Tavegia, MA, Crosby Troha, MA, Brennan Young, MA, Jay Willoughby, MA

CHC Faculty Edwin Asturias, MD Steve Berman, MD Karen Call, MD Karen Dodd, PNP David Fox, MD Annie Gallagher, MD Sita Kedia, MD Allison Kempe, MD Lindsey Lane, MD Maureen Lennsen, PNP Tai Lockspieser, MD Dan Nicklas, MD Steve Poole, MD Bart Schmidt, MD Chris Stille, MD Christina Suh, MD Meghan Trietz, MD Shale Wong, MD

CHC Staff Liz Gonzales Nicole Vallejo-Cruz

CLIMB Research Team Ryan Asherin, MA Mandi Millar, BA Molly Nowels, MA

Research Interns: Hamid Hadi, Traci Lien, MD, Iman Mohamed, Cody Murphy, BA, Molly Nowles, BA, Shagun Pawar, BA, Nick Pesavento, Clare Rudman, Danica Taylor, BA, Jen Trout, MA, Zeke Volkert, MD, Tyler Weigang, MPH

CLIMBhow we started Partnership of Psychiatry and Pediatrics Initial Health Foundation fundingStarted with: Developmental screening (>85% rates) Added pregnancy-related depression

screening Built foundation of collaboration and co-

management of two disciplines Planned for sustainability with funds from ASQ & Dept of Peds making it whole

10

Program and Services Developmental Screening Initiative (Child) Pregnancy related depression (PRD) screening (Caregiver,

Child, Family) Healthy Steps for Young Children & MIECHV (Child, Caregiver,

Family) Baby & Me at the CHC (Child, Caregiver, Family) Case-based consultation (Child, Caregiver, Family) Care coordination, triage, and referral (Child, Caregiver, Family) Psychopharmacology consultations (Child) Counseling and brief therapy services (Child, Caregiver, Family) CLIMB to Community pilot (Child, Caregiver, Family) Training and education (Providers/Health Professionals)

Formal didactics Precepting trainees Collaborative care

Medical and Psychiatric Diagnoses (by age)Medical Dx Total 0-3 3-6 6+

Well Child Check 3885 2685 (69%) 167 (4%) 1033 (27%)Asthma 364 34 (9%) 28 (8%) 302 (83%)Weight Issues 340 19 (6%) 29 (9%) 292 (86%)Feeding problems 265 241 (91%) 3 (1%) 21 (8%)Failure to Thrive 145 117 (81%) 5 (3%) 23 (16%)

Psychological Dx Total 0-3 3-6 6+

ADHD 1135 1 (0%) 11 (1%) 1123 (99%)Mood Disorder 387 2 (1%) 1 (0%) 384 (99%)Behavior problems 340 19 (6%) 29 (9%) 292 (85%)Developmental Delay 252 88 (35%) 23 (9%) 141 (56%)

Other mental health concern 110 8 (7%) 13 (12%) 89 (81%)PTSD 49 0 (0%) 0 (0%) 49 (100%)

Consultation Type by Age (%)

* Mothers of patients birth to 4 months were screened for pregnancy-related depression

Chart1

0.250.10.250.310

0.330.030.5100.03

0.0900.6400.21

Developmental

Healthy Steps

Mental Health

Mat. Depression*

Psychopharm

Sheet1

Column1DevelopmentalHealthy StepsMental HealthMat. Depression*Psychopharm

0-3 years25%10%25%31%0%

3-6 years33%3%51%0%3%

6+ years9%0%64%0%21%

To update the chart, enter data into this table. The data is automatically saved in the chart.

Clinician Identified Problem by Age Group (%)


Chart1

0.050.130.83

0.140.110.75

0.460.120.42

0.560.050.4

0.9900.01

0.70.030.27

0.890.040.07

0-3 years

3-6 years

6+ years

Sheet1

0-3 years3-6 years6+ years

Autism5%13%83%

Behavior Problems14%11%75%

Developmental Delay46%12%42%

Family Circumstances56%5%40%

Pregnancy-related Mood Issues99%0%1%

Resource issues70%3%27%

Typical developmental issues89%4%7%


ADHDBehavior ProbsDev DelayFamily IssuesPsychosocial IssuesTypical Dev

Developmental3%13%18%18%7%19%

Healthy Steps0%1%2%15%3%64%

Mental Health8%17%4%26%10%3%

Mat. Depression*0%0%1%38%11%9%

Psychopharm44%9%7%3%2%0%

CLIMB Recommendations Made by Age Group (%)


Chart1

0.640.050.31

0.50.060.44

0.480.040.48

0.160.050.79

0.750.040.21

0.660.110.23

0-3 years

3-6 years

6+ years

Sheet1

Column10-3 years3-6 years6+ years

Dev/Behav Resources Provided64%5%31%

Dev/Behav Strategies Discussed50%6%44%

Follow-Up with Project CLIMB48%4%48%

Outside Mental Health Services16%5%79%

Parental Referral to Mental Health Service75%4%21%

Referral to Community Developmental Service66%11%23%


Dev/Beh StrategiesDev/Beh ResourcesCommunity Dev Svc76%

Developmental7%24%1%95%

Healthy Steps19%26%0%84%

Mental Health4%18%1%86%

Mat. Depression*6%15%1%78%

Psychopharm1%2%0%

Developmental Screening and Closing the Referral Loop

19

Talmi, A., Bunik, M., Asherin, R., Rannie, M., Watlington, T., Beaty, B. and Berman, S. (2014). Improving Developmental Screening Documentation and Referral Completion. Pediatrics, 134: 4 e1181-e1188. (PMID: 25180272).

ASQ and EI Findings

Developmental screening and referral is necessary but not sufficient.

Success of developmental screening process depends on enhancing referral completion.

An intervention providing phone follow-up and assistance with referral yielded higher rates of referral and greater provider knowledge of referral outcomes.

Talmi, A., Bunik, M., Asherin, R., Rannie, M., Watlington, T., Beaty, B. and Berman, S. (2014). Improving Developmental Screening Documentation and Referral Completion. Pediatrics, 134: 4 e1181-e1188. (PMID: 25180272).

Healthy Steps for Young Children (www.healthysteps.org) Provide enhanced developmental services in

pediatric primary care settings; Focus on developing a close relationship between

the clinician and the family in order to address the physical, socioemotional, and cognitive development of babies and young children;

Currently used in 18 residency training programs nationally

MIECHV funding to expand our program and develop new sites across Colorado

Baby & Me at the CHC (Child, Caregiver, Family)

Content analysis of well-child visits, Healthy Steps vs. control

35% *

38% *

33%**

35%**

63%**

28%**

28% *

90% *

23% *

75%**

48%**

70% *

8%

3%

3%

0%

28%

6%

0%

56%

3%

6%

11%

17%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Language Development

Social Skills

Importance of Play

Daytime/Nighttime routines

Sleep

Promoting healthy eating

Temperament

Home Safety

Child Care

How parent is feeling

Postpartum depression

Breast Feeding

Control

Healthy Steps

* 0.03** 0.01

Buchholz, M., & Talmi, A. (2012). What we talked about at the pediatricians office: Exploring differences between Healthy Steps and traditional primary care visits. Infant Mental Health Journal, 33(3), 1 7.

24

Baby & Me at the CHC(Child, Caregiver, Family)

Pregnancy-Related Depression

Formal screening at well-child visits from birth to four months using Edinburgh Postnatal Depression Scale (Cox et al., 1987)

Primary care services Training for providers Psychoeducation Support to mothers Referral Electronic medical record

System changes Capacity building

(Caregiver, Child, Family)

Lovell, J., Roemer, R., & Talmi, A. (2014). Pregnancy-related depression screening and services in pediatric primary care. CYF Newsletter of the American Psychological Association, May. http://www.apa.org/pi/families/resources/newsletter/2014/05/pregnancy-depression.aspx)

http://www.apa.org/pi/families/resources/newsletter/2014/05/pregnancy-depression.aspx

And How are You Doing?

BHIPP:0-5Behavioral Health Integration for Pediatric Populations: 0-5

BHIPP:0-5 Practices

Nine metro-area practices Private and non-profit pediatric PC Safety net clinics Family medicine

Baseline data collection Population Data Screening Processes Behavioral Health Activities

Population Data0 2000 4000 6000 8000 10000 12000 14000 16000 18000 20000

# Unique Patients Served (All ages)

Total # Visits (All Ages)

# Unique patients served (0-5)

Total # Visits (0-5)

# WCCs for children birth through 5 years

Nov-15

Dec-15

Technical Assistance Team Early childhood behavioral health integration: Identifying current and desired EC care delivery

model Collection and evaluating data Training and skill building for EC service delivery Developing processes and implementing EC

practice change Practice transformation Building data systems for collection/extraction,

reporting, rapid cycle QI Change management Risk stratification Parent/patient engagement Team-based care Population health

Systems Issues

LAUNCH and LAUNCH Together Maternal Infant Early Childhood Home

Visitation (MIECHV) federal funding State Innovations Model (SIM) - $65M Office of Early Childhood Accountable Care Collaboratives (ACCs) Behavioral Health Organizations (BHOs)

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Early Childhood Colorado Frameworkhttps://prezi.com/gbkpjhycxowr/early-childhood-colorado-framework-update/?utm_campaign=share&utm_medium=copy

Young Minds Matter

Obstacles & Opportunities: Access and

Delivery Models Financing Workforce &

Systems Capacity

What we learned along the wayChallenges

Design a service that uniquely meets needs

Attend to implementation and process details

Train in the model Whose patient is it? Long-term sustainability

Lessons

Build relationships, meet often, engage stakeholders

Set up systems that allow for ongoing evaluation, QI, and scholarship

Practice change requires practice

Develop protocols together Pilot, partner, and proactively

seek funding

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Acknowledgements

Child Health Clinic, Childrens Hospital Colorado Project CLIMB Team BHIPP:0-5 Technical Assistance Team University of Colorado School of Medicine,

Departments of Psychiatry and Pediatrics Childrens Hospital Colorado Pediatric Mental Health

Institute Irving Harris Program in Child Development and

Infant Mental Health

Thank you.

Questions?

Slide Number 1Slide Number 2Why primary care? Early Childhood Behavioral Health IntegrationCORNET Study: Collaborative Care LevelsPediatric Residency Survey In Mental Health in Primary Care PRISM_PCGenerously Funded By:with special thanks to Childrens Hospital Colorado Foundation and Kathy Crawley and Jennie DaweChild Health ClinicOur TeamCLIMBhow we startedProgram and ServicesSlide Number 12Slide Number 13Slide Number 14Slide Number 15Consultation Type by Age (%)Clinician Identified Problem by Age Group (%)CLIMB Recommendations Made by Age Group (%)Developmental Screening and Closing the Referral LoopASQ and EI FindingsSlide Number 21Healthy Steps for Young Children (www.healthysteps.org)Slide Number 23Slide Number 24Slide Number 25Pregnancy-Related DepressionAnd How are You Doing?Slide Number 28BHIPP:0-5Behavioral Health Integration for Pediatric Populations: 0-5 Slide Number 30BHIPP:0-5 PracticesPopulation DataTechnical Assistance TeamSystems IssuesEarly Childhood Colorado Frameworkhttps://prezi.com/gbkpjhycxowr/early-childhood-colorado-framework-update/?utm_campaign=share&utm_medium=copySlide Number 36Young Minds MatterWhat we learned along the wayAcknowledgementsThank you.

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