lakewood health system · • substance misuse • baby safety 10 ... postpartum mh burden: anxiety...
TRANSCRIPT
Developing a Maternal Mental Health Promotion
Model in a
Rural Health Facility
Nicolle Uban, Ph.D., CNM, RNPaul Davis, Ph.D., LP
2
• Quick, guess which number is higher:
– The number of people who sprain an
ankle each year?
– The number of people who have a
stroke?
– The number of women who experience
postpartum depression?
3
Outline
1. Review: LHS and mental health burden.
2. Background: Integrated Care Model.
3. Epidemiologic data.
4. LHS: Developing the Model
5. Discuss challenges.
6. Next steps.
7. Questions?
4
Purpose• To develop a maternal mental health promotion
model centered on standardized, frequent
screening of pregnant and postpartum women
in order to adequately address maternal mental
health needs.
• To improve treatment outcomes for women
identified with major depression or dysthymia
during their pregnancy and the first postpartum
year through an integrated care model.
5
Background:
Lakewood Health System
• City of Staples, Todd County, MN
• Federally certified Rural Health Clinic and Critical Access Hospital
• High Medicare/Medicaid/Medical Assistance– Serving 5 of the poorest counties in MN
– Tri-county area has some of the highest teen pregnancy rates in the state.
• Large population of Army Reserve and National Guard members, their spouses, and families
6
Mental Health Burden on the
Healthcare System
• Greater healthcare utilization rates:
highest 20% pts use 88% of healthcare
• Increased medication use (and misuse):
e.g., opioids 3-6x if MH co-morbidity
• Tx noncompliance, drop out, and relapse
• Only 40% of prescriptions taken
7
MH Burden: Comorbidities
• Poorer lifestyle management: inactivity,
alcohol/drug use, obesity
• Increased pain complaints, severity, duration
• Greater functional impairment/disability
• Poorer rehab and surgery outcomes
• Delayed return to work
MH Burden during PG: Depression
• Negatively impacts birth outcomes.
Independent risk factor for:
– Low fetal birth weight
– Premature delivery and associated risks
• Medication noncompliance
• Treatment burden
• Maternal comorbidities
8K.J. Gold & S.M. Marcus (2008). Effect of Maternal Mental Illness on Pregnancy Outcomes. Expert Rev of Obstet Gynecol. 3(3), 391-401.
MH Burden during PG: Anxiety
• Negatively impacts birth outcomes:
– Preterm delivery and low fetal birth weight
– Associated with increased risk of miscarriage
– Temperamental problems and fussiness
– Problems with attention regulation and emotional
reactivity
– Lower scores on measures of mental development
9
Postpartum MH Burden: Depression
• Poor attachment
• Neonatal depression
• Delayed return to work
• Substance misuse
• Baby safety
10Photo retrieved from: middlesexhospital.org
Postpartum MH Burden: Anxiety
• PP anxiety and stress:
– Ineffective maternal coping
– OCD behaviors
11
12
MH Treatment Data
• De facto BH tx system is Primary Care
– PCP prescribe 60-80% all psychotropic meds
• BH needs routinely not assessed!
• When assessed, pts are lost to follow-up
• PCP don’t have time
• BHC/MHP not available
13
Other Factors
• 80% U.S. Population sees PCP yearly
• PC job dissatisfaction due to BH issues in pts
• Medicaid/Medical Assistance population has greater BH needs
• Medication only tx insufficient/less effective
• Rural areas lack access to BH specialists
14
Societal Demands• Healthcare Reform
– Increased access expected
– Bundled services
– Prevention focused!
• Outcome focus– NPI data
– Pay for performance
– Cost savings incentives
• Medical/Health Care Home Model
LHS
• Hybrid system: Integrated + Traditional Mental Health (MH) care
• Similarities to DIAMOND
• Improves access, satisfaction, and outcomes
15
LHS: Interdisciplinary Team
BH• MD Psychiatrist (2)
• PsyD, LP
• PhD, LP
• APRN, CNS
• MSW, LICSW
• MA, NCC, LPCC, LAMFT (2)
• LPN
• Administrative Assistant/Coordinator
WH• OB/GYN (2)
• CNM
• FNP
• WHNP
• RN case managers (3)
• LPN (5)
• Expectations Nurses
• WH coordinator
16
LHS Behavioral Health Team
• Addressing Perinatal Mood and Anxiety Disorders (PMAD), as well as other Maternal Mental Health (MMH) disorders.
• Additional Targeted populations: – Women’s Health
– Palliative Care
– Dementia
– FASD
– Chronic Pain
• Multifaceted Outpatient BH Clinic17
18
Integration Model
• Primary Care Behavioral Health Model– Population focused
– Collaborative service with PCPs
– BHC part of PC team
• BHC assesses pt psychosocial needs
• BHC develops tx plan, PCP implements
• Allows easy access to BH care• Not traditional BH care;
19
Benefits of Integrated Care
• Improvement in depression remission rates from 42% to 71%
• Improved self management skills for patients with chronic conditions
• Improvement in MH
• Significant improvement in health outcomes for comorbidities
20
Benefits of Integration
• Increased Productive Capacity:
– Estimate of revenue ceiling of a health care system is
closely tied to productive capacity of medical
providers
– Current capacity is overwhelmed with frequent
management of behavioral health conditions
– Integrated behavioral health “leverages” BH patients
out of PCP practice schedules
– PCP’s are freed to see medical patients with higher
RVU conditions/top of license
21
Benefits of Integrated Care
• Better clinical outcome than by treatment
in either sector alone
• Improved consumer and provider
satisfaction
• High level of patient adherence and
retention in treatment
• Population health benefits
22
Benefits of Integrated Care
• Improved process of care:
– Improved recognition of MH and CD
disorders
– Improved PCP skills in medication
prescription practices
– Increased PCP use of behavioral
interventions
– Increased PCP confidence in managing
behavioral health conditions
23
Economic Benefits of Integration
– Meta-analysis: 57 controlled studies show
a net 27% cost savings
– 40% savings in Medicaid patients receiving
targeted treatment
– In older populations, up to 70% savings in
in-patient costs
– 20-30% overall cost savings overall
average
24
Epidemiologic Data• PMAD most common complication of
pregnancy and childbirth:
• ~20% suffer from prenatal depression
• 45-60% suffer from prenatal anxiety
• 1 in 7 women suffer from PPD
• Fathers are affected too:– Approximately 4% in the 1st PP
year
Diagnosis and Treatment of Women with Depression
25Source: CDC Fact Sheet
26
Epidemiologic Data cont…• U.S. Lifetime prevalence for MH Disorders in
general population:
– 46% DSM-IV disorder
– 21% Depressive mood disorder
– 29% Anxiety disorder
– 40-50% medical patients have Depression or
Anxiety
Epidemiologic Data cont…
• Major Depressive Disorder #1 disability in U.S.
• 70% all PCP visits contain psychosocial elements.
• 50% all PCP visits are specifically for a MH disorder.
27
LHS: Addressing a Critical gap in
Maternal Mental Health Services
• What we identified:
– A lack of a standardized approach to MMH
screening and MH promotion, in spite of a
growing need among our patient population.
28
Our Response:
• Organize a taskforce.
– Key Stakeholders
• Screening tools selected.
• Algorithm developed:
– Intervals for screening
– Pathways for care
– Follow up
29
30
Plan
31
8 Critical Screening Points Identified:
• Antenatal x3
• Postnatal x5
• Other maternal visits in
the 1st year PP
32
Screening Method
1. PHQ 2: If positive…
2. PHQ9
3. Next Step: Decision made based on
severity of depression, issues of safety,
and MH history.
33
Positive Screens
• PHQ9 score: Severity of Depression
– 0-4 Minimal Depression
– 5-9 Mild Depression
– 10-19 Moderate Depression
– 20+ Severe Depression
34
Safety and MH History
35
Severity of Depression
Minimal to Mild (0-9)
• Consider Safety and MH Hx:
– Suicidal/homicidal; MH hx, on
meds, sig. FH = STAT MH
referral
– Enhanced F/U protocol
• If Safety and MH Hx negative:
– Ongoing screening
• MH hx only:
– Consider med tx
– MH visit within 10 days
– Enhanced F/U
Moderate to Severe (10-20+)
• MH providers triage for level
of referral and acuity of
need.
– STAT MH referral
– Medication
– Enhanced F/U protocol
– Ongoing screening
• Other risk factors
considered.
36
Plan
37
Referral to BH
• Referral system:
– Collaboration between primary care providers
and BH team
– Collaboration between WH and BH
• 2-4 weeks for non-emergent BH services for
Pregnant/PP women
• Immediate/STAT visits for acute Patients
• ER if BHP unavailable
38
LHS: BH Integrated Services• What we offer:
– Therapy: Short term and traditional
– Psych testing
– Medication initiation and management
– OT
– Dietary
– Primary Care
– Close collaboration with: ARMHS/Social
Services/County
39
Enhanced Follow Up: • Based on BH recommendations
• EMR Tracking
– Can “flag” at risk patients to providers (OB, peds)
– All calls documented and visible in EMR
– F/U calls flagged to BH and OB provider
• Ongoing screening/therapy/monitoring
– BH provider
– OB Care/PCP
– Pediatrician/Baby doc40
*mom screened at child’s WELCH visit
41
Screen # screened
54/69 (468)
Min
0-4
Mild
5-9
Mod
10-19
Severe
20+
1st Trimester 8 (7 TOC)
(4 CPN)
2 2 4 0
2nd Trimester 12 (3 TOC)
(10 CPN)
4 1 0 0
3rd Trimester 24 (0 TOC)
(5 CPN)
0 0 0 0
6 Wk PP Visit 47 (6 no PP) 2 3 3 2
3 mth WELCH* 0 ? ? ? ?
6 mth WELCH* 1 1 ? ? ?
9 mth WELCH* 1 1 ? ? ?
12-15 mth WELCH* ? ? ? ? ?
Midwifery Patients 2013: 54/468
Midwifery Patients 2013: 54/468Number of Pts BH Referral BH Visit Med Start
1 Yes No Yes
1 Yes ? No
1 No No Yes
3 Yes Yes Yes
1 Yes Yes No
42
Additional Data: 2013• Other Prenatal Care Providers:
– OB/GYN x2
– Family Practice MD x 8
• Verbal Polling: Are you doing the PHQ9 with
you PP patients?
– 6 wk Screen: YES!
– Additional Maternal Screens in first year PP: NO!
– Screens at WELCH: NO!
43
Other OB Care Providers, 2013
44*mom screened at child’s WELCH visit
Screen # screened
54/69 (468)
Min
0-4
Mild
5-9
Mod
10-19
Severe
20+
1st Trimester ? (? TOC)
(? CPN)
2nd Trimester ? (? TOC)
(? CPN)
3rd Trimester ? (? TOC)
(? CPN)
6 Wk PP Visit ? (? no PP)
3 mth WELCH*
6 mth WELCH*
9 mth WELCH*
12-15 mth WELCH*
Barriers to Full Implementation
• MMH not a patient care priority
• Did not get buy in from all providers and
nursing staff on importance of this model
• Time consuming
• Lack of workable EMR
• Limited availability of BH staff for acute
referrals
45
What Now?
• Revisit the algorithm
– Is it feasible?
• Market the importance of MMH as a community
health measure and core principle of overall
patient health
• Training: Providers and Nursing staff
46
47
Challenges
• Tradition: not like PC and not like therapy
• Cultural issues: PCP vs. MH providers
• Space!
• Population health vs. Individual health
• Balancing traditional MH care and integrated care innovations
• Cost offset vs. Revenue
• Administrator buy in
• Payor buy in
• Bundled services
48
Summary
1. Reviewed mental health burden.
2. Discussed integrated care generally.
3. Shared data demonstrating the need for a maternal mental health promotion model.
4. Outlined Lakewood Health System’s process for developing the model.
5. Discussed challenges.
6. Reviewed next steps.
Questions?
Thank you very much!
49