Session # Behavioral Health Disorders In An Integrated ...€¦ · Behavioral Health Disorders In...

Management of Pediatric Behavioral Health Disorders In

An Integrated Pediatric Medical Home

Stephanie Chapman, PhD, Assistant Professor Baylor College of Medicine, The Center for Children and Women

Arlene Gordon-Hollingsworth, PhD, Assistant Professor Baylor College of Medicine, The Center for Children and Women

Stephanie Marton, MD, Assistant Professor, Baylor College of Medicine, Associate Medical Director, The Center for Children and Women

Mudassar Tariq, MD, Assistant Professor, Baylor College of Medicine, The Center for Children and Women

Session #

CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas

Faculty Disclosure

The presenters of this

session have NOT had any

relevant financial

relationships during the

past 12 months.

Conference Resources

Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017

Slides and handouts are also available on the mobile app.

Learning Objectives

Learners will be able to describe

• Clinic process that support successful

interdisciplinary and integrated treatment of

pediatric behavioral health care

• Interdisciplinary skill competencies and care roles

in the treatment of pediatric behavioral health

care

Management of Pediatric Behavioral Health Disorders In An Integrated Pediatric Medical Home

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TCHP The Center for Children and Women

The Center for Children and Women

– A Hybrid Model

MinimalCoordinated –At a Distance

Co-locatedFully

Integrated

1) Independent outpatient behavioral health services2) Just in time behavioral health services during medical appointments

Medical Home Model

8

Capacity and Accountability

Provider Led Teams

Care Coordination& Integration

Whole Person Orientation

Safety and Quality

Continuity of CareEnhanced

Access

Center Patient Race/Ethnicity

67

25

41

0

10

20

30

40

50

60

70

80

Latino Black White Asian

Percentage

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Funding – Capitated Payment

• Flat fee per patient member

• 100% Risk model

Value:

• No fee for service = ability to innovate

• Value on prevention and maintenance

• Incentives for reducing costs

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Access

Hours

Pediatric Hours:

Sunday 9 AM – 7 PM

Monday 7 AM – 11PM

Tuesday 7 AM – 11PM

Wednesday 7 AM – 11PM

Thursday 7 AM – 11PM

Friday 7 AM – 11PM

Saturday 9 AM – 7 PM

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Integrated Care = Easy Access

OB/GYN PediatricsBehavioral

HealthOptometry

Speech Nutrition PharmacyHealth

Education

Dentistry Lab RadiologyCare

Coordination

OVERVIEW OF BEHAVIORAL

HEALTH

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Interdisciplinary BH Team

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5 FTE BH clinicians

2 social workers

1 psychiatrist

6 pediatricians5 nurse practitioners

BEHAVIORAL HEALTH CARE –

ADHD AND DEPRESSION /

ANXIETY

15

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Screening

Care Coordination

Diagnostic Assessment

Medication Management

School Accommodations

Evidence-based Therapy

Care Interventions for ADHD at the Center

Use of Screening and Psychological Assessment Tools

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Evidence-Based Treatments

Parent Management Training

– A brief (4-10 session) therapy

designed to teach parents skills to

change child behavior

– Effective for a variety of presenting

problems:

• Enuresis/Encopresis

• Sleep disturbances

• Feeding difficulties

• ODD, ADHD, and DBD

Thoughts

Feelings Behavior

Evidence Based Treatments –

Exposure Therapy

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Evidence-Based Treatments -

Motivational Interviewing

Medication and Treatment AdherenceSubstance ReductionHealth Goal maintenance

Coordination of Care

Patient Registries

Staffed regularly by social work and care

coordinators

• ADHD Follow-Up

• 7 and 30 Day Psych Hospital Follow-up

• Maternal Depression Screen Follow-up

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Telehealth Increases Access

Telehealth = 7% of Psychiatry encounters

Contributes to 100% psychiatry template utilization

PCP – Medication Management

Psychiatry – Formal Consult Role

BH Clinician – Assessment & Therapy

Social Worker-Resources

Patient

Collaborative Medication

Management

• Protocols standardize care

• Increase timely access to care for medication titration

Medication Management

BH Clinicians and PEDI/OBGYN

providers partner to manage the majority of BH medications

• ADHD

• Anxiety

• Depression

• Sleep

Psychiatry - 30 % of time allocated to curbside consult

Psychiatrist only sees patients with complex psychiatric disorders

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Center PEDI Medication

Management

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Good Psychiatry Referrals• Patients with complex psychotropic medications• Patients with psychiatric histories other than

ADHD / depression/anxiety• Lack of progress with first line treatments• Children under 6 years

Psychiatry can always be consulted• Inbasket• Curbside consult• Patient office visit

Case Example – John

16 yo male who presents for his well child check

• PSC-17 is elevated; pediatric provider asks

further questions of child

– Concerned that child may be depressed

– Real time behavioral health consult

• Depression diagnosed at visit by psychologist

– SSRI started same day

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John returns

• Behavioral health team calls John in one week to

check on his symptoms, he is doing well with no

side effects noted

• At follow-up in clinic in 2 weeks John has had

some stomach aches and no real change in

mood

– Pediatric team increases SSRI dose

– Behavioral health team provides therapy same day

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John continues to return

• Over next month behavioral health team sees

John twice

• He returns to pediatric clinic and reports he has

more energy but still does not see a change in

his mood

– Pediatric team briefly curbsides psychiatry to enquire

as to how long should John stay on same medication

with no change in his mood

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John returns

• John is maintained same dose of SSRI for an additional month with continued therapy

• After 2 months John reports he is having more energy and improved mood

• Therapy continues. Behavioral health team messages pediatric team that he is doing well and pediatrician team refills medication for an additional month.

• John stops coming to therapy; pediatrician continues SSRI and checks in with therapist when he comes for medication management visits.

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John

• John’s symptoms were caught early through annual

screening exam and he was never hospitalized.

• A team of multidisciplinary healthcare providers

were able to manage John’s symptoms; he was never

seen by psychiatry.

• John’s treatment was successful due to frequent

communications and a modifiable treatment plan.

• John received cost-effective, quality care.

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CENTER OUTCOMES- ADHD

EXAMPLE

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ADHD / Depression/Anxiety

Screening Rates - % of Screening

Completed at Well-Child Checks

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CENTER ADHD PATIENTS and VISITS 2016

Members with ADHD Treated

by PCP VS Psychiatrist

40%

22.80%

60%

77.20%

TCHP 2016 Center 2016

Psychiatry PCP

Use of Generic Pharmaceuticals

ADHD Meds

Center Psychiatry 42.30%

TCHP top prescribers 28.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

PEDIATRIC BH HEDIS METRICS

ADHD stimulant initiation

95th Percentile

ADHD continuation/maintenance

95th Percentile

7 Day psychiatric hospitalization follow-up 75th Percentile

30 Day psychiatric hospitalization follow-up 50th Percentile

RIGHT CARE / RIGHT PLACE -

BEHAVIORAL HEALTH Behavioral Health Integration Increases

Engagement in Underserved Communities

Thank you!

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