A Model of Integrated Behavioral Health in a

Pediatric Primary Care Setting

Carol Lilly, MD, MpHCarrie Adams, PhD

University of South Florida, COM, Dept. of Pediatrics

Collaborative Family Healthcare Association 17th Annual ConferenceOctober 15-17, 2015 Portland, Oregon U.S.A.

Session # C2a in Period 2October 16, 2015

Faculty Disclosure

The presenters of this session• have NOT had any relevant financial

relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to: Explain the rationale for providing behavioral

health through an integrated model Review implementation of an initiative to

integrate behavioral health into primary care settings

Discuss roles of school psychologists and medical providers in Integrated Behavioral Health (IBH)

References AHRQ: Provider- and Practice-Level Competencies for Integrated

Behavioral Health in Primary Care: A Literature Review. March 2015 - http://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcadLitReview.pdf

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Arndorfer, R.E., Allen, K. D. & Aljazireh, L. (1999). Behavioral health needs in pediatric medicine and the acceptability of behavioral solutions: Implications for behavioral psychologists. Behavior Therapy, 30, 137-148.

Asarnow JR, Rozenman M, Wiblin J, & Zeltzer L. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis. JAMA Pediatrics. Published online August 10, 2015. doi:10.1001/jamapediatrics.2015.1141.

Cooper, Valleley, Polaha, Begeny, & Evans. (2006). Running Out of Time: Physician Management of Behavioral Health Concerns In Rural Pediatric Primary Care. Pediatrics Electronic Pages, 118, e132 - e138.

Davis DW1, Honaker SM, Jones VF, Williams PG, Stocker F, Martin E. Identification and management of behavioral/mental health problems in primary care pediatrics: perceived strengths, challenges, and new delivery models. Clin Pediatr (Phila). 2012 Oct;51(10):978-82. doi: 10.1177/0009922812441667. Epub 2012 Apr 18.

Foy, J., Enhancing Pediatric Menthal Health Care. Algorithms for Primary Care. American Academy of Pediatrics Task Force on Mental Health. PEDIATRICS Volume 125, Supplement 3, June 2010.

Guarneri, E., Horrigan, B.J., & Pechura, C.M. (2010). The efficacy and cost effectiveness of integrative medicine: A review of the medical and corporate literature. Bravewell Collaborative Report.

Hinkle, J., Population-Based Mental Health Facilitation (MHF): A Grassroots Strategy That Works. (2013) The Professional Counselor\Volume 4, Issue 1.

Knapp, P. K., & Foy, J. M. (2012). Integrating Mental Health Care Into Pediatric Primary Care Settings. Journal of the American Academy of Child & Adolescent Psychiatry , Volume 51 , Issue 10 , 982 - 984

References Kolko, D.J., Campo, J.V., Kelleher, K., & Cheng, Y. (2010). Improving access

to care and clinical outcome for pediatric behavioral problems: A randomized trail of a nurse-administered intervention in primary care. Journal of Behavioral and Developmental Pediatrics, 31, 393-404.

Lavigne, J. V., Gibbons, R. D., Arend, R., Rosenbaum, D., Binns, H. J., & Christoffel, K. K., (1999). Rational service planning in pediatric primary care: Continuity and change in psychopathology among children enrolled in pediatric practices. Journal of Pediatric Psychology, 24, 393-403.

Magill, M. K., & Garrett, R. W. (1988). Behavioral and psychiatric problems. In R. B. Taylor (Ed.), Family medicine (3rd ed., pp. 534-562). New York: Springer-Verlag.

Mechanic, D. (2003). Policy challenges in improving mental health services: Some lessons learned. Psychiatric Services, 54, 1227-1232.

Sharp, L, Pantell, R.H., Murphy, L.O., & Lewis, C.C. (1992). L Psychosocial Problems during child health supervision visits: Eliciting, Then what? Pediatrics, 89, 619-623.

Strosahl, K. (2000). The psychologist in primary health care. In: Kent AJ, Hersen M, eds. A psychologists’ proactive guide to managed mental health care. Mahwah, NJ: Lawrence Erlbaum Associates; 87-112.

Wildman, B.B., Stancin, T., Golden, C., Yerkey, T. (2004). Maternal distress, child behavior, and disclosure of psychosocial concerns to a pediatrician. Child: Care, Health and Development, 30, 385-94.

Williams, J., Klinepeter, K., Palmes, G., Pulley, A., & Foy, J.M. (2004). Diagnosis and treatment of behavioral health disorders in pediatric practice. Pediatrics, 114, 601-606.

Learning Assessment

A learning assessment is required for CE credit.

A question and answer period will be conducted during/at the end of this presentation.

Behavioral Concerns in Pediatric Care

Parents most often bring their children with behavior problems to primary care first (Wildman, Stancin, Golden, & Yerkey, 2007).

Up to 25% of all Pediatric visits are for specific behavioral health concerns (Lavigne, Gibbons, Arend, et al, 1999; Williams, Klinepeter, Palmes et al, 2004, Cooper, et al, 2006).

During 50% to 80% of child health care visits, parents or physicians raise concerns of behavioral or psychosocial issues (Sharp, Pantell, Murphy, & Lewis, 1992).

Question:

What are current challenges to addressing pediatric behavioral health

concerns?

Challenges Addressing Behavioral Concerns

Problem: Access to trained pediatric behavioral health professionals

Shortage of community-based psychologists

Shortage of school psychologists in the schools

Florida Medicaid regulations limit access to psychologists

Low follow-through with BH referrals: 46% for children and 25% for adults (Strosahl, 2000)

Child & Adolescent Psychiatrists (CAPs) number only 8,300, (including the semi-retired) …Estimates place the current need at over 30,000 CAPs in the U.S. (AACAP, 2013; Knapp, 2012)

Those serving children lack training related to early development and have little coordination with primary care (Knapp, 2012; Davis, 2011)

Problem: Expectation of pediatricians to address behavioral health concerns

Pediatricians rank BH as most common problem (over otitis) (Arndorfer, Allen, & Aljazireh, 1999)

60% of all BH visits occur in Primary Care settings (Magill & Garrett, 1988)

25% pediatric PC visits include BH concerns (Cooper, Valleley, Polaha, Begeny, Evans, 2006)

Schools refer children to their pediatrician Pediatricians and Pediatric residents report insufficient training in

BH when starting practice (Davis, 2011)

Challenges Addressing BH Concerns

Problem: Logistics needed for pediatricians to address BH

Lack of time to address BH during a pediatric care appointment (Average Primary Care Office visit is 10-15 minutes)

Lack of brief evidence-based interventions available in primary care to address BH needs within that setting (AHRQ 2015)

Insufficient reimbursement for BH services provided by any provider including physicians (AHRQ 2015)

Challenges Addressing Behavioral Concerns

Proposed Solution: IBH in Pediatric Primary Care

Integrated Behavioral Healthcare (IBH) defined as:

Provision of behavioral health care within a primary health care setting

Integration of behavioral and physical health care services

Preventive and first line interventions for common behavioral/mental health problems presenting in primary care practices (Hinkle 2013; Foy 2010)

Figure 1. Modified WHO Pyramid Framework: MHF (Hinkle, 2013b)

Implementing IBH in USF Pediatrics

Funding and Logistics

Grant from University of Nebraska Medical school has funded 1 full-time or 2 part-time interns each year for the past 3 years

USF Pediatrics funds 1 psychologist to implement IBH part-time & assist with supervising interns/training students This is the 4th year; 1 full-time intern with dedicated time at each site

Service locations: two primary care resident teaching sites – one with primary care only in underserved area, the other with combined adolescent health, complex care program within University clinic.

Faculty participation recruited through general pediatrics – medical directors of both offices one of which is Division Chief (strong support from leadership)

Referral process established informally at first, now more formal through standard referral

Documentation of service is within same record for medical and behavioral health team

Utilizing School Psychologists

School psychologists receive training specifically related to BH concerns raised in pediatric care Have trained a minimum of 1 year working in a school

Able to serve as a liaison between the primary care setting, school setting, & the home

Utilize evidence-based behavioral interventions that work at school & at home

Conduct screenings & evaluations at each site to assist with both medical interventions, psychoeducational evaluations and interventions

Provide feedback on site and within shared record Assists with resource and referral of more complex needs

Continuum of Services

Provide services through “hand offs” & co-appointments Triage need for further assessment Spend additional time on psychoeducation and answering questions

Acute services provided between pediatrician appointments 1-2 sessions Triage and other evaluations (clinical interviews for differential & comorbid

diagnoses- ADHD, SLD, DD, Depression/anxiety, ASD, etc.)

Continuity services Often 3-10 sessions Individual parent behavior training, brief therapy, etc.

Collaborate with schools and pediatricians to develop educational and health intervention plans– Medication monitoring and adjustments– IEP and 504 Plan development

Types & Frequency of Services

Data for 2014-2015 academic year Triage assessments (56)

Often includes ADHD, sleep, anxiety, etc.

Triage + interventions (47) Other diagnostic Assessments (16)

SLD, DD, ASD, etc.

Parent behavior interventions (146) Therapy (176)

Coping skills to address mood, anxiety, etc. Social skills, family communication skills, etc.

Diagnosis psychoeducation & intervention (24)

Types & Frequency of Services- cont.

Crisis Intervention (4) Medical intervention monitoring (7) Academic interventions (5)

Demonstrating reading interventions

Meeting with another community agency (13) IEP and 504 Plan development

Total intervention session=

Total NS/same day cancellations=293

494

Benefits of IBH for the Child/Family

Easier and quicker access to care Increased access to BH services for under/non-insured

Early intervention and prevention possible Reliable, often immediate, communication between providers Less stigma associated with obtaining behavioral health care in

primary care setting Recent meta-analysis of integrated care compared to TAU

demonstrated significant effect in pediatrics (Asarnow et al., 2015) 66% probability that a randomly selected youth would

experience better outcomes after receiving IBH than a randomly selected youth receiving usual care

Successes Implementing IBH

Survey of caregivers (n= 11) of patients that received 3+ appointments involving IBH (co-appointments or sessions with psychologist in pediatric office) reported: “Very satisfied” with IBH/psychology services (X=4.5) Services “greatly helped my child’s progress” (X=4.7) Problems presented prior to IBH services were “greatly

improved” or improved post services (X=4.1) Relationships with their child were “greatly improved” (X=4.4)

Caregivers would recommend IBH to other parents 10= yes, 1= maybe

Successes Implementing IBH

Caregivers stated: “It provides more opportunities for a "team" approach addressing

all the areas where my son needs improvement. Knowing the physician and the psychologist are able to discuss issues when the psychologist is present makes the treatment more effective. The psychologist when working independently sometimes ignores the medical approach.”

“She listened and worked with us. Without her I don't think I would have gotten through my sons I.E.P. process.”

“It is great to have the pediatrician and psychologist working together. Everyone is one the same page and the plan is jointly formed between the providers and the parents and child.”

Benefits of IBH for Pediatricians

Physicians have a “ready” referral source Able to “hand off” complicated patients during

appointments Patients are seen “in” the practice and

recommendations immediately communicated Physicians more productive (15-20%) Cost effective (Guarneri, Horrigan, & Pechura,

2010) Improves pediatrician’s skills and confidence to

handle BH concerns

Successes Implementing IBH

Sample of attending pediatricians, pediatric residents, & medical students reported regarding perceptions of IBH 100% stated “very helpful” to their own professional

development (4 scale of 1-4)

91% reported “greatly improved” overall healthcare for their patients (5 scale of 1-5)

All respondents would recommend IBH continue in pediatric primary car

All residents and attending pediatricians reported desire to increase availability of IBH services

Benefits of IBH for Schools

Interpretation of school-based assessments for pediatric care

Medical information translated into useable data for school-based assessments

Improved behavioral outcomes related to improved academic outcomes

Improved access to a provider within the primary care setting

Typical Goals Achieved

Physical health Improved sleep Improved weight

Behavioral health: Decreased frequency and intensity of tantrums and outbursts Improved compliance Often measured using ECBI (Eyberg Child Beh. Inventory)

Improved mental health coping skills, reduced symptoms of anxiety, depression Measured using frequency of symptoms (# of panic attacks, etc.),

self ratings, and caregiver ratings

Academic achievement gains

Case Example Mother brought Michael to pediatrician because he was

in danger of failing 2nd grade; had numerous office referrals for behavior; thought he might have ADHD

Pediatrician referred to school psychologistEvaluation revealed:

Poor sleep hygieneADHD Combined TypeOppositional behaviorNocturnal enuresis Poor peer social skills (impulsive, interrupting, teasing)

Pediatrician consulted at end of triage and coordinated plan decided

Michael-continued

Initial Interventions Changes to sleep routine 1 mg Melatonin Low dose stimulant medication Parent behavioral training

HOT DOCS

Psychoeducation regarding ADHD Consultation with school Social skills training

Michael-continued

Follow-up 6 sessions w/school psychologist across several

months Co-appointments with pediatrician

Modifications to sleep interventions Continued parent behavioral training Met with school to implement Tier 2 interventions and

facilitate assessments Medication monitoring and adjustments

Changed medicines based on side effects

Enuresis interventions

Michael’s Outcomes

All academics improved Passed 2nd grade on grade level in math & reading

Behavior improved at home & at school 4+ “greens” each week at school Reduced argumentativeness from “constant” to infrequent

(ECBI)

Eliminated finger biting

Improved night time dryness

Progress Monitoring: ECBI

11.6.13 11.27.13 5.28.14 Date Date45

50

55

60

65

70

75

80

69

60

54

6059

50

Intensity t-scoreProblem t-score

Challenges to Overcome

Balancing scheduled sessions and “hand off” appointments

Need for services exceeds availability Space issues Improving continuity/improving show rate Funding: current funding is through grant with

agreement of Division to pay additional cost from PSR (this works for us as we can see more patients for whom we can be reimbursed).

Tips for Successful IBH Implementation

Senior leadership buy-in Educate primary healthcare providers for appropriate

referrals Create a schedule with room for both “hand offs” and

between PC sessions Establish relationship with schools and community

resources “Give psychology away”

Questions?

Carrie Adams, Ph.D.

cadams@health.usf.edu

(813) 974-1048

Carol Lilly MD, MPH

clilly@health.usf.edu

(813)-259-8752

For more information, please contact:

Session Evaluation

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