SPARK NH: INFANT MENTAL HEALTH SCREENING

Kristen Lynch • Laura Marden Moore Courtney Marrs • Debra Samaha

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Objectives

Project goals & Spark NH Introduction Barriers Recommendations

New Hampshire Other states

Conclusion of findings

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Project Overview

Research the delivery of socio-emotional/ mental health services to children less than nine years.

Assess barriers to screening, assessment, and treatment. Medicaid billing mechanisms Access to providers and services

Conduct key informant interviews and share feedback

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Spark NHMission

To provide leadership that promotes a comprehensive, coordinated, sustainable

early childhood system that achieves positive outcomes for young children and families, investing in a solid future for the

Granite state.

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Introduction5

Definition Infant Early Childhood Mental Health (I-ECMH)

Developing the capacity of an infant/young child to: Experience, regulate, and

express emotion Demonstrate

developmentally appropriate behavior

Develop and sustain stable relationships

Explore the environment and learn

What is meant by infant?

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Why is I-ECMH so Important?5 Numbers to Remember

700 18 90-100

3:1 4-9

700 per second18

Months 90-100 %

3:1 Odds

4-9 Dollars

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5 Numbers to RememberTake Home Messages

• Getting things right the first time is easier and more effective than trying to fix them later

• Early childhood matters because experiences early in life can have a lasting impact on later learning, behavior and health.

• Highly specialized interventions are needed as early as possible for children experiencing toxic stress

• Early life experiences actually get under the skin and into the body, with lifelong effects on adult physical and mental health.

• All of society benefits from investments in early childhood programs.

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Barriers9

Barriers for I-ECMH

Definition of I-ECMH

Lack of awareness

Access to screening

Lack of investment

Medicaid and private insurance

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Medicaid

Covers 54,800 children in NH (2010-2011) Provides a comprehensive set of benefits 0-18 Every state is required to provide screening for

physical, cognitive and emotional issues for eligible children and provide treatment. Early Periodic Screening, Diagnosis, and Treatment

(EPSDT) Screening for developmental delays

Variable across states- only 10% meet federal benchmark of 80% screened, 50% pay for treatment if diagnosis assigned 50% pay for treatment without diagnosis

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Private Insurance

Approximately 67% of NH population is utilizing coverage other than Medicaid.

Private insurance companies don’t reimburse for I-ECMH screening outside of the physicians office. Community-based interventions Dyadic therapies

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Distribution by Insurance Status2010-2011

Statehealthfacts.org

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Insurance and MedicaidDiagnosis Challenges

Provider approval to receive insurance or Medicaid payments

Requires a diagnosis to provide payment Lack of:

Appropriate infant-toddler diagnostic criteria Diagnostic and treatment codes that qualify for insurance

reimbursement Comments from key informants:

“For lack of better words, codes are babied down to try and fit the needs of young children and it simply doesn’t work.”

“The use of diagnosis codes labels children.”

American Psychologist February-March 2011 page 135

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New HampshireBehavioral Health Law Suit

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April 2011 – Investigation by the Dept. of Justice concluded that NH violated the American with Disabilities Act by:

“failing to provide services for individuals with serious mental illness in the most integrated setting appropriate to their

needs”.

Advocates are hopeful that this will impact children’s mental health.

NH Medicaid will not speak with us due to this suit.

http://www.nhcdd.org/documents/SpringRAP2013.pdf

New Hampshire Perspective

Recommendations 16

Multidisciplinary Approach

“No one individual can possess the expertise to evaluate and treat all the possible mental health,

relational and developmental issues that can affect a young child”.

-Stakeholder Evaluate needs, resources and priorities in NH to

come up with the best approach for I-ECMH. Community based interventions Use evidence based tools

Watch Me Grow

NH Pediatric Society initiative

Project LAUNCH

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Medicaid

Spending Smarter Checklist A funding guide for policymakers and advocates to

promote social and emotional health and school readiness.

Report results to Spark NH and key Stakeholders

Establish a sustainable cost-per-unit reimbursement rate

“Medicaid needs to establish a sustainable cost-per-unit reimbursement rate. Current rate for reimbursement is very low $10, as compared to a vaccination, which is over $20.” - Stakeholder

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I-ECMH is a Public Health Issue I-ECMH: Mental Health or Public Health Issue? NHPHA : Identify I-ECMH as a public health

priority. New legislature is more receptive to work with

NHPHA

Focus on Prevention (i.e. screening) Develop key messages for public health

audiences Topics to include: Where to find resources, the

importance of I-ECMH indicators, early detection, multidisciplinary approach, and parent-child relationship.

Eliminate the stigma of “mental health” Our children are our future!

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Create Partnerships

Partner with a community-based programs New Hampshire WIC program

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“Deliver assessment/screening to children at various times (start, midway and/or exiting the program) - It’s a way to partner with a program with similar goals and gives access to children 0-5 years of age”

-Stakeholder

Caregiver Support

Parents/Primary Caregivers Home visiting and family support programs Strengthen confidence

Childcare providers and teachers Liaison between mental health and child care

providers Promote awareness of I-ECMH and

development

“There is a lack of understanding about the importance of accessibility within child care

facilities.”

-Stakeholder

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Workforce Development

~75% of families turn to their PCP for support

Cross training opportunities

Increase capacity and the level of expertise of

providers

Expand eligibility for “qualified providers” to

perform I-ECMH screening

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“It is important to allow qualified staff, other than physicians, to screen and review findings with parents and caregivers. Qualified staff include those who have received training on developmental screening tools.” - Stakeholder

I-ECMH ScreeningBest Practices

Build Initiative 2013

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I-ECMH Screening:Examples of Best Practices

Best practices by discipline: Primary Care - Bright Futures

Assessment – Brazelton Touch Points System

Treatment - Trauma Informed Care Model

Caregiver support – Head Start Model

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Physician Standard of Care: Bright Futures

A Barometer to gauge the state’s performance on key child health indicators.

Recommended by the American Academy of Pediatrics

Documented success The standard of care for Maine physicians Has been implemented in New Hampshire

(Dartmouth) Implement the use of Bright Futures clinical

forms at Well-child visits Bonus! Providers who complete the forms are

reimbursed at an enhanced rates.

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I-ECMH in NHProgress

Transforming Children’s Behavioral Health Care Plan Community Bridges Early Childhood & Family Mental Health Competency

System Utilization of video interviewing/conferencing with

providers September 2013 - Improvement of the credentialing

system Self assessment for providers Incentive to improve skills

Medicaid reform Reimbursement rates increase Allow use of DC:0-3R

Must include coverage for children’s preventative care

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Other States

Recommendations27

I-ECMH ClassificationDC:0-3R

An age-appropriate approach for assessing infants, toddlers and preschool children.

Created to complement other diagnostic and classification systems by describing symptoms, patterns, and associated events/developmental features.

The DC:0-3R Crosswalk Table used in some states to address payment barriers and improve reimbursement rates Maine Florida

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Adoption of DC:0-3R Crosswalks

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In Summary…

We have an opportunity to educate parents, caregivers, professionals, and providers.

Frame as a I-ECMH as a public health issue Create a multidisciplinary approach Adopt Bright Futures as the state standard of

care for NH physicians. Develop partnerships

NHPHA Policy Committee Community child programs i.e WIC

Connect with other states to implement crosswalk table. Mark Rains – Psychologist Vienna Mountain Consulting Kathryn Shea – President and Chief Executive Officer for FL

Center for Early Childhood Inc.

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Acknowledgements

1. JoAnn Cobb- Program Director, Early Childhood and Family Support Program and President of the NH Association for Infant Mental Health Phone call interview 03/19/2013

2. Jane Zill, LICSW- Licensed therapist, Individual practice, Portsmouth, NH Emailed me 04/09/2013

3. Egon Jenson- Administrator, Children's Mental Health Services for the Department of Health and Human Services. Spoke on 04/05/2013

4. Jodi Lubarsky- Child Adolescent and Family Services Director, Seacoast Mental Health Center, Email interview: 04/01/2013:

5. Laura Milliken-Director of Spark NH- Early Childhood Advisory Council- several interviews

6. Deirdre Dunn-Early Childhood Special Projects Coordinator Maternal & Child Health Section DHHS

7. Ellyn Scheiber- Director of Early Childhood Services, Community Bridges. Phone interview 03/12/2013

8. Kim Firth, Program Director, Endowment for Health

9. Kathryn Shea- President & Chief Executive Officer, The Florida Center for Early Childhood, Inc.

10. Geoffrey Nagle: Clinical social worker, Associate Professor of Psychiatry at the Tulane University School of Medicine and the Director of the Institute of Infant and Early Childhood Mental Health

11. Rebecca Marrs Child and Family Therapist Riverbend Community Mental Health12. Sean Ellison Therapeutic Behavioral Services Riverbend Community Mental Health

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Acknowledgments, cont’d. 1. Michael Rovaris-Technical Assistance, Educational Assistance Center, Waltham, MA 2. Greg Prazar MD, Chapter President of NH Pediatric Society 3. Rae Sonnenmeier, PhD, Clinical Assoc. Professor, Dept. of Communication Sciences

and Disorders, Institute on Disability at the University of New Hampshire. 4. Mark Rains PhD, Psychologist, Vienna Mt. Consulting, Maine 5. Luanne Moody- Pediatric Psychiatric Nurse, North Shore Medical Center, Union

Hospital, Lynn, MA 6. Debra Nelson- Administrator. NH Head Start State Collaboration Office. NH

DHHS/DCYF 7. Claudia Ferber-Claudia Ferber, MS, Child and Family Programs Director, NAMI NH 8. Jane Hybsch-Representative of NH DHHS Office of Medicaid Business and Policy 9. Dr. Steven Chapman, MD- Director, Boyle Community Pediatrics Program, Associate

Director of Child Health, Center for Primary Care and Population Health, Dartmouth Medical Center

10. Watch Me Grow Steering Committee 11. Liz Collins Title V12. Marie Mulroy – President NH Public Health Assc.13. Beth Achorn- Child and Family Therapist Riverbend Community Mental Health 14. Debra Grobowski- Executive Director- Foundation of Seacoast Health15. Diana Weiner Child Psychiatrist Riverbend Community Mental Health A number of individuals wished to not be identified.

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References Bruner, C.. A Framework for State Leadership and Action in Building the Components of an Early Childhood

System

Project LAUNCH webinar featuring Kay Johnson of Johnson Group Consulting. This is in reference to Medicaid funds: https://edc.adobeconnect.com/_a1002235226/p4gz3zrx3w4/?launcher=false&fcsContent=true&pbMode=normal

Early Childhood Systems Working Group, National Governors Association, State Early Childhood Development System, (Washington, D.C.: National Governors Association, Early Childhood Systems Working Group, 2006), at: http://www.nga.org/Files/pdf/07EARLYCHILDFRAMEWORK.PDF

Smarter Checklist by the National Center for Children in Poverty http://www.nccp.org/publications/pdf/download_136.pdf

Opportunities in Public Policy to Support Infant and Early Childhood Mental Health: The Role of Psychologists and Policy Makers; Nelson, Florence: Zero to Three; Mann,Tammy:Frederick D. Patterson Research Institute; American Psychologist; February-March 2011, pages 129-137

Abelman, D.; Antal, P.; Oldham, E.; Printz, M.; Brallier, S.; Nelson, D.; Schreiber, E.; Brandt, K. Mental Health Services for New Hampshire’s Young Children and Their Families: Planning to Improve Access and Outcomes. Endowmentforhealth.com. 2009. Web. Feb. 2013. Retrieved from:  http://www.endowmentforhealth.org/resource-center/resource-center-detail.aspx?id=76 Graph of Insurance Status; NH State Health Facts.org

New Hampshire Association for Infant Mental Health. (2009). From Peek-a-Boo to Parenthood: A Look at Early Childhood Mental Health in New Hampshire.

Spark NH website

Center on The Developing Child (2012). 5 Numbers to Remember About Early Childhood Development. Harvard University. Retrieved from http://developingchild.harvard.edu/resources/multimedia/interactive_features/five-numbers/ 

Hart, B., & Risley, T. (1995). Meaningful differences in the everyday experiences of young American children. Baltimore, MD: Brookes.

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