DUVAL COUNTY HEALTH DEPARTMENT Maternal

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DUVAL COUNTY HEALTH DEPARTMENT Maternal
Child Health DivisionJACKSONVILLE, FL

• Integrating Behavioral Health Into Primary Care

Donna Buchanan, MSW, LCSW Behavioral Health
Services
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Outline

• Overview of Duval County Health Department
• Community Profile
• Mental Illness in Jacksonville, FL
• Duval County Behavioral Health Services
• Holistic Approach to Care Model
• Medicaid Reform Challenges
• Study of Maternal Depression
• Future Program Plans

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Overview of Duval County Health Department

• ?DCHD mission-To lead continuous improvement in
  the health and environment of all people in
  Greater Jacksonville, Florida
• Largest public health clinical program in
  Florida. 4th largest metropolitan area in the
  state.
• ? 21 health centers and clinics, 15 community
  based sites
• Adolescent health Adult health
• Communicable Diseases Dentistry
• Immunizations Pediatrics
• Psychiatry Womens Health
• Florida state and National Healthy Start
  Initiative are funded and implemented through
  Maternal and Child Health.

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Overview of Duval County Health Department

• ?The focus is on addressing health disparities in
  communities that have higher rates of infant
  mortality, diabetes, heart disease and other
  issues.
• ?DCHD serves culturally diverse families and
  individuals of all ages.

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Overview of Duval County Health Department

• ?As of 2007, the population of the greater
  Jacksonville area is over 1.2 million.
• ?2005 Census Data
• White population 506,961
• Black population 240,117
• Hispanic population 43,604
• Asian population 28,646
• Persons of 2 or more races 12,689
• Other 19,739

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Mental Illness in Jacksonville, Florida

• ?62,000 residents with severe mental illness such
  as Schizophrenia
• ?26 of children and adolescents in Duval County
  experience the signs and symptoms of a mental
  health disorder
• ?1 in 4 adults suffer from diagnosable mental
  disorder
• ?50 of all severe cases of mental illness
  manifest by age 14 and another 25 by age 24
• ?11,000 Jacksonville adults with severe mental
  illness receive public assistance

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Mental Illness in Jacksonville, Florida

• ?Mental healthcare resources are scarce in
  Jacksonville as are providers.
• Psychiatrists, Psychologists, LCSW, LMHC,
  LMFTs
• ?The uninsured, the working uninsured and the
  poor find themselves unable to access mental
  health services because of the inability to pay.

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Holistic Approach to Care Model

• ?As a result of the shortage of providers and
  services, Duval County Health Department
  Behavioral Health Services was formed in 2004 to
  provide counseling services to Medicaid clients
  in our health delivery system. Staff is composed
  of
• An adult and child psychiatrist
• 2 LCSWs,
• 1 LMHC
• 2 MSWs.
• A licensed professional is available 24 hours a
  day, 7 days a week for emergency or urgent
  services.
• ?Prior to that time we were focused on providing
  services to Healthy Start families especially in
  the area of postpartum depression.
• ?Program goals are to empower individuals and
  families in our community to become
  self-sufficient and able to deal with difficult
  life circumstances.

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Holistic Approach to Care Model

• ?DCBHS provides services in 9 of the Health
  Departments area clinics. All are located in
  areas to serve high risk populations.
• ?Services are available to
• Children 6 years old
• Adolescents
• Adults

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Holistic Approach to Care Model

• ?Research indicates that 25 30 of clients
  that come for medical appointments have
  underlying behavioral health related disorders.

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Holistic Approach to Care Model

• ?DCHD provided medical services to 28,764
  Medicaid recipients in 2005.
• ?DCBHS provided 963 client sessions and
  generated 183,000 in revenue.
• ?Referrals generated by DCHD providers to mental
  health licensed providers and psychiatrists
• ?One stop shopping
• increases access to mental health treatment
• reduces barriers to treatment as clients are
  seen in an already familiar environment.

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Holistic Approach to Care Model

• ?DCHD provided Medicaid services in 2005 to
• 18,710 African Americans
• 3,826 Caucasian
• 2,303 identified minorities
• ?DCBHS has monthly behavioral health partners
  meetings to
• Conduct peer review
• Training
• Provide staff support
• ?The clients prognosis for recovery and
  adherence to other medical treatment is increased
  by integrating behavioral health into primary
  care with our team approach.
• ?Monthly/Quarterly audits are conducted
  internally and externally.

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Holistic Approach to Care Model

• ? Treatment Interventions
• individual, family and group
• brief solution focused
• Cognitive behavioral
• Reality/insight
• Empowering young men and families to succeed
  Child/parent rites of passage/skill group

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SPECIALTY SERVICES

• ?Foster care children at our Kids N Care program
  are seen by a Pediatric Psychiatrist, licensed
  mental health counselor and a masters level
  social worker.
• ?The goal of Kids N Care is to be the premier
  health system for children in foster care and so
  far has provided care to over 5,000 children in
  Duval County.
• ?Last year 3,937 teens were seen at The Bridge
  Adolescent Health Center for Medical and
  Behavioral Health Services.

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SPECIALTY SERVICES

• ?Last year 1,399 HIV/AIDS clients and their
  families were seen at our Boulevard Comprehensive
  Care Clinic (BCCC) for Medical and Behavioral
  Health services.
• DCBHS links to services within the community that
  support the care and treatment of mentally ill
  people.

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SPECIALTY SERVICES

• ?Behavioral Health staff are involved with the
  local child and adult mental health task force of
  N.E. Florida.
• Assess community mental health needs
• Make recommendations
• Bring together stakeholders
• ?Community relations are also fostered with a
  local historical black college in a predominantly
  African American community.
• Health fairs
• Mental health month
• Collaboration with student counseling center
• Attending monthly professional support groups

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BEHAVIORAL HEALTH PROGRAM OUTCOMES

• ? Mothers reunited with their children no
  longer living in violent home environments
  stabilized families.
• ? Healthy pregnancy positive development of
  early mother child relationships. Improved
  depression and postpartum depression scores
  increased self-esteem.
• ? High school diplomas, GED and employment
  obtained.
• ? Client satisfaction surveys and feedback from
  referral sources indicate that individual mental
  health has improved which indicates that the
  overall health of the community have improved.

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MEDICAID REFORM CHALLENGES

• ? Impact to clients
• Confusion
• Uncertainty
• Provider/plan unknown
• Clients frequently move to a new residence
• Often times mail is not received by the client
  because of failure to notify the
  postal service of their new address.

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MEDICAID REFORM CHALLENGES

• ? Financial Impact
• delay in reimbursement from reform health
  plans
• delay in client services due to providers needing
  notifications/authorization from managed care
  companies prior to providing services.

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MEDICAID REFORM CHALLENGES

• ? Impact to provider
• new requirements, guidelines and paperwork
• obtain notification and pre-authorization upon
  admission to program
• reauthorization after 250 units of service every
  6
• months
• quarterly audits

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Study of Maternal Depression

• ? In 2005, a candidate for Doctorate for Public
  Health in Community Health and Prevention, at
  Drexel University in Philadelphia, chose DCHD for
  her internship from the Bureau of Maternal and
  Child Health.
• ?Goals and Objectives of Internship analyze and
  evaluate depression data on 195 pregnant and
  postpartum women enrolled in the Healthy Start
  program.
• ?Screening Tools
• Are you in danger of post partum depression?
• Assess women at risk for PPD
• Identifying support system or lack of
• Stressful life events
• Lack of income
• Family History
• ?Edinburgh Postnatal Depression Scale
• 10 item questionnaire which screens women 6-8
  weeks postpartum, as to how they have felt over
  the previous 7 days.
• Range 0-30
• Score of 9-13 may indicate depression
• Score of 14 and above is indicative of depression
  and the person should be followed by a clinical
  interview

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Findings

• Race
• African American 66
• Caucasian 32
• Other (Indian and Latino) 2
• Depression
• 113 women completed the Edinburgh
• 38 of the women scored 13 or higher
• Average score was 14
• Race and Depression
• Research indicates that African American women
  are more likely to have stressors in their lives
  which leads to depression but did not indicate
  any significant findings.
• Both groups scored higher than 13 indicating that
  both groups are depressed.
• White women scored slightly higher on the
  Edinburgh.

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Findings

• Age average age was 22 (range 11-47 yrs of age)
• Education
• 45 did not graduate from high school
• 10 still in high school
• Symptom Focus
• Depression 16.8
• Sexual abuse history 16
• Domestic violence 5
• History of depression (factor in PPD) 59
• Insurance
• Medicaid 67
• HMO (job, parent or spouse) 19

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Findings

• ? Prenatal Care
• 92 received prenatal care
• 6 received late prenatal care
• 2 did not received care
• ? Birth Outcomes on 135 women
• Birth weight ranged from 1 pound to 10.10 pounds
  with average weight of 6 pounds)
• 14 premature births
• 16 had very low to low-birth weights (under 2500
  grams or 5 lb. 8 oz.)
• 8 women had twins (weight ranging from 3.12 to
  7.30 lbs.)
• 2 miscarried
• 5 infant deaths
• ? Treatment completion
• Average length of sessions 3
• Completed with symptom improvement 40
• Could not be contacted for follow up 36
• Referred for additional services 12
• Declined further services 10

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Findings

• ? Number of sessions and healthy birth outcomes.
  
• ? Advocate for more finances and staff to provide
  counseling sessions before and after delivery to
  impact high infant mortality rates.
• Women who declined services at 16.5, scored the
  highest on the Edinburgh test. Women who
  completed the sessions at 13.29, scored the
  lowest. Although this was not statistically
  significant it was concluded that those who
  declined services are more depressed.
• The majority of the women indicated that they
  cannot financially support themselves alone.

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Future Program Plans

• The program is in the process of setting up more
  program evaluation with DCHDs Health, Policy and
  Evaluation Research Department.
• DCHD recently added on the Department of
  Institutional Medicine in 2006.
• Medical and Behavioral Health Services are
  provided to inmates.
• An additional need was identified to provide
  inmates and their families counseling to assist
  with the transition of inmates back to the
  community.
• An additional licensed mental health professional
  is being hired to provide these services.