What does Texas need for Medicaid children

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What does Texas need for Medicaid children?

• Improving Medical Home
• Services in Primary Care
• November 2007

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Disclosure/ Acknowledgement

• Health eTouch is trademarked by Nationwide
  Childrens Hospital.
• Supported through grants from
• the National Institutes of
• Mental Health and Drug Abuse

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Improving Medical Home Services Goals for Today

• State of MH Services
• Central premise
• Existing solutions
• An alternative solution
• Recommendations

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State of Mental Health ServicesWhat We Know,
What We Do
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State of MH ServicesWhat We Know

• Improvements in screening techniques
• Improvements in assessment tools
• Improvements in treatment technologies

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State of MH ServicesWhat We Know

• Improvements in Screening Techniques
• Evidence for psychometrics of brief screens
• Ages and Stages/PEDS for development
• PSC/SDQ for emotion/behavior
• CRAFFT for drug use
• Routine use increases identification

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State of MH ServicesWhat We Know

• Improvements in Assessment Tools
• PHQ-A for physician administration
• Computerized DISC for parents/child
• Depression, anxiety, ADHD rating scales

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State of MH ServicesWhat We Know

• Improvements in Treatments
• http//nrepp.samhsa.gov/
• 30 meta-analyses
• 50 community effectiveness studies
• 100s of randomized trials
• 28 for antidepressant drugs alone

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State of MH ServicesWhat We Do

• In Primary Care
• Low recognition
• Under-dosing
• Low rates of followup
• Inadequate referral processes

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State of MH ServicesWhat We Do

• In Specialty Care
• Difficult access
• High rates of no-show
• Inconsistent diagnoses
• Wide variation in treatment practices

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State of MH ServicesWhat We Do

• Consequences
• Only major indicators of child health worsening
• Increased use of other medical services
• Stigma
• Highest rates of dropout

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Central Premise
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Central Premise

• We know
• How to screen
• How to evaluate and assess
• How to treat
• But we dont do these things.
• We need a delivery system that is accessible,
  equitable, reliable, effective, efficient.

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Existing Solutions
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Existing Solutions

• Primary Care Physician-focused efforts
• Specialty-focused efforts
• System-focused efforts

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Existing Solutions

• Flaws
• Patient-physician dyad model
• Physician-centric roles
• Chronic nature of conditions
• Lack of continuity across sites and time
• Segregation of MH from other conditions
• Paper based

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An Alternative Solution
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An Alternative SolutionSystem Attributes

• Patient Centered
• Equitable
• Efficient
• Effective
• Safe
• Digital

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An Alternative SolutionPopulation Health
Management

• Population Health Management
• Organized and planned approach to caring for
  group
• Anticipatory
• Not physician or single patient focus

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An Alternative SolutionComponents

• Chronic Care Model
• Patient/Family Engagement
• Motivational interviewing
• Workbook exercises
• Decision Support
• Guidelines and pathways
• Automated order sets

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An Alternative SolutionComponents

• Chronic Care Model
• Monitoring systems
• System accountability for preventive and
  treatment tracking
• Community support
• Mapping and coordination
• Integration of tools across systems
• Financing and organizational support

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An Alternative SolutionComponents

• Information integration
• Automated screening/communication tools
• Facilitated tracking/engagement
• Online/telephony support services

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Health eTouch Health Service Model
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Youths are given the tablet while in the primary
care waiting room.
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Stylus or finger used. For privacy, the system
moves to the next question as response is entered.
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The screening report and recommendations are
printed.
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The clinician can follow-up on any issues
identified in the computerized screening.
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Health eTouch Screening Results
High levels of behavioral health risk found in
nine urban primary care clinics serving a
Medicaid population.
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Results Frequency of Recommendations for
Treatment of Drug Use by PCPs
Recommended counseling, referral, medication or
other interventions. OR 2.31, p lt .001.
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User Satisfaction
Over 95 of users we satisfied or very satisfied
with their experience.
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Overall User Perceptions of Health eTouch
Users also found the system to be easy, useful,
and trustworthy.
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An Alternative SolutionMechanism

• Regionalization of services (APA, 2007)
• Characteristics of evidence based mental health
  care
• Standardized assessments
• Integrated medication and psychotherapy
• Evidence based treatments
• Titration trials and outcome monitoring
• Coordination with medical care and education

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An Alternative SolutionMechanism

• Regionalization of Services
• Models such as cystic fibrosis, transplant,
  sickle cell, genetic disorders, trauma, burn
  care, pediatric cancer
• Population health management

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Improving ServicesRecommendations

• Access
• Short Term
• Long Term

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Improving ServicesRecommendations

• Access
• North Carolina Medicaid reforms
• Tele-psychiatry and psychology reimbursement
• Private insurance reform
• Pay for performance incentives
• Screening reimbursement

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Improving ServicesRecommendations

• Short term
• Standardize screening and assessment
• Monitor/certify referral resources
• Evaluate and expand TMAPS
• Monitor psychiatric drug use
• Telephone consultation support (eg Mass)

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Improving Services Long Term

• Regional primary care support
• Telephone engagement
• Monitoring of patients on drugs
• Tracking referrals
• Mapping of referral resources

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Improving ServicesLong Term

• Regional MH specialty services
• Case coordination
• Transparency of outcomes
• Standardized assessments

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Conclusions

• Patient/PCP/specialist delivery ineffective
• Physician focused solutions inadequate
• Population model with chronic care parts holds
  hope
• Requires commitment to digital information and
  regional responsibility for low income care

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