Utilizing Bright Futures in Practice: The Mental Health Practice Guide and Tool Kit

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Utilizing Bright Futures in PracticeThe Mental
Health Practice Guide andTool Kit

• Paula Duncan, MD, FAAP
• Co-chair, AAP Bright Futures PIP-PAC
• Burlington, Vermont paula.duncan_at_uvm.edu
• Joseph F. Hagan, Jr., MD, FAAP
• Co-Chair, AAP Bright Futures Steering Committee
• Burlington, Vermont jhagan_at_aap.org

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Real Vermonters
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The Bright Futures Vision

• To promote the mental and emotional health and
  wellbeing of all children and adolescents
• A critical element of health
• Mental health-- the ability to
• Experience a range of emotions
• Possess positive self esteem
• Respect others
• Harbor a sense of security and trust in self and
  the world

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Bright Futuresunder construction

• is a set of principles, strategies and tools that
  are theory - based, evidence - driven, and
  systems - oriented, that can be used to improve
  the health and well-being of all children through
  culturally appropriate interventions that address
  the current and emerging health promotion needs
  at the policy, community, health systems and
  family levels.

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AAP Mental Health Consensus Statement

• Mental health needs of children and adolescents
  are increasing while access to behavioral health,
  mental health and substance abuse service is
  decreasing.
• AAP, 2000

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PROS Data

• 20 of primary care office visits identify a
  psychosocial problem
• Increased from 7 20 years ago
• Kelleher, 1997.

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PROS Data

• Increased identification unrelated to advanced
  training
• Increase in the number of families in poverty
• Increase in single parent families
• Kelleher and McInerney, 2000.

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Access to Mental Health Services

• Increased s of providers
• Decreased access
• Not all see children and adolescents
• Third party payor issues

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The AAPs Committment

• The New MorbiditiesHaggerty
• The New Morbidity Revisited A Renewed Commitment
  to the Psychosocial Aspects of Pediatric Care
• Family Pediatrics The Report of the Task Force
  on the Family
• AAP, 2001, 2003

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Are primary care Pediatricians able to provide
MH services?

• Training
• Consultations
• Referral sources
• Reimbursement

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Training in Pediatrics

• A science of human growth and development
• RRC of ACGME

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Training in Pediatrics

• Continuity primary care practice experience
• Training in normal and abnormal behavior
• Training in normal and abnormal child development
• ACGME, 2002

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Grandmothers and Grandfathers

• Pre-RRC practitioners
• Continuing Medical Education
• AAP Section of Developmental and Behavioral
  Pediatrics
• Board status for Developmental and Behavioral
  Pediatricians

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Are primary care Pediatricians able?

• Training
• Consultations
• Referral sources
• Reimbursement

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Consultations

• Who to call?
• When to call?

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Are primary care Pediatricians able?

• Training
• Consultations
• Referral sources
• Reimbursement

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Referral Sources

• Available?
• 6300 of 30,000 needed child psychiatrists
• Local?
• Affordable?
• Other Mental Health Professionals?

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Are primary care Pediatricians able?

• Training
• Consultations
• Referral sources
• Reimbursement

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Are primary care Pediatricians able?

• Reimbursement
• More later

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Bright Futures in Practice Mental Health

• Michael Jellinek, MD
• Bina Patel, MD
• Mary Froehle, PhD, eds.

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Bright Futures in Practice Mental Health

• Mental health promotion
• In a developmental context
• Mental health problems
• Specific issues
• Specific diagnoses

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Bright Futures in Practice Mental Health

• Three parts
• Developmental Chapters
• Infancy, early childhood, middle childhood,
  adolescence
• Mirrors Bright Futures Guidelines
• Bridge Topics
• Common mental health problems in childhood and
  adolescence
• Mental Health Tool Kit

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Screening or Surveillance?

• Most providers of primary pediatric care rely on
  surveillance
• Long term relationship
• Knowledge of child development
• Observation over time
• Does it work?
• NOPE!

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Surveillance?

• Ready.
• Fire!
• Aim.

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Screening

• Uses tools!
• Tools are tested
• Tools are validated
• Sensitivity and specificity

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Developmental Screening

• What tools do pediatricians use?
• Denver
• Low sensitivity and specificity
• Sort of the Denver
• No sensitivity and specificity
• Other screens
• PEDS
• Brighance
• Others all are proprietary

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Mental Health Screening
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Mental Health Screening the Essential
library

• Bright Futures in Mental Health
• BF in MH Toolkit
• DSM-PC
• CPT 2004

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Mental Health Screening

• What tools do pediatricians use?
• Any?
• None
• What were we trained to use?
• Probably none

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Mental Health Screening

• AAP ADHD Guidelines
• Diagnosis
• Treatment
• Diagnostic Guidelines
• DSM-IV criteria
• More than one environment
• Confers disability

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Mental Health Screening

• Vanderbilt ADHD Diagnostic Rating Scales
• Wolraich ML, Feurer ID, Hannah JN

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Mental Health Screening

• Pediatric Symptoms Checklist
• PSC
• Jellinek MS, Murphy JM, Little M, etal

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Mental Health Screening

• Center for Epidemiological Studies
  Depression Scale for Children
• CES-DC
• Faulstich ME, Carey MP, Ruggerio L

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Mental Health ScreeningAdditional Topics

• Edinburgh Postnatal Depression
• Included in BF-MH
• (2 question screen alternative)
• Anxiety Disorders
• Bipolar Disorder

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The argument for payment

• Psychosocial issues important in primary care
  settings
• A system is needed to help PCPs describe Mental
  Health in Primary Care settings
• Preventive activities need to be justified and
  reimbursed in primary care settings

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Reimbursement in primary care

• Well child care
• Physical surveillance and screening
• Behavioral health surveillance and screening
• Social surveillance

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Reimbursement in primary care

• Acute care
• Pyschosocial factors complicating illness
• Pyschosocial factors presenting as illness
• Pyschosocial factors as presenting problem

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Reimbursement in primary care

• Diagnosis codes
• ICD-9
• DSM-IV
• DSM-PC
• Procedure codes
• CPT 2004

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DSM-PC

• The Classification of Child and Adolescent Mental
  Health Diagnoses in Primary Care Diagnostic and
  Statistical Manual for Primary Care
• Wolraich, Felice, Drotar, eds,
• AAP, 1996

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DSM-PC

• Mental health diagnostic criteria
• Normal variant
• Problem behavior
• Diagnostic
• Situational criteria
• Environmental factors
• Severity factors

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DSM-PC

• Demonstrates the breadth of problems cared for
• Documents time spent
• Justifies services claimed
• Allows assessments of outcome
• Counters the claim Pediatricians
  dont do that!
• Appendix, letter

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DSM-PC

• If you bill it

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DSM-PC

• If you bill it
• they will pay!

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DSM-PC

• V codes
• Very unlikely to be reimbursed
• ICD-9 a problem is present which influences a
  persons health

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Third Party Reimbursement

• Fee for service
• Capitation
• Mental health carve outs
• Special contracts

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Partnerships

• Collaborations in communities
• Community mental health
• Social services
• Schools
• Hospitals
• Churches
• Hagans hot picks

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Partnerships

• Collaborative practice models
• Case management services
• EPSDT services
• NC AAP Referral Model
• Creative uses of SCHIP

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Reading List

• DSM-PC
• Bright Futures
• Bright Futures in Mental Health
• Family Focused Behavioral Pediatrics

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Implementation
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Implementation

• Have the materials
• Use the materials
• Toolkit for Implementation
• Strategies for Implementation
• CME, Online, academic detailing
• Measurement based parent driven health care
• NICHQ learning collaboratives

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Implementation

• Build on what clinicans already know and do
• Family centered care
• Medical home
• Community partnerships
• Operationalize concepts
• ADHD plus
• Strength based counseling
• Stretch Goals

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Next Steps with Implementation

• Prevention
• Early intervention
• Diagnosis, treatment and referral

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Diagnosis Treatment and Referral

• Mental retardation
• Pervasive Developmental delay
• Child Maltreatment
• ADHD
• Learning Disorders
• Eating Disorders

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Diagnosis Treatment and Referral

• Parental Depression
• Domestic Violence
• Substance abuse
• Mood disorders depression/suicide/bipolar
• Anxiety /obsessive compulsive
• Oppositional Defiant - conduct

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Diagnosis Treatment and Referral

• What to Do
• Common chief complaints
• Tools
• Options for referral /consultation
• Co location
• SC
• Community mental health

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Diagnosis Treatment and Referral

• Role for Public Health, Mental Health and
  Medicaid
• Funding
• Data for unmet need to support legislative
  advocacy effort
• Children and youth in Foster Care custody of
  the state

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Diagnosis Treatment and Referral

• Current Efforts
• North Carolina
• Vermont

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Early Office Intervention in Areas of Concern

• Infancy(5)
• Sleep nighttime waking
• Feeding
• Attachment
• Children with special health needs
• Lack of stimulation

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Early Office Intervention in Areas of Concern

• Early Childhood (9)
• Bedtime struggles
• Chronic biting or aggression
• Critical or detached parenting
• Difficulty forming friendships
• Parents who limit self-care

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Early Office Intervention in Areas of Concern

• Middle Early Childhood (8)
• Relationships peers, teachers
• Mastery adjustment to school, enuresis
• Health Behaviors
• Substance abuse
• Safety verbal abuse,bullying,media viol

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Early Office Intervention in Areas of Concern

• Adolescence (10)
• Relationships excessive peer influence,loner
• Mastery academic diff, truancy
• Health Behaviors
• Sex assault, STDs puberty
• Emotional wellbeing - mood

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Early Office Intervention in Areas of Concern

• Role for Public Health and Medicaid
• Support at practice settings
• Schools and Community resources -
• skill building groups
• mentoring for physical activity
• Groups and support for parents at WIC
• Youth in Foster care

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Prevention

• Role for Public Health
• Data for Focus, Accountability and Change
• Guidelines/material development and dissemination
• Social marketing media
• Support for Families of Young Children
• Work with AAP, AAFP, NAPNAP Chapters

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Prevention

• Parental and Youth concerns
• Use a framework to address protective factors and
  strengths
• Anticipatory guidance
• Longitudinal Monitoring and structured screening

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Framework Bright futures mental health

• Self
• Self control
• Self -esteem
• Family
• Friends
• Community - school

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Framework READY For Adulthood

• R - relationships
• E - energy and expertise for meaningful
  activities
• A - access to an understanding of the larger
• community and your place in it
• D - decision- maker
• Y - yes to healthy behavior choices
  nutrition, physical activity, safety, sex,
  drugs,

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Framework - Brendtro

• Mastery
• Belonging
• Independent decision -making
• Generosity

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Promoting behavior Change

• Motivational Interviewing
• Shared Decision-making
• Helping Skill

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Case StudiesInfant

• 1 week check, breast feeding every 1-2hrs
• 1 month check, maternal fatigue apparent
• ?supports
• ?spouse
• ?eating -- baby and Mom
• ?Mom sleeping
• Is this mother depressed?

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Case StudiesMiddle Childhood

• 4 yr Checkup, new daycare
• 5 yr Checkup, ?ready for Kindergarten
• 6 yr Checkup, teachers recommend repeat KG
• ?birthdate
• ?behaviors of concern
• Does this child have ADHD?