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Mental Health Screening in the Medical Home: Introduction


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Title: Mental Health Screening in the Medical Home: Introduction

Mental Health Screening in the Medical Home
  • Jane Meschan Foy, MD
  • Department of Pediatrics
  • Wake Forest University School of Medicine

Prevalence of mental health problems in childhood
  • 11 of children have a MH diagnosis evidence of
    functional impairment (SED)
  • 16 of children have symptoms that do not rise to
    level of a diagnosis, but have functional
  • 9 have a diagnosis without current impairment
  • 27-36 total may have need for MH services
  • Great Smoky Mountain Study of Youth. Health
    Affairs, Fall, 1995

Risk factors for mental illness children with
serious emotional disturbance are
  • Twice as likely to be living in poverty (40 vs.
  • 40 more likely to have a parent who has been
    arrested (17 vs. 12)
  • 50 more likely to have a parent with a drug or
    alcohol problem (11 vs. 7)
  • 3 times as likely to have a mother who is
    depressed (18 vs. 6)
  • 25 more likely to have a parent who did not
    finish high school (42 vs. 32)

Risk factors for mental illness (cont.)
children with serious emotional disturbance
  • Nearly 3 times as likely to have a poor
    relationship with his/her parents (49 vs. 17)
  • Nearly 2 times as likely to have witnessed
    physical violence between parents (13 vs. 8)
  • Nearly 2 times as likely to have one or both
    parents unemployed (17 vs. 9)
  • 50 more likely to come from a family other than
    one with two biological or adoptive parents (77
    vs. 50)

Risk factors for mental illness (cont.)
  • Children with 6 or more stress factors are 40
    times more likely to have SED than children
    without stress factors.
  • Children with chronic medical illnesses are at
    higher risk for mental health disorders
    (including mild and moderate disorders).
  • Adolescents tend to have the most significant
    health problems and the lowest utilization of
    healthcare services of any age group, esp. ethnic
    minorities, and are least likely to be insured.

Consequences of mental illness
  • Children with SED are more likely to
  • be expelled from or drop out of school
  • become pregnant
  • be convicted of a crime
  • use alcohol or other illicit drugs
  • Children with mental illness are more likely to
    use medical services / emergency rooms
    (displaced utilization) their parents are also
    higher users of health services.
  • Bernal, Hidden Morbidity in Pediatric Primary
    Care, Pediatric Annals 326, June,2003.

  • 70 of children in need of MH services are
  • Surgeon Generals report

Mental illness treatment sources
  • Specialty MH system
  • Child welfare and juvenile justice system
  • Education (70 sole provider for 50)
  • Health

Barriers to treatment of mental illness in MH
specialty system
  • Stigma
  • Fragmentation / schism
  • Cost
  • Cultural biases / trust issues
  • Absence of care coordination mechanisms
  • Funding / reimbursement issues
  • Shortage of mental health professionals generally

Barriers to treatment of mental illnessin MH
specialty system (cont.)
  • MH system reform targeting of public services
    to the severely ill
  • Procedural requirements of public and private
    mental health programs
  • Poor communication with primary care
  • Non-parity of mental health benefits in insurance
  • Adolescent-specific issues denial,

Barriers to treatment of mental illness in child
welfare and juvenile justice system
  • Adversarial relationship with family
  • Under-funding
  • Family disorganization
  • Agency focus on non-MH aspects of care
  • Discontinuity in custody
  • Incomplete medical and mental health history
  • Poor communication among agency, family, and
    healthcare providers

Barriers to treatment of mental illnessin schools
  • Focus on educational mission (e.g. testing,
  • Confidentiality issues inhibiting exchange of
    information with healthcare providers
  • Inadequacy of school funding
  • Shortage of school-based mental health
    professionals and school nurses
  • Reimbursement issues for school-employed

Barriers to treating mental illness in primary
care settings
  • Comfort of primary care providers (other than
    uncomplicated ADHD /- anxiety, depression)
    deficits include
  • Diagnostic skills / familiarity with DSM
  • Giving bad news / concerns about labeling
  • Collaborative experience with MH providers
    (public and private)
  • Psychopharmacology (except ADHD)
  • Non-pharmacologic treatment methods
  • Coding and billing for MH disorders

Barriers to treating mental illness in primary
care settings (cont.)
  • Time limitations
  • Access to psychiatry consultation
  • Reimbursement issues, esp. for non-face-to-face
    elements of care
  • Managed care requirements / limits
  • Low utilization by adolescents
  • Perceptions of scope of primary care
  • By-pass through self-referral
  • Perceived and actual confidentiality barriers
    that limit sharing of information

Barriers to screening for MH problems in primary
  • Concern about handling positive screens
    (diagnostic methods, referral sources, bad news,
    etc. see previous slides)
  • Lack of familiarity with screening instruments
  • Cost of instruments
  • Variation in cultural norms of screening tools
  • Time requirement
  • Patient flow concerns

Advantages of medical home for identifying and
serving children with MH problems
  • Opportunity for prevention and early
  • Relative absence of stigma
  • Relationship with provider / trust
  • Convenience, comfort, familiarity
  • Coordination with medical services
  • Cost efficiency

Overcoming barriers in primary care delivery of
MH services
  • Training / education (appropriate to stage of
    behavior change!)
  • Advocacy with public and private insurers
  • Local/regional resource directory
  • Mixers, collaborative office rounds
  • Access to psychiatry consultation, esp.
  • Referral brochure (AAP)
  • Co-location model
  • Introduction of screening instruments / coaching
    in use and interpretation

Barriers to Mental Health Services for Children
  • The Clinical Physicians
  • Point of View

The Barriers We See
  • Lack of mental health personnel
  • Lack of training
  • Lack of time
  • Lack of screening tools
  • Services not available
  • Inefficient processes
  • Lack of communication
  • Liability
  • Costs exceed break-even

Insufficient number of mental health personnel
  • Not enough psychologists for the demand
  • Not enough psychiatrists for the demand
  • Not enough counselors for the demand

Lack of Training
  • Most primary care physicians do not see
    themselves as providers of mental health
    services, though that may have to change
  • Its not our job . . .
  • Most feel justified taking this position because
    they have had little training in this area of

Lack of time
  • To do an adequate job for a child requires a
    large investment in time
  • Even when the willingness is there, the time may
    not be
  • Production quotas are a reality in many
    employment contracts

Lack of screening tools
  • Other than ADHD tools, good screening tools are
    difficult to procure
  • Costs can be prohibitive
  • Primary care physician often knows child the best
    and would be in best position to helpbut may not
    recognize certain types of problems

Services not available
  • Child often requires services not available in
    the community
  • Waiting time can be very long
  • Gate keeping mechanisms delay entry into programs
  • Professionals in the community may not deal with
    particular types of problems

Inefficient processes
  • Mental health providers and organizations do not
    communicate with each other (huge problem)
  • There is no bonafide case management process in
  • Mental health records are judiciously guarded

More Inefficiencies
  • Primary care physicians are often asked to assume
    prescribing responsibility
  • Children are returned to parents, and parents
    dont know the diagnosis
  • PCP may not be familiar with the medication and
    its uses.

Lack of Communication
  • Physicians often expected to assume management of
    case with NO information
  • Not inadequate information
  • NO information
  • No Master Plan developed
  • Unmanageable plan

More Lack
  • Because communication among involved parties is
  • Some services are needlessly duplicated.
  • Some services never happen
  • Some services arent needed, but they are done
    because they are covered.

What are you looking for?
My keys.
Where did you lose them?
In the parking lot.
So why are you looking here?
  • Willingness to help may be there, but insurance
    carriers discourage involvement.
  • Were you trained to do this?
  • Are you certified to do this?
  • Why are you doing this?

Costs exceed break-even
  • Doing a good job takes time
  • Doing a good job takes personnel
  • Physician may even be willing to pro-bono his
    fees, but staff fees still must be met
  • One 99215 does not equal four 99213s

We want to help, but what can we do?
Our tentative plan
  • Add counselor in office
  • Add case manager in office
  • Why we think the case manager
  • in office idea is workable
  • Case manager more important
  • initially but cost is an issue

Barriers we have encountered
  • Feasibility study
  • Doesnt pay for itself
  • Might pay for counselor alone
  • Counselor alone will not get kids the help they
    really need.

Circle of HOPE
  • Circle of Hope
  • 21.6 of kids could benefit
  • 2.8 receiving help for SED
  • Prefer help from pediatrician rather than MHP

Mental Health, Behavioral Integrated Services
Pediatric offices are increasingly becoming a
place where children and families access
psychological services because surroundings are
familiar and there is no stigma associated with
visiting the pediatrician. The Youth Mental
Health Committee commissioned a feasibility study
to determine the implications of integrating
behavioral health services into Lakeside
Pediatrics. the study identified a need, however
funding to develop an implementation plan is
lacking. This proposal provides funding to the
committee for development of strategies to
integrate behavioral health services into the
pediatric practice, including mapping of local
resources, determining long-range
outcomes, identifying external funding
opportunities, and preparing grant applications.
A Late Break through . . .
  • Family Guidance collaboration
  • In office case manager
  • Procure services
  • Coordinate services
  • Prevent duplication
  • Keeps all parties communicating
  • In office counselor
  • We provide space
  • They provide personnel

Mental health Screening and the Medical
HomeThe Bright Futures Model
  • Joseph F. Hagan, Jr., MD, FAAP
  • Co-Chair, AAP Bright Futures Steering Committee
    and PAC
  • Primary Care Pediatrics
  • Burlington, Vermont

Bright Futures Vision
  • To promote the mental and emotional health and
    wellbeing of all children and adolescents
  • A critical element and 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

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.

Bright Futures in Practice Mental Health
  • Michael Jellinek, MD
  • Bina Patel, MD
  • Mary Froehle, PhD, eds.

Bright Futures in Practice Mental Health
  • Mental health promotion
  • In a developmental context
  • Mental health problems
  • Specific issues
  • Specific diagnoses

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

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

  • Ready.
  • Fire!
  • Aim.

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

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

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

Mental Health Screening
  • AAP ADHD Guidelines
  • Diagnosis, 2001
  • Treatment, 2003
  • Diagnostic Guidelines
  • DSM-IV criteria
  • More than one environment
  • Confers disability

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


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

Essential library
  • DSM-PC
  • Bright Futures in Mental Health
  • BF in MF Toolkit
  • CPT 2004

The argument for payment
  • Psychosocial issues important in primary care
  • 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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Pediatrics Collaborative Care Program
  • Anjie Emanuel, MPH

Pediatric Collaborative Care Program (PedsCare)
  • 4 Year Cooperative Agreement with the AAP and
  • Components of the grant mental health, oral
    health, child care and international activities

PedsCare Mental Health Activities
  • Publish Taskforce on the Family Report
  • Develop a compendium of community based
    collaborative care and referral models
  • Develop a training for pediatricians to improve
    mental health services for children and families
  • Establish the pediatricians role in improving
    mental health services

Next Steps
  • Cross Functional Mental Health Work Group
  • Mental Health Tool Kit
  • Mental Health Training for Pediatricians

AAPs Position
  • January 2004 Board of Directors Meeting
  • 04-05 Strategic Plan

National Center for Medical Home Initiatives
Putting the Pieces Together
  • Amy Brin, MA
  • Manager, Training Initiatives

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How can the National Center help?
  • Technical assistance
  • Interdisciplinary training initiatives
  • Screening initiatives
  • Web site link to mentors

Training Curriculum Accomplishments
  • Developed national curriculum that is endorsed
    by MCHB, AAP, FV, and NACHRI
  • Since 1999, trained 4,500 pediatricians, allied
    health care professionals, and family members
  • Utilized in all 50 states Puerto Rico Guam
  • Consists of 7 components in facilitator and
    participant versions
  • Translated curriculum into Spanish

Surveillance and Screening Curriculum What to
  • Outlines continuous surveillance proper
    screening techniques and their roles in medical
  • Highlights recommended tools and resources to
    assist in integrating screening into practice
  • Identifies proper follow-up strategies after
    screening tests are performed
  • Offers difference screening tracks
    developmental hearing vision oral and mental

Surveillance and Screening Curriculum Mental
Health Track
  • Mental health screening track provides practical
    framework for implementation
  • Includes
  • AAP recommendations
  • Mental health screens to use in primary care
    setting PSC CDI Pediatric Intake Form
  • Appropriate CPT codes for administering
    interpreting tests

Surveillance and Screening Curriculum Where to
Get It?
  • Contact Holly Noteboom at 800/433-9016, ext. 7081
  • Downloadable at
  • Curriculum is made available through the
    continued partnership between Shriners Hospitals
    for Children and the American Academy of

Because in the end
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