Caring for Youth: Building Partnerships with Primary Care to Improve Health and Functioning

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Caring for Youth Building Partnerships with
Primary Care to Improve Health and Functioning

• Joan R. Asarnow, Ph.D.
• Professor of Psychiatry Biobehavioral Sciences
• UCLA School of Medicine

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Presentation Goals

• Review rationale for building partnership with
  primary care
• To illustrate this approach, we present
  preliminary data from our current study aimed at
  improving care for adolescent depression through
  primary care
• Offer some conclusions and recommendations
  regarding directions for further clinical and
  research initiatives

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Why Primary Care?

• Most children and adolescents have some contact
  with a primary care provider each year
• 70 of youth, ages 10-18, visit a primary care
  provider a year, with an average of 3 visits
• Psychiatric and behavioral complaints more common
  among high utilizers of primary care
• True for children and adolescents

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Detection of Need in Primary Care

• Not currently a major source of mental health
  care
• Need identified in only a small subset of youth
• Sensitivity Low Primary care providers detect
  mental health problems in a small proportion of
  youth with need (Kramer Garralda,1998)
• Specificity high When primary care providers
  detect mental health need it is likely to be
  present (Kramer Garralda,1998)

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• Youth Partners in CareA Research Project to
  Improve Treatment of Adolescent Depression in
  Primary Care
• Joan Asarnow, Ph.D., Lisa Jaycox, Ph.D., Ken
  Wells, M.D., M.P.H., Margaret Rea Ph.D., Emily
  McGrath, Ph.D., Janeen Armm, Ph.D., Anne LaBorde,
  Ph.D., Psy.D., Martin Anderson, M.D., Pamela
  Murray, M.D., Chris Landon, M.D., James McKowen
  and colleagues
• Sponsored by the Agency for Healthcare Research
  and Quality (AHRQ)
• 5-year study to identify ways to improve
  quality of care for adolescent depression in
  primary care

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YPIC Participating Sites

• Academic Medical Centers
• UCLA Mattell Childrens Hospital Satellite
  Clinics
• University of Pittsburgh Childrens Hospital
• Managed Care Clinics
• Kaiser Permanente Los Angeles Medical Center
• Family Practice Pediatric Departments
• Sunset East LA Sites
• Public Sector Clinics
• Ventura County Medical Center-Family Practice
  Pediatrics
• Venice Family Clinic

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Study Flow Chart
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Need Rates of Depression
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NeedTrauma Exposure and PTSD Symptoms
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60
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Barriers to Detection in Primary Care

• Brief visits
• About 10 minutes with children
• About 16 minutes with adolescents
• Emphasis on physical health
• Multiple health issues need to be addressed
• Youth may not disclose difficulties

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Barriers to Detection in Primary Care

• If detected, additional time required to address
  problem
• Lack of resources for addressing mental health
  needs in primary care
• Referral to specialty care often associated with
  lack of follow-up due to barriers to initiating
  care (e.g. perceived stigma, lack of insurance,
  transportation)

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When is detection best?

• Continuity of care best predictor of whether
  provider detects need is whether provider saw
  their own patient (Kelleher et al., 1997)
• Well child vs acute care visits (Horwitz et al.,
  1992)
• Severe impairment (Kramer Iliffe, 1997)

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Models for Treating Depression Within Primary Care

• Provider training and increased management by
  primary care providers
• Little evidence of improvements in objective
  provider behavior or child outcomes
• Some data suggest brief provider training may
  lead to changes in subjective outcomes, such as
  provider confidence and knowledge

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Models for Treating Depression Within Primary Care

• Use of specialty mental health providers within
  primary care
• Absence of adequately controlled evaluations of
  this approach
• Likely that interventions that are effective in
  mental health settings will show comparable
  effects in primary care when delivered by
  comparable providers with similar patients
• Patient characteristics may differ in primary care

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Depression in Primary Care Populations
Comorbidity With Chronic Physical Health Problems
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Models for Treating Depression Within Primary Care

• Consultation liason
• Specialty mental health providers support primary
  care management
• Mimimal data
• Some data suggests reduced rate of specialty
  referrals and more appropriate referrals
• Only small percentage of providers felt knowledge
  and skills had improved

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Models for Treating Depression Within Primary Care

• Team based disease management program
• Non-physicians play a major role in patient
  assessment, education, treatment, and monitoring
• Mechanisms developed for improving partnerships
  between primary care and specialty mental health
  care
• Addresses major barriers such as inadequate
  practice resources, insufficient time in primary
  care visit, limited access to specialty services
  and evidence based treatments

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YPIC Goals

• To test an innovative model of care for
  depression among youth in primary care
• To evaluate intervention effects compared to
  care as usual on
• Quality of care
• Clinical outcomes
• Social outcomes
• Costs

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YPIC Intervention Goals

• To improve initiation of and adherence to known
  effective treatment regiments
• Psychotherapy (CBT)
• Antidepressant medication
• Taking into account patient, parent and provider
  preferences can choose any treatment or no
  treatment
• Enhancing the doctor-patient relationship and
  maintaining provider autonomy
• Real-world practice conditions

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Intervention Components

• Provider education
• Care managers to track cases and support primary
  care providers
• Patient family education
• Study trained cognitive-behavioral therapists
  within primary care
• Emphasis on patient, parent and provider choice
• Local expert teams
• Tailoring the depression management model to each
  system

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Study Flow Chart
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Figure 1. YPIC INTERVENTION FLOW CHART
Patient Identified Screener indicates high
levels of depressive symptoms
Referred to Care Manager (CM)
Patient contacted and visit with CM and Primary
Care Provider scheduled
Primary Care Provider contacted and briefed

• Initial Patient Visit with CM
• (45 min.)
• Structured Evaluation
• Basic Patient and Family Education

• Patient Visit with
• Primary Care Provider
• (15 min.)
• Develop Primary Care MD management plan
• Consider specialty mental health consultation

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• POST-VISIT
• EDUCATION WITH CM

Medication or medication plus psychotherapy is
prescribed
Psychotherapy is prescribed
Patients not started on treatment
CM refers to therapist and arranges primary care
follow-up
CM re-contacts In 4 weeks for follow-up
Follow-up visits/phone calls by CM and primary
care clinicians
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Intervention Implementation Site 1 Preliminary
Data
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Barriers to Intervention Implementation

• Care Manager unable to reach patient
• Unable to schedule was modal reason for no
  initial evaluation (75)
• Unable to schedule was modal reason for not
  following treatment plan (90)
• No perceived need for additional services, low
  motivation (Youth, Parent)
• Access problems (no time, transportation,
  conflicting demands)

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Barriers to Intervention Implementation

• Stigma associated with care (e.g. Its against
  my religion to see social workers)
• Health care organization cant implement and
  sustain treatment model (Motivation, flexibility,
  perceived value)
• Discrepancy between Care Manager role and
  traditional psychotherapist role

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Strategies for Addressing Barriers

• Telephone contacts
• Flexible hours
• Treatment provided through primary care setting

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Pathways to care for depression through primary
care
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Conclusions Access

• Need to ensure access to primary care
• Universal access not guaranteed in United States
• Some youth, particularly uninsured and/or
  disadvantaged, never reach primary care
• Outreach needed to emergency services, urgent
  care, and OB-GYN

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Conclusions Detection

• Need to develop and test strategies for improving
  detection
• Will need to be brief and require minimal time
  from primary care provider
• Use of practice assistants, nursing staff, or
  associated mental health workers
• Brief self-report instruments likely to lead to
  over-identification and will need to be
  supplemented with additional evaluation and
  triage of youth to appropriate services

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Conclusions Issues

• Detection likely to yield a somewhat different
  population than the population of youth
  identified in specialty mental health clinic and
  schools (e.g. health problems
• Need for efforts to better understand barriers to
  care within primary care settings and develop
  intervention strategies to reduce barriers and
  improve access to high quality care

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Conclusions Motivation for Treatment

• Motivation for treatment may be low, particularly
  when youth have not identified themselves as
  needing or wanting mental health care
• Adolescents tend to seek care for sensitive
  issues (e.g. pregnancy) and parents may be
  unaware of youth problems and/or visits to
  primary care
• Need for effective strategies to work with
  families and help families to mobilize and
  support treatment

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Conclusions Treatment

• Collaborative care models have shown promise for
  improving patient care and outcomes
• This approach builds on the strengths of primary
  care settings, but supports primary care
  practices with resources needed to evaluate and
  treat depression and other mental health problems
• Future research is needed to clarify the
  effectiveness, costs, and benefits of this
  approach in real-world practice settings