Mental Health Screening as part of the CentraCare Integrated Behavioral Health Initiative

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Mental Health Screening as part of the
CentraCare Integrated Behavioral Health
Initiative

• L. Read Sulik, MD, FAAP
• Medical Director
• Child and Adolescent Psychiatry
• St. Cloud Hospital / CentraCare Health System
• sulikr_at_centracare.com

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The St. Cloud Model

• Co-location and Consultation
• Education on Childrens Mental Health
• School Professionals
• Social Service Professionals
• Parents / Community
• Health Care Professionals
• School-based Integrated Care Model
• Primary Care-based Integrated Care Model
• The CentraCare Integrated Behavioral Healthcare
  Initiative

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The St. Cloud Model

• An informal model of co-location and primary care
  access to child psychiatry for consultation and
  education . . .
• Access to ongoing consultation between
  pediatricians and child psychiatry (curbside,
  email and phone consult)
• Build Relationship, Establish mentoring/consultati
  ve role
• Access for community pediatricians to child
  psychiatry as well (phone consult)
• Access to family practice physicians throughout
  community (phone consult)
• Co-located child and adolescent psychiatry and
  psychology with large pediatric specialty center

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The St. Cloud Model

• Education of primary care providers on childrens
  mental health
• Pediatrics and Family Practice CME Conferences
• Child and Adolescent Psychiatry Practical Review
• An Annual 4 day conference for primary care and
  mental health providers
• Depression Management and FDA Black Box warning
  discussion meetings
• Development of Integrated Behavioral Healthcare
  Model

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St. Cloud Hospital Behavioral Health Services

• St. Cloud Hospital is only hospital / emergency
  room in St. Cloud and surrounding areas
• Only emergency room in Central Minnesota with
  full time behavioral access nurse coverage for ER
  triage assessments
• Only in patient adolescent psychiatric unit in
  Central Minnesota

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St. Cloud HospitalTotal Mental Health Cost(not
outpatient counseling center)
There is a significant reduction in utilization
of ER, PHP, Inpatient for St. Cloud children and
adolescents
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The St. Cloud Model

• CentraCare Health System Integrated Behavioral
  Healthcare Initiative
• Mental Health Care provided in Primary Care
  Clinic through
• Mental Health Screening at well visits
• Consultation with and Referral to Clinic-based
  Crisis Intervention Triage Therapist
• Clinic-based Crisis Mental Health Assessment
• Referral, disposition planning and initial case
  management
• Primary Care Mental Health Treatment Protocols
• Psychiatrist to Primary Care Consultation
• Emergency Psychiatric Evaluations

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The St. Cloud ModelCentraCare Integrated
Behavioral Healthcare Program
Screening Identified
Provider Identified
Triage Assessment
Psychiatrist Consultation
Primary Care Provider Managed Treatment Protocol
Emergency Psychiatric Evaluation
Community Therapist
Depression Management Protocol
Anxiety Management Protocol
ADHD Management Protocol
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Screening

• 0 to 4 age
• Ages and Stages Questionnaire (ASQ)
• Ages and Stages Questionnaire Social / Emotional
  (ASQ-SE)
• CHADIS Zero To Three
• 5 to 12
• Pediatric Symptom Checklist
• Pediatric Quality of Life Questionnaire
• 13 to 18
• Pediatric Symptom Checklist
• Patient Health Quesitonnaire Adolescent (PHQ-A)
• Pediatric Quality of Life Questionnaire

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Consultation

• Physician-to-physician consultation payment
  passed the Minnesota Legislature and will go into
  effect on January 1, 2006
• Current proposal is to submit CPT code 99371 or
  99372 for consultation
• Requires primary care provider to document
  purpose of consult and results of consult in the
  patients medical record
• Most likely scenario will be that the Primary
  Care Clinic submits the code and receives the
  reimbursement and contacts with a psychiatrist
  for the service.

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Clinic Assessment and Triage

• Masters Level Social Worker or Psychologist
• CentraCare proforma identified that each triage
  therapist must see two new assessments per day to
  cover ALL direct costs (salary, benefits,
  expenses)
• Therefore, available for consultation, patient
  education and case management / care coordination

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Spectrum of Collaborative Care
Primary Care with Consultation
Shared Care and Higher Levels of Care
Primarily Mental Health Care
Primarily Primary Care
Shared Care
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Pediatric Triage ReferralsJune 2006 to May 2007

• Number Patients Referred
• June  06 9
• July  06 11
• Aug. 06 23
• Sept. 06 35
• Oct.  06 32
• Nov. 06 33
• Dec. 06 29
• Jan.  07 27
• Feb. 07 33
• Mar. 07 27
• Apr.  07 23
• May  07 - 42
• ___________ 
• Total       324

• Age Breakdown
• 0-5   years 88     (27)
• 6-11 years 135   (42)
• 12 years 100   (31)

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Pediatric Triage ReferralsJune 2006 to May 2007

• Reason for Referral
• Anx/Dep. 93    (29)
• ADHD     78    (24)
• Behavior  68    (21)
• Other         23   (.07)
• ASQ         9     (.03)
• Other most often includes issues such as sleep,
  anger, eating, sexual identity, Tourettes
  Syndrome, Autism, and psychotic behaviors.

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Pediatric Triage ReferralsJune 2006 to May 2007

• Disposition
• Back to provider to manage medication 40  (12)
• Child Psychiatry Referral 37  (11)
• Clinic Therapist 65 (20)
• Community Therapist 52  (16)
• Inpatient 4   (.01)
• School Educational Assessment 17 (.05)
• PCP advised 17 (.05)
• Advised / Consult /not seen 16 (.05)
• Cancellations/declined/no shows 51 (16)

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Screening Pearls

• Providers do not want to get behind (at all) as a
  result of the screening
• Parents when given the choice to fill out paper
  forms or complete the electronic screen, they
  choose the electronic screen.
• Multiple children at an appointment greatly
  disturbs the process/flow (supports being able to
  do it at home)
• Data collection alone is improved with electronic
  system
• Output of screening needs to be simple!
• One place for the provider to look to see if it
  is positive or not
• This needs to be a simple alert, not pages to
  review.

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Screening Pearls

• Screening is a conversation starter
• must be followed up on by provider directly with
  the patient
• does not immediately lead to other action such as
  referral).
• If positive then hold gently
• some patients need to be followed before referral
• Some parents may not act on a referral from a
  positive screen in the very young children. 
• May need to build a case over time for the
  further assessment with some parents.
• The screen is often more effective at identifying
  the social/emotion/behavioral problems than the
  routine well visit
• yet our experience is that we are not seeing an
  over identification with the screening process
• 10 positive out of 189 ASQ-SE in June, ½ were
  referred to CAT

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Screening Pearls

• If positive, provider still uses clinical
  judgment
• requires minimal documentation if just observing,
  etc. 
• Some providers expressed concern about liability
  if they chose not to act
• providers need reminders about other screening
  practices they already do
• Physicians are afraid to open up issues without
  sufficient resources to respond
• Support system in place in the clinic to respond
• our Crisis Assessment Therapist in the clinic
• Our availability of child psychiatry consultation
  to pediatricians