Adding Community Services to Your Pediatric Practice Gain KNOWLEDGE OF STRATEGIES FOR ADDING OR ENHANCING COMMUNITY SERVICES WITHIN YOUR

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Adding Community Services to Your Pediatric
PracticeGain KNOWLEDGE OF STRATEGIES FOR ADDING
OR ENHANCING COMMUNITY SERVICES WITHIN YOUR

• Francis E. Rushton, M.D. F.A.A.P.

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I have no relevant financial relationships with
the manufacturers(s) of any commercial
products(s) and/or provider of commercial
services discussed in this CME activity. I do
not intend to discuss an unapproved/investigative
use of a commercial product/device in my
presentation.
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What we plan to cover

• Screening for those families at risk of poor
  mental health outcomes
• Adding services within the practice
• Mental Health Professionals
• Care Coordinators
• Positive Parenting (Reach Out and Read)
• Linking to Services outside the practice
• Home Visitors
• Parenting Programs
• Developing new services collaboratively
• Well Baby Plus

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What do Parents Want Discussed?From 2000
National Survey of Early Childhood Health
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Family Experience with Primary Care Physicians
and Staff

• Families emphasized that having a primary care
  pediatrician ask about development, emotional and
  behavioral issues during well care visits was
  important and would help normalize mental health
  issues. It also helps to make families feel more
  comfortable discussing these issues. They also
  stressed the importance of having primary care
  pediatricians use mental health screening tools,
  questionnaires and checklists as part or routine
  clinical practice
• National Alliance on Mental Illness May 2011

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Home
Visitation Formal Social Capital
Programs Child care School Systems Medical
Home Parks Early Intervention Social
Service Transportation Other health
care WIC Program
Informal Social Capital Extended
family Friends Neighbors Housing Education Housing
Information needs Cultural
beliefs Language
Child development outcomes -optimal
intellectual growth -safe and healthy -motivated
for learning -capable of reciprocal
relationships -capable of emotional self
regulation -sense of conscience And
responsibility
Family characteristics 1.Family Mental
Health 2.Child characteristics 3.Socioeconomic
Status 4.Family Connectedness
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Screening is the first step

• Developmental Screening
• Maternal Depression Screening
• Socioeconomic distress
• Language issues
• Social Capital and Supports
• Social Isolation
• Domestic Violence
• Familial Substance Abuse
• Family Mental Illness
• Autism
• Child Mental Health Status
• Special Health Care Needs

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Many psychosocial screens available

• 2 Question screen
• Edinburgh Depression Screen
• Domestic Violence Screen
• Dubowitz PSC Screen
• Kemper/Kelleher protocol
• Orrs A Social Environment Inventory (SEI) and
  pre-natal form (PSEI)
• Our Beaufort screen

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Kelleher/ Kemper Protocol

• Parental depression
• Parental substance abuse
• Domestic violence
• Parental history of abuse as a child
• Housing instability
• Family Health Habits
• Inadequate social support

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Pediatric Screening Questionnaire (PSQ) (Dubowitz)

• Easy to read
• Easy to answer (yes/no)
• Brief
• Convenient, time to complete
• Voluntary
• Part of SEEK Program at Maryland

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During the past month, have you often been
bothered by feeling down, depressed or hopeless? ?
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? Yes ? No In the last year, have you
been hit, slapped, kicked, or otherwise
physically hurt by a partner (for example, a
husband, boyfriend, or other intimate partner)? ?
Yes ? No Do you think your partner has a
problem with alcohol or drugs?
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Comparing the PSQ to Standardized Measures
PSQ
Standardized Measures
Depression
Beck Depression Inventory II
Domestic Violence
Revised Conflict Tactics Scale
Substance Abuse
CIDI Drug and Alcohol Sections
Food Security
USDA Food Sec./ Hunger Core Module
Caregiver Stress
Parent Stress Index Short Form
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Prevalence Rates PSQ
Standardized Measure

• 19 depression - past month 18
• 13 abused by a partner ever 9 - 79
• 5 drug/alcohol abuse - past year 17
• 33 food insecurity - past year 31
• 30 high levels of stress 21

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Other Screens

• Child Health and Development Interactive System
  (CHADIS) Developed by Barbara Howard and Ray
  Sturner at Johns Hopkins University, Computerized
  version www.childhealthcare.org
• ASQ-SE (Ages and Stage Socio-Environmental)

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BEAUFORT PEDIATRICS, PA

• In house mental health counselor (MSW)
• Care coordinator for children with special health
  care needs
• Parent coordinator
• Strong links to local health department and PT/OT
• Joint staffings for home visitor services
• Oldest ROR program in SC

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Beaufort Stress Index

• Modified from Orrs Prenatal Social Environment
  Inventory (PSEI) Orr ST, James SA, Caspter R
  Psychosocial stressor and low birth weight
  development of a questionnaire. Journal of
  Developmental and Behavioral Pediatrics 1992 13
  (5) 343-47
• Available online in A Practical Guide for
  Improving Child Developmental Services
  http//www.cmwf.org/usr_doc/mod3_Sample_Psychosoci
  alScreen_Stresstest.pdf

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Beaufort Stress Index

• Family characteristics illness, death, personal
  health, living arrangements, financial worries,
  employment, substance abuse, school,
• Informal social supports marital arrangements,
  other family members
• Maternal mental concerns concerns about
  pregnancy, ability to be a parent, fears.
  Positive scores correlate with depression
• Child Characteristics

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Beaufort Stress Index

• is quick and easy for families to complete
• has been assessed for reliability and validity
• the individual questions on the screen identify
  specific social issues that can be addressed
• the screen is less intrusive than others

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• A Stress Index Beaufort Pediatrics Modified
  PSEI Social Inventory
• Have any of these things happened in your life in
  the last year? Yes No
• A family member died.
• You worried about the safety of your children.
• Someone close to you was in an accident.
• You were hospitalized for something besides
  having a baby.
• You worried about a health problem (such as high
  blood pressure, diabetes, etc.).
• You worried about how your neighborhood affected
  your children.
• Your husband or boyfriend lost his job.
• One of your children was in an accident.
• You were ill for longer than a week.
• You worried about your childrens emotions.
• You worried about the babys health when you were
  pregnant.
• You had to put off starting prenatal care because
  of money.
• You lost your job
• Your husband or boyfriend had a drinking problem.
• Someone close to you got in trouble with the law.
• You worried about being able to be a good parent.
• You worried about how breaking up with your
  husband or boyfriend would affect your children.

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19. You worried about spotting, bleeding or pain
when you were pregnant. 20. Your home was too
crowded or needed repair to be safe. 21. One of
your children had a serious illness. 22. You
worried that other children might be a bad
influence on your own. 23. You worried about
having enough money to pay your bills. 24. You
and your husband or boyfriend broke up. 25. You
worried because you had problems with an earlier
pregnancy. 26. Someone in your family was sick
for longer than a week. 27. A family member had
money problems. 28. A family member was using
drugs. 29. Caring for the baby or your children
all the time was a problem for you. 30. You had
problems with your mother or father. 31. A
family member had a drinking problem.
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32. You and another family member didnt get
along. 33. You worried when you were pregnant
about how your drug use would affect the
baby. 34. You were sick to your stomach a lot
with your pregnancy. 35. You wanted to go back to
school but you couldnt 36. You were unhappy in
your job. 37. You worried about labor and
childbirth. 38. Your husband or boyfriend was
without a job for more than a month. 39. You were
without a job for more than a month.
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Screening Medicaid Newborns in Beaufort, SC With
Stress Index

• 100 total patients
• Low risk 0-6 47 positive responses
• Medium risk 7-9 26 positive responses
• High risk gt 10 27 positive responses
  automatically referred

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Beaufort Pediatrics Screening Protocol
AGE nb 2 wk 2mo 4mo 6mo 9mo 1yr 15mo 18mo 2yr 3yr 4yr 5yr
CSHCN?
Stress Index
depression
Concerns
PEDS/
autism
PSC
Connected Kids A1-2 A-3 A4 B1-2 A4 A4 A2-3 B2 B1 B1-2 C1 B2 C3 A5-7 C3 A1-7 C1-3
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Community ConnectednessCo-location of services

• Mental Health services in pediatric medical homes
  more common
• Hall way consults
• Links counseling, talk therapy with drug
  management
• Less threatening environment
• Common charts
• Supports the medical home concept/ healer-patient
  relationship
• School sites

• Quick mental health services for staff
• Funding issues
• Rural health clinic status
• Patient compliance issues
• Focused on treatment, not on prevention

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Co-Location of Case Managers/ Care Coordinators
in the office

• Publicly funded? care coordinators for children
  at risk, including those who are environmentally
  at risk
• Knowledge of referral services
• Able to communicate with other early childhood
  providers.

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Joint Staffing

• Jointly staffs those families at risk to make
  sure appropriate services offered

• Meets monthly
• Beaufort Pediatrics
• School System
• First Steps Program
• Health department
• Social Services
• All home visiting programs

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Co-location Models Collaborative Partners Program Description
Commonwealth Fund/ Healthy Steps Health care provider, Developmental specialist Enhanced pediatric well child care through home supervision. Also works with Reach Out and Read to encourage educational development.
Florida/ Illinois Lactation consultant Paid lactation consultant added to pediatric medical home staff Improved Breast Feeding
Hastings Pediatric Social Worker Social worker added to traditional pediatric medical home Impact effect of social environment on childrens health status
Hawaii Healthy and Ready to Learn Nurse practitioner Early Childhood Educator Social Worker Well Child Health Supervision focused on children at risk, linked to home visitation with Hawaii Healthy Start. Includes a residency training component
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Develop better care coordination mechanisms
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Well Baby Plus Collaborative Approach to the
Parent Child Relationship

• Beaufort Pediatrics
• BJHCHS
• Beaufort Elementary
• Beaufort County School District FACES Program

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Well Baby Plus intervention

• Group well child visits staffed by a private
  pediatric practice (8 clinicians), who provided
  other medical home services at their office.
  Group visits were scheduled using the AAP
  periodicity schedule
• Utilized a school-based home visitation program
  (Parents as Teachers curriculum). Home visitors
  provided assistance with coordination,
  appointment reminders, transportation and post
  visit reinforcement. Home visitors attended the
  group well visits.
• Visits were provided on a school site where other
  auxiliary services were present

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Features of Well Baby Plus Evaluation Group

• 119 Families offered WB
• 91 families enrolled
• 70 families still engaged at 15 months of age
• 51 families completed exit questionnaire
• Lived east of Battery Creek

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Comparison Group Features

• Received traditional pediatric care within the
  medical home
• Lived west of Battery Creek
• Matched retrospectively one to one with WB
  patients by maternal age, marital status and SE
  stress (Orr SES)

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Completed all Well Child Visits

• Children in the WB intervention group (65) were
  more likely than comparison group (37) children
  to attend all scheduled well-child visits
• ( p 0.006)

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Immunization UTD as recorded in Patient Chart

• 92 of WB children were fully immunized vs. 78
  of comparison children (p 0.01)

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Trend towards Lower ER Utilization

• Well Baby Plus children showed a trend towards
  lower ED usage with an average of 1.0 visit vs.
  1.45 visits in the control population (p0.18)
• Not statistically significant

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Family Spacing Well Baby Plus Mothers more
likely to be using birth control

• WB 25/41 using birth control (61)
• Comparison 17/43 using birth control (40)
• p 0.03

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When child was 15 months, parents recalled their
clinician had discussed

• WB
• P Poisoning 65 (p0.003),
• D Discip.69 (plt0.001),
• L Literacy 87 p0.16) N
  Nutrition 8(p0.17)
• T Toi-train35(p0.01)
• Control Group
• P Poisoning 41,
• D Discipline 31
• LLiteracy 75
• N Nutrition 78
• TToilet-Training 12

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Impact on Obesity? Were Well Baby Plus patients
less like to be obese at 15 months of age?

• WB
• weightsgt 90 percentile 8
• Average 50 percentile
• Control Group
• weightsgt90 percentile 24
• Average 55 percentile
• p0.03
• This difference disappeared when Weight vs.
  Height percentiles used (p.3)

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Home
Visitation Formal Social Capital
Programs Child care School Systems Medical
Home Parks Early Intervention Social
Service Transportation Other health
care WIC Program
Informal Social Capital Extended
family Friends Neighbors Housing Education Housing
Information needs Cultural
beliefs Language
Child development outcomes -optimal
intellectual growth -safe and healthy -motivated
for learning -capable of reciprocal
relationships -capable of emotional self
regulation -sense of conscience And
responsibility
Family characteristics 1.Family Mental
Health 2.Child characteristics 3.Socioeconomic
Status 4.Family Connectedness
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Conclusion Coordinating Care in the Medical Home

• Recognition of need Screening
• Developmental
• Psychological
• Social Connectedness
• Knowing community resources and linking to
  appropriate services
• Team-based approach to care Care coordinators,
  mental health, development specialists, social
  workers, lactation consultants, early childhood
  educators
• Impacts both physical and mental health outcomes