Trauma and Resilience Informed Integrated Healthcare for Youth and Families

Transcription

1 NCTSN Integrated Healthcare Collaborative Group presents Trauma and Resilience Informed Integrated Healthcare for Youth and Families Moira Szilagyi, MD, PhD American Academy of Pediatrics Moderated by: Mark Rains, PhD Pediatric Integrated Care Collaborative Joshua Kaufman, LCSW Los Angeles Unified School District

2 Integrating 3 Views of Child Traumatic Stress Trauma/Resilience Informed Lens Trauma prevalence, outcomes and interventions Health impact & potential to reduce chronic costs Parent-child interaction to protect/soothe stress Health-Informed Lens Relationship-Informed Lens

3 Learning Objectives Participants in this webinar series will be able to: Define trauma-informed integrated healthcare across a continuum of child and family serving settings Describe various models of trauma-informed integrated healthcare Understand the relationship between trauma, the human body and the role of trauma-informed integrated healthcare Characterize trauma-informed integrated healthcare within the child welfare system Articulate practices for identifying and responding to early childhood trauma in pediatric settings

4 Upcoming Webinars (dates and speakers to be announced) Childhood Traumatic Experiences, the Body, and the Role of Integrated Healthcare Two Models of Trauma-Informed Integrated Care: Comprehensive Care for Children and Youth in the Child Welfare System Identifying and Responding to Early Childhood Trauma in the Pediatric Setting

5 Trauma-Informed Integrated Healthcare: Models Moira Szilagyi, MD PhD Department of Pediatrics, University of Rochester American Academy of Pediatrics

6 Goals Define what trauma-informed integrated healthcare is (and what it is not) across a continuum of child and family serving settings Understand how trauma-informed integrated healthcare differs from traditional physical and behavioral healthcare Describe four different models of trauma-informed integrated healthcare Identify obstacles to integrating physical, mental health and trauma-informed practices Identify strategies for overcoming those obstacles Articulate the advantages of trauma-informed integrated healthcare

7 Integrated Care Integrated health care is the systematic coordination of physical and behavioral health care. The idea is that physical and behavioral health problems occur at the same time. Integrating services to treat both will yield the best results and be the most acceptable and effective approach for those being served. The Hogg Foundation for Mental Health (

8 Integration Across Systems of Care Primary care settings Mental health Education Early childhood services Child welfare Childcare Juvenile Justice

9 Traditional Healthcare Model Pediatrician/PCP sees patient Maybe administers a validated screening instrument that probably does not address trauma, but at least might identify symptoms of concern Scores validated instrument and shares results with family Offers limited age appropriate anticipatory guidance to family because of limited time Refers out to a MH provider who may or may not have the skills and training to provide TI-care Maybe speaks with education system or childcare provider

10 Traditional Model: Either/Or Lens MEDICAL MENTAL HEALTH

11 Integrated Care: Holistic Lens Protective Factors/Innate Resilience Medical Illness Symptoms MH Condition Stressors

12 System Characteristics of Integrated Care: 3 C s Collaboration Communication Coordination

13 Goals of Integration To improve the 3 C s: communication, collaboration and coordination across systems and with families To emphasize a care team approach to: address and improve mental and physical health Improve family and patient assets and resiliency strengthen families

14 How do we get there from here?

15 Integration: Step-wise Process No single right way to go about this Models out there to learn from Implementation Service delivery Range from distributing information to families about mental health To co-locating mental health care in primary care and educational settings To fully integrated collaborative care

16 Advantages of Integration with Pediatric Medical Home Longitudinal, trusting relationship with family Periodicity: regular contact intervals Intervene early: prenatally on Opportunities for prevention Screen for psychosocial problems Less stigmatizing Improved communication and care coordination

17 PRIMARY CARE AND MENTAL HEALTH 4 MODELS OF CARE

18 MODEL 1 REFERRAL WITH COLLABORATION

19 Referral with Collaboration Looks a lot like traditional model But requires some cross-systems work (3 C s) Screening/assessment in primary care setting Identified network of MH providers skilled in TI-care Referral summarizes patient & family needs & strengths Accessible services (right services, skilled, timely) Feedback loop -Periodicity

20 Advantages & Challenges ADVANTAGES Improved 3 C s: communication and collaboration improves care, Improved education and hopefully patient outcomes CHALLENGES Requires pediatric and MH providers to work together across systems to develop all the necessary pieces Additional time for above not reimbursed

21 MODEL 2 CO-LOCATION OF MH CARE COORDINATION

22 Co-Location: MH Care Coordination Usually an MSW, but could be a another MH professional Coordinates for the primary care office: MH referrals Referrals to community based services Communication with educational system

23 Co-Location: MH Care Coordination PCP makes in-house referral to MSW re patient/family needs MSW does brief interview with family to assess needs MSW, PCP and family arrive at a plan MSW makes the referral to appropriate entity MSW follows-up to ensure services obtained

24 Advantages & Challenges ADVANTAGES Improved communication and collaboration improves care, education and hopefully patient outcomes Designated qualified person to ensure happens CHALLENGES Cost of care coordination professional not reimbursed Communication often ends once the referral to MH made No direct services at primary care site

25 MODEL 3 CO-LOCATION OF MH SERVICES

26 Co-Location Mental health provider is physically co-located at least part of the time in the pediatric medical home Licensed MH Professional Full-time or Part-time Employee/consultant/grant-funded Evaluation and some services on-site; some services may be off-site

27 ADVANTAGES Advantages Improved communication and collaboration improves care, education and hopefully patient outcomes Designated qualified MH person providing services on-site MH person can bill for services Opportunity for cross-fertilization among professionals Enables MH provider to draw patients from multiple practices if retain own office space

28 Challenges Co-location does not guarantee improved collaboration, communication or care coordination: parallel play Productivity of MH provider may not fully support their time: no shows Payment models: contract, employment, grantsupported

29 MODEL 4 CO-LOCATION: FULLY INTEGRATED

30 Full Integration MH professional engages in the daily huddle Internal referral process still has to exist (verbal/paper/emr) Periodic updates (paper/emr plus verbal) exist MH professional engaged in educating staff Curbside consultation occurs and is documented

31 Advantages Convenient for families Reduced stigma especially for teens Accessible more timely referrals Care is coordinated across systems Improved education of pediatric staff Improved outcomes?

32 Reality Check Even when integrate MH providers with Pediatrics Will see the spectrum of preceding approaches In-house MH assessment and treatment Referrals to outside MH Referrals to community services Some care provided by pediatricians, nursing Education/counseling/brochures/hand-outs

33 BARRIERS AND CHALLENGES

34 Barriers FUNDING: implementation & ongoing Information flow Siloes (different languages and cultures) Scheduling- might need 2 systems MH and pediatrics EMR access-license cost, training

35 Challenges Space or lack of it Picking a model Implementation Workforce issues Where is MH information recorded (in chart ideally) Sustainability: funding, staffing, training

36 Challenges Overcoming parallel play Communication making it effective Confidentiality-what information is shared, with whom Care coordination of all health needs Pediatric office staff responsibility Founded in good communication among Pediatrics and MH

37 FACILITATORS AND BENEFITS

38 Facilitators: Implementation Put a leadership team together MH, pediatrics, peds administration, IT, nursing Common Vision and Mission Shared goals Some expertise in Quality Improvement methods

39 Facilitators Quality improvement approach to introduce changes in office Do small PDSA cycles (plan-do-study-act) Work kinks out before spreading to whole system American Academy of Pediatrics EQUIPP QI system Can adapt to new projects

40 Facilitators: Ongoing Huddles Team meetings Systems issues Case-based Cross-training/education Shared information system But entering info into pediatric EMR in other ways works: fax/ /scan Key for pediatrics is putting diagnostic information and medication updates into problem list etc.

41 Consumer Feedback Engaging consumers Include consumers in (some) systems meetings Periodic Surveys Just Ask

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43 Sustainability Champions: MH and Pediatrics Team meetings QI process Pay for MH services Missed appointments with MH Administrative costs: scheduling, billing Adding providers to EMR Meeting time

44 Benefits of Integrated Care Increases access to & convenience of MH services Less stigmatizing Earlier identification, prevention and treatment Curbside consultation and formal education among staff increases knowledge and efficiencies Reduces use of &errors in psychotropic medications? Reduces ED use for MH issues? Improves outcomes?

45 School-Based Trauma-Informed Integrated Care Joshua Kaufman, LCSW School Mental Health Specialist Los Angeles Unified School District

46 Why school-based, trauma-informed integrated care? Youth are experiencing traumatic events at greater numbers Most youth with mental health needs do not seek treatment Many internalizing disorders in children go undetected Children and adolescents need high quality, accessible, culturally competent, comprehensive health care The school setting is a sensible and appropriate place to deliver health care because that is where the students are

47 High rates of trauma exposure among youth nationally 61% of U.S. youth experienced 1+ direct or witnessed event in the past year 46% physical assault 6% sexual victimization 25% property offense 25% witnessed violence 10% maltreatment 10% injured 39% experienced 2+ events in past year 10% experienced 5+ events in past year 2% experienced 10+ events in past year (Finkelhor, Turner, Ormrod & Hamby, 2009)

48 Adverse Childhood Experience Findings ( ACE Score 0 36% 1 26% 2 16% 3 9.5% Prevalence 4 or more 12.4% 64% had at least 1 ACE ACEs determine the likelihood of the 10 leading causes of death in the US With an ACE of 4 or more, the majority of adults have multiple risk factors for these diseases OR the diseases themselves

49 Health Risks Associated With ACEs Autoimmune Disorders Obesity & Eating Disorders Substance use disorders Chronic Obstructive Pulmonary Disease (COPD) Depression Fetal Death Health-Related Quality of Life Difficulties Heart disease (IHD) Liver disease Risk for intimate partner violence Sexually transmitted infections (STIs) Unintended pregnancies

50 Impact of Trauma on Learning Decreased IQ and reading ability (Delaney-Black et al., 2003) Lower grade-point average (Hurt et al., 2001) More days of school absence (Hurt et al., 2001) Decreased rates of high school graduation (Grogger, 1997) Increased expulsions and suspensions (LAUSD Survey)

51 Integrated Care: Looking Through a Trauma Lens Understanding that behavior and health status is a developmental response to past experience. Shifting from What s wrong with him/her? To What might have happened that might explain her/his behavior or health status?

52 ACEs, Integrated Care and Prevention/Early Intervention (PEI) Integrated Care can play an important role in addressing neurological, biological, psychological & social effects of adverse childhood experiences

53 Resilience: Risk factors do not always equal predictive factors External Factors Caring and supportive relationships High expectations for success Opportunities for meaningful participation Internal factors Social Competence Problem-Solving Skills Autonomy Sense of purpose and future 53

54 LAUSD Wellness Centers Offer full service care (including physical, mental and oral health care services) by joining forces with community clinic providers with a strong emphasis on prevention and early intervention. Based around family, school and community engagement in order to build healthier neighborhoods, school by school.

55 Health Hotspots Mapping

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58 Best Practices for Integrated Behavioral Health Care Standardized, comprehensive health risk assessment Formal collaboration for high risk cases Warm Hand Off Single, integrated treatment planning and a combined chart Formal team conference to review student (patient) progress, particularly for those in crisis and those seen by multiple providers mechanism for communicating significant updates Informal consultation between health and behavioral health provider in which to coordinate and communicate regarding student care Best Practice Protocols for Delivering Behavioral Health Services in a School-Based Health Center, School Based-Health Alliance, 2014

59 Multiple Levels of Integration Health/Mental Health Supporting the School community Community Support & Wellness Network

60 Fully Integrating Mental Health Services into the School Community UNIVERSAL Practices that promote Safe and Healthy Schools (Trauma-Informed Schools) TARGETED Interventions that address risk factors and foster protective factors for students at-risk INTENSIVE Coordinated, comprehensive, and culturally relevant interventions delivered at the Wellness Center

61 Universal/Preventive Prescriptions for Wellness (e.g. Nutrition, Mindfulness, Yoga/Zumba, etc) MH Awareness (e.g. Outreach (Bullying Prevention month in Oct; MH Awareness Day in May), Health fairs, Drop in times & lunch clubs) Classroom-based learning, connecting MH topics to Common Core Health Curriculum Teacher/School-based MH Consultation Staff, Parent & Community Trainings/Presentations (e.g. Trauma Awareness/Psychological First Aid; Promoting Staff & Student Resiliency; Suicide Prevention; Inhalant Abuse Prevention)

62 Targeted Services School-Based Evidence-Based Group Interventions (e.g., CBITS, Triple P) Screening Monitoring Community Referral Classroom Support Risk Assessment and Management

63 Intensive Services-Wellness Center Evidence based mental health services Psychiatric consultation & Medication support Psychiatric Hospitalization school re-entry planning Intensive Case Management Crisis Intervention

64 Health/Mental Health Integration Challenges Confidentiality/sharing of information- HIPPA/FERPA Cross-screening Identifying shared instruments Formal collaboration beyond a hand-off

65 School Integration Challenges Supplantantation of services (e.g. school nurses, school social workers, etc.) Role confusion school staff vs Wellness Center staff (School Nurse or Wellness medical provider; School Counselor/SSW or Wellness MH provider?) Student access to confidential services vs. district attendance policies Automated attendance letters and phone calls Student access to Wellness Center services during a school day

66 Thank you for your attention! Moira Szilagyi, MD, PhD American Academy of Pediatrics Joshua Kaufman, LCSW Los Angeles Unified School District Moderated by: Mark Rains, PhD Pediatric Integrated Care Collaborative