Integrated Depression Care Management (IDCM) Approach: Primary Care and Mental Health Collaborations on the Treatment of Child/Adolescent Depression

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1 Universal and Indicated Screening Universal Screening = All children in the specified age range (ages 6-17) are screened for mental health concerns at well-child checks and for appointments where mental health is listed as a concern. We are using the Pediatric Symptom Checklist (PSC, full version, Jellinek et al) both parent and youth versions as indicated. The PSC-17 might be an option as well. Indicated Screening = Those with positive PSCs or with parent, child, or clinician concerns; somatic symptoms; or behavioral symptoms that suggest depression receive screening for depression. This project uses the Child Depression Inventory (CDI, Kovacs). Other screening tools, such as the internalizing scale of the PSC-17, might be options as well as long as the tool has been validated as a screening tool with good reliability and validity. Ideally, clinics would want to find a tool with well-validated cutoff scores. Initially, indicated screening was planned to occur at the same visit as initial screening; but, experience indicated that a follow-up visit often needed to be scheduled for the indicated screening. Tracking of Identified Cases This part of the model is essential, although difficult to implement. We have found that a care coordinator is integral to this process. Once a child/adolescent is identified as having a potential depressive disorder, they need to be tracked to assure that they receive the mental health evaluation and possible treatment needed and that their case does not fall through the cracks. Currently, there have not been great tools or systems available for this purpose. Care coordinators on this project have been working with their partners to develop good tracking systems for active cases and to monitor when to administer followup outcome measures. We hope to have the tracking systems developed by each site available for the public following the completion of the pilot. The issue of tracking has also brought up issues of informed consent for this approach. While there has not been a definitive answer on the informed consent issue, the tendency is to view tracking as the standard of care for patients treated in the clinic and therefore not needing additional informed consent outside of the forms completed by patient at the onset of care in the clinic. However, treatment consent forms should be reviewed to verify that this is the case.

2 Standardized Referral and Treatment Protocols Clinics identify a referral trigger for mental health specialist involvement based on screening (using the CDI the current referral trigger is 16 or higher, although there is the caveat that patients are also referred if there are patient, parent, or physician concerns as well). The clinics in this project have a MOU with at least one mental health agency, although referrals can go to others the physician, patient, or parents prefers as well. The treatment protocols incorporate current evidence-based knowledge and each organization applies this to their clinics and how their clinic operates. The protocol developed by the MN-KIDS Workgroup for depression management was based on national practice guidelines and research. This protocol is also available through the Children s Mental Health website as part of a psychiatric consultation project ( This protocol is still in the pilot phase so the level of adherence to the protocol varies by site and by doctor at this time. Treatment protocols also include the type of educational materials medical providers or clinics have available for parents or children/teens diagnosed with depression. Each grant location has developed educational brochures or packets. Links to possible educational information is available on the depression protocol. Treatment protocols should establish monitoring and follow-up procedures for children/adolescents prescribed depression medications by their primary care physician, among other issues. Recommendations for follow-up appointments are in the depression protocol. Bidirectional Communication and Collaboration between Primary Care and Mental Health This involves both formal and informal communication practices. Formal systems have been the most difficult to institute and vary between sites and mental health partners. One site uses a secure system along with quarterly meetings with a representative from the partner mental health agencies. The other has been working to develop a system with an identified care coordinator at their partner mental health site and use regular updates at weekly curbside consultation meetings between a psychiatrist, pediatricians, and occasionally the mental health psychotherapy providers. While there have been many successes in this area including increased referrals to mental health specialists, improved relationships between primary care and mental health specialists, and shared or exchanged training opportunities between medical and mental health clinics, there are a lot of challenges in this area as well. Primary care was not used to using ongoing release of information forms and started out very leery of this. The tendency was to want to refer and go refer to a mental health professional and not utilize any formal or informal ongoing communication strategies. This is particularly problematic if the pediatrician or family doctor is managing the depression medication and there is a mental health specialist outside the primary care organization treating the client as well. There is also the ongoing issue of communicating when there is no shared file. Both sites are looking at ways to address these issues effectively. The medical professionals have indicated that the usual practice of sharing a mental health diagnostic assessment with them is not very useful and have been working on developing forms that capture the information they do need.

3 Training in Evidence- Based Treatment Approaches for Depression (Both Primary Care and Mental Health) ALL OF THE ABOVE ACTIVITIES WERE COMPLETED WITH A FOUNDATION OF TRAINING IN EVIDENCE-BASED TREATMENT APPROACHES FOR DEPRESSION: For mental health providers, the evidence-based training was in the form of a week-long training in February 2011 followed by 7 months of consultation calls. This training was conducted by staff of PracticeWise ( and Child First at UCLA. For medical providers, we initially completed a live/itv combination training lead by board-certified child and adolescent psychiatrists in Duluth. However, we found the need to manualize a treatment approach in order to allow for broader/consistent distribution and application. Thus, the MN-KIDS Oversight committee developed a protocol based on current practice guidelines and research as well as the clinical experience of the committee members. This protocol is currently being piloted by the grant sites. The IDCM Team

4 The IDCM Team (Descriptions) Care Coordinator - The care coordinator is integral to the process of integrated depression care management. Responsibilities include spearheading and developing processes needed for screening, tracking, referring, and collaborating care on behalf of the clinic s patients; standardizing systems that adapt to the clinic s functioning; coordinating with mental health specialists to develop standardized referral and communication strategies; training staff on procedures; monitoring patient follow-up through tracking systems; monitoring compliance with management approaches; and assisting patients in negotiating medical and mental health systems. Administrative Champion - The administrative champion is essential in adapting this process to the clinic, identifying funding streams for its components, and assessing how procedures should be adapted and enforced in the clinic. Administrative support is crucial in the adoption of practice change in the clinic/organization. Physician Champion The physician champion is critical in assessing how proposed changes will affect the zeitgeist of professional practice in the clinic. The physician can translate the concepts of integrated practice into manageable steps in day-to-day practice. This physician can serve as a resource for other physicians as they try to adapt their own practice and can work with the care coordinator and administrator on training, referral, care coordination, and screening efforts. Mental Health and/or Psychiatric Consultant A consulting relationship with a mental health partner is extremely helpful in developing the referral, communication, and collaboration patterns that are necessary to effectively manage patient care. A strong relationship between medical and mental health partners was found to be central to effective coordinated care and opened the door to other opportunities such as shared training experiences, increased cross-referral, and increased informal communication patterns. Caregiver/Family Advocacy Consultants Adding the perspective of parents/patients to your team is invaluable to understanding the strengths and barriers experienced in addressing depression. Other Child Service Consultants As an integrated depression care management system develops and stabilizes, it is often helpful to consult with other child service providers who work with your patient base such as county social service representatives, schools, juvenile corrections, etc. These consultants can often aid in supporting clients in additional ways and can keep the clinic appraised of resources. Pacing of Implementation of IDCM A depression care management approach involves changing clinic practice in complicated ways and much consideration should be given to the process of phasing in this approach. Many clinics begin the progress with optimistic goals. However, if too many steps are accomplished at the same time, the system can become overwhelmed and result in losing track of identified youth or not having the resources needed to address the needs identified. A lot of groundwork is needed before screening can begin, including training and developing participant (physician/nurse practitioner) skills and enthusiasm for the project. Plans should be developed for what to do with positive screens and what resources are available for referral and coordination. The following pages illustrate the phasing in process for the pilot projects.

5 Additional Considerations Many tracking, registry, and care coordination efforts have been developed and implemented in Minnesota over the past few years. Current grantees are looking at ways to adapt or incorporate this approach to the other projects their clinics are using. This will be an important consideration for any clinic wanting to use this approach. Electronic records can be very useful in tracking and flagging cases for follow-up, however, systems vary in their ability to do this and in their ability to provide useful information in these endeavors. Understanding the abilities and limitations of any electronic records system is essential in developing tracking systems.