Navigating the Mental Health Maze CME/Roundtable Dinner Huntsville November 17, 1 Summary of Presentation and Roundtable Discussion

Transcription

1 Navigating the Mental Health Maze CME/Roundtable Dinner Huntsville November 17, Summary of Presentation and Roundtable Discussion The Birmingham meeting was held November 17, at the Bradley Lecture Center at Children s Hospital. There were 43 persons in attendance, representing a variety of mental health providers, mental health agency representatives, psychiatrists, psychologists, pediatricians, family practice doctors and parent advocates. Our speaker was Dr. Donald Paoletti, a multi-talented and multi-tasking child psychiatrist. He was an excellent speaker, and we were both entertained and informed. Dr. Paoletti s handout is available, and also Child/Adolescent Psychiatrist Tom Vaughan, MD, FAAP, which goes extensively into each of the objectives for the meeting. I am going to take the liberty of highlighting a few parts of Dr. Paoletti s talk in my report. These are the portions which seemed most pertinent to my particular pediatric practice needs, although all of the talk was equally valuable. Dr. Paoletti first discussed various ways to screen for childhood depression, mania, and anxiety disorders. (Later, the pediatricians expressed desire to learn more detail about this.) I must say that he advocated a few simple questions, asked directly to the child, which applied to each topic. His is a quick and simple approach which we should be able to master. He gave us a list of disorders that he believes pediatricians should and should not treat on their own. He believes that uncomplicated ADHD and depression can and should be treated by the pediatrician. He believes that SOMETIMES pediatricians can treat complicated ADHD, complicated depression and generalized anxiety disorder. He believes that pediatricians should ALWAYS REFER: Oppositional defiant disorder, Conduct disorder, Substance abuse, SI or SIB, Bipolar disorder, obsessive-compulsive disorder, social phobia, Posttraumatic stress disorder, autism, eating disorders, psychosis, and abuse and neglect. (Also, later, the pediatricians expressed desire to learn more about treating depression. ) He gave some brief information about various medications for depression and anxiety. He mentioned some of the controversy surrounding the SSRI s. In his opinion they are safe and effective for depression, but should NOT be used it there is any question of mania. (The pediatricians expressed desire to learn much more about these medications.) The last portion of Dr. Paoletti s talk was directed toward problems with the mental health system. There are multiple issues here, and it is difficult for the mental health providers, the pediatricians, and the families involved. At the root of the problem are insurance and money issues. He offered some models for going into the future to try to make things better. One model which is important for the pediatricians to think about is the case manager model. He suggests having someone in the office (both the pediatrician s office and the psychiatrist s office), who would coordinate the referral

2 process. This person would probably be a social worker or an RN, she/he could screen, triage and follow up, would have knowledge of insurance issues and referral sources, and would develop relationships with his/her counterpart in other offices, to better improve access to care. Roundtable Discussion The second half of our meeting involved our roundtable discussions. We had been carefully divided into 5 tables of 8 persons each. I had compiled a list of questions which were generated from the work already done by the committee and the July meeting of the Psychiatric Institute. Each table had one or two questions to discuss and report on solutions. The discussions were productive, with positive ideas and interaction occurring. Each table reported on their answers. I will summarize this as well as possible. Question 1: How can we access EMERGENCY services for mental health needs? Example: A child in the office threatening suicide, or a mother on the phone stating her child is threatening suicide? The best way is to call a friend or colleague that you know well. If that is not available: Send to an ER. Sometimes it is actually better NOT to call the ER first, because you might be told that they won t accept the child, but if the child shows up, they have to accept it. We identified these hospitals as having psychiatric services: Children s UAB, ages 13 and up Hillcrest, all ages Baptist Montclair, all ages Bradford, addiction problems Question 2: At the ADMH/MR Child and Adolescent Psychiatric Institute in July, a desire was expressed to compile a list of available mental health services in our area. How can such a list be compiled? What all should be included? How can it be made available to the pediatricians? How could it be updated? We discovered that this project is already underway through Alabama Family Ties. Sarah-Ellen Thompson is in charge of this project. A first draft was included in our handout. There will be a web site with this information, and Alabama Family Ties ( ) will be responsible for keeping it updated. Also, it was recommended that we access the web site and go to the section on the Department of Children s Affairs for further information. In addition, the directory put out by United Way listing services was recommended. I will add here some other agencies that were identified in the course of the evening that need to be added to the existing list: Gateway Amelia Center grief counseling Oasis women and children, have Spanish Futures th grade and up, family, behavior and school issues Glenwood Autism Grayson & Associates largest private agency in town Hillcrest The emergency rooms listed under Question 1

3 Project Find See below under question 6 for Substance Abuse referrals See question 8 for Mental Retardation and Autism issues Question 3: On a statewide survey the committee performed in July 2005, 84 percent of the pediatricians expressed difficulty with getting timely appointments for children in need of non-emergent mental health services. The psychiatrists expressed feelings of being overwhelmed. However, some of the mental health agencies mentioned problems with no-shows for appointments. Frequently the pediatricians never find out if the patient got an appointment or not (a violation of Medicaid rules.) There are different systems for different types of insurance. How can the appointment process to mental health be streamlined to be more effective? We discovered that both the public and private sector are having difficulties with this, and that the psychiatrists are having a lot of difficulty also. At the root of this problem are insurance issues. Insurance plans are extremely complicated and the mental health coverage is generally not laid out and explained, but is obscure. People do not know what type of coverage they do or do not have, or what providers are on their list. People are hesitant to ask questions about this or demand better coverage because of shame or secrecy still surrounding mental health issues. The psychiatrists have difficulty negotiating decent pay for their services with the insurance companies. Medicaid pays for a certain number of visits, but pays at a low rate. Qualified people are going into psychiatry at a lesser rate because of these issues, leading to shortages. As a reasonable solution to current issues, the in-office case manager model described in Dr. Paoletti s talk (see the above summary) would be the best practical solution at present. On a deeper and more long-term level, we need to begin to lobby for better coverage and more openness in the insurance plans. To do this we need a roadmap, which could possibly come out of this committee, in conjunction with the AAP, Alabama Family Ties, and parent advocates. Question 4: On the statewide survey of pediatricians in Alabama, 80 percent expressed difficulty with getting feedback from psychiatrists and/or mental health services on patients which the pediatricians referred. This is also a Medicaid requirement, that the referring physician receive feedback. In our group discussion at the July meeting, the psychiatrists expressed feelings of being overwhelmed with referrals, and of frequently not receiving information regarding any medication the child was already taking. How can the psychiatrists (or other mental health entities) and the pediatricians communicate better regarding patients who are being and have been referred? One excellent suggestion was a standardized two-way mental health referral form. The form would definitely need to include the reason for referral, past medical history, past and current medications, and contact numbers. This would then come back to the pediatrician with the diagnosis, medications prescribed, and the treatment plan (not great detail, but at least a time frame) and some contact numbers. Also the pediatricians need this information after a psychiatric hospitalization. We generally get a fax from Hillcrest with the above information, but not from other places. The diagnosis and medications is ESSENTIAL for the pediatricians to safely manage their patients. Some of the psychiatrists raised the ugly head of HIPAA.

4 There was a good deal of discussion about this. The general consensus is that HIPAA does not apply to this sort of basic safety information between the referring (primary care) doctor and the consultant. But some of the psychiatrists vehemently disagreed; they feel that they cannot disclose anything without a specific consent form. The pediatricians raised the question: are they ASKING for the consent form up front, or are they waiting for the pediatrician to come back and then ask for the info, by which time the patient is not available to sign consent. One of the psychiatrists stated that on occasion the patient will refuse to give consent. The pediatricians feel that this is basic safety information that we MUST have to avoid giving the patient a medication that might interact with what they are on. So we did not reach agreement on this very important issue. My suggestion: the committee research this issue, get an informed HIPAA opinion, and develop a form that can be used between the primary care doctor and the referral source WITHOUT signed consent. Question 5: At our meeting in July, the pediatricians learned of a Community Mental Health program run by the Jefferson, Blount, St. Clair Mental Health Services. This is an extensive program including in-home services. However, intake for this program is through DHR, Juvenile Justice, and a little bit through certain schools. The pediatricians expressed strong interest in obtaining mental health services for our patients BEFORE they are involved in Foster Care or Juvenile Justice. Is there a way for this program to accept referrals from the pediatricians? Can this program communicate with the child s pediatrician once the child is in the program? This program was established through Family Court; it is for severe kids who have failed traditional outpatient care. It is a comprehensive program lasting 12 to 16 weeks. They accept Medicaid, uninsured, all kids, and various third party payers. We can refer through Project Find or As far as receiving information about the children in the program, they do not want to release any information about the children (see above discussion about HIPAA issues). We need our referral form to work BOTH WAYS, so that when the children in these programs go to see a primary care doctor, some information follows them around. Question 6: What resources are available for substance abuse treatment? Bradford UAB, the ASAP program, which is a grant program associated with Family Court SAMSA web site EAP Shelby County Drug Court, Monica Harris or Connie Jackson, Chilton Shelby Mental Health, SA division, Joe Wittner or Laurie Pierce Juvenile Court Liaison, Emily Bashinsky (Shelby) (Chilton) Question 7: What resources are available for families, or for parents with mental health issues affecting the children? How can the pediatricians make it easy for these parents to get help? (examples: postpartum depression, maternal schizophrenia?) Probably the best resource for this is Alabama Family Ties or National Alliance for the Mentally Ill (NAMI-Alabama).

5 UAB Comp Clinic (maternity) has a clinic for postpartum depression Oasis is another resource for this. Question 8: What resources are available for children with mental retardation or autism? Also, what about young adults with these problems who are about to transition out of the pediatrician s practice? Autism: Mitchell s Place (need insurance) Sparks Clinic Alabama Disability Advocacy Glenwood (Dr. Eddie Finn) King s Ranch and Big Oak Ranch acute care cottage Teen Training Clinic in Sturdivant Mental Retardation: School systen Title 19 waiver Teen Transition Clinic by DRS Hand in Hand United Cerebral Palsy Various group homes The last few minutes of the meeting explored possible topics for our Spring meeting, and ideas on how to continue communication. The pediatricians expressed interest in educational issues, such as those raised in Dr. Paoletti s talk. Childhood depression, more comprehensive education about the drugs that the pediatricians can safely prescribe, and more information about screening procedures were the three topics specifically mentioned. I would add to this that if the pediatric offices begin to implement the case manager model, then the case managers will need training. This might be a seminar that could be sponsored by the committee. Another topic that was mentioned under education was better mental health training for pediatric residents. I m not sure that this is within the scope of our committee at this time, but it is something to think about. Respectfully submitted, Linda Reeves, M.D. November 20, 2005