NICH Novel Interventions in Children s Healthcare
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1 Novel Interventions in Children s Healthcare Michael A. Harris, PhD Kimberly B. Spiro, PhD Matthew Heywood, MPH Dana Hoehn, MS David Wagner, MA Child Development and Rehabilitation Center Oregon Health & Science University October 212 Collaborative with CareOregon Intensive behavioral health care Youth with complex medical conditions Birth 21 yo Poor adherence with treatment High utilizers of unnecessary medical care Repeat hospitalizations for diabetes Repeat emergency visits for recurrent pain Evidence-Based Treatment Empirical Support Behavioral Family Systems Therapy (BFST), Robin and Foster,1989 Family-based problem solving Several federally/foundation grants demonstrating efficacy & effectiveness Theoretical Underpinnings Multisystemic Therapy (MST), Henggeler and Hanson Context-driven behavior 1
2 Intervention 24/7 therapeutic support BFST family-based problem solving Pragmatic & systematic behavioral intervention Care coordination Medical Social services Community mental health School School consultation Employment, social and life skills coaching Where the Rubber Meets the Road Joining, engagement & buy in Family has been marginalized by the healthcare system Understanding context & challenges Establishing clarity for family and determining a direction and next steps Paying attention to and reinforcing small wins Serving as care ambassador Assist in re-engaging with care Titrating services and support in independent management and problem solving Delivery of Care Inpatient Clinic Telehealth Skype Text Phone Home visits School visits Care coordination 2
3 Diagnoses January September 212 Cystic Fibrosis Chronic Pain Diabetes Cancer Recurrent Abdominal Pain Chronic Renal Disease Economics of Hospital Care averages $28/day (21) Avoidable hospitalizations cost insurance companies Inpatient $ increased 31% above inflation past 2 yrs > 6% for those with complex conditions Examples: DKA - $11, CF clean out - $4, Without intervention likelihood of repeated hospitalizations increases Case 1 9 yo diagnosed with brain tumor, in remission Referred by Coping Clinic for unexplained neuropathic right leg pain Extensive testing performed Presented to clinic i in a wheelchair h 16 days absent from school across 2 months 3 emergency department visits in 2 months 1 admit 3
4 Intervention Coordination with Pain team & PCP 2x/week BFST across 2 months in-home 24/7 therapeutic support and phone check-ins School consultation Pain management Progressive muscle relaxation Deep diaphragmatic breathing Cognitive reframing of pain Distraction Re-initiation in school and physical activities Case 1 Outcome Pre Last 4 months ED Visits Case 2 14 yo with Type 1 Diabetes Living with mother and 3 siblings 8 DKA episodes requiring hospitalization over 8 months Poor supervision at home 7 months out of school Crisis at home Endocrinologist believed insulin resistance resulting from reported traumatic event 4
5 Intervention Collaboration with PCP, endocrinologist & DHS Weekly family therapy Daily phone contact 24/7 therapeutic support Crisis intervention and planning DHS report Removal from mothers care, placed with aunt Education, support and problem solving Incentive for daily reporting of glucose readings School consultation Initiation of IEP and tutoring service Case 2 Outcome Pre Last 3 months 2 ED Visits Case 3 17 yo with Type 1 Diabetes & Celiac Disease Living independently in mothers home, mom at the coast with boyfriend Inconsistent school attendance DHS involvement 3 DKA events in 8 months 5
6 Intervention Coordination with PCP, endocrinologist, DHS case worker Facilitated move to aunt s home Skype BFST sessions weekly 24/7 therapeutic support Incentive for sending glucose readings School consultation and re-engagement Summer planning Case 3 Outcome Pre Last 4 months 1 ED Visits Case 4 19 yo diagnosed with leukemia at 17 Received a bone marrow transplant - April 211 Developed GVHD, pulmonary embolism, pulmonary hypertension, some cardiac problems, deconditioning due to obesity History of non-compliance with treatment recommendations, including medication and nonpharmacological interventions History of sexual abuse, meets criteria for Borderline Personality Disorder. 6
7 Intervention Collaboration of and Hem/Onc department Combined medical and behavioral plan Behavioral guidelines alert in EPIC for ED and Inpatient/Outpatient Implementation of pragmatic behavioral intervention arrive to Hem/Onc clinic i visits it on-time (9 am) call with symptoms before presenting to ED schedule clinic visit if symptoms appear enroll in Portland DBT program Compliance with this plan = >Pediatric Hem/Onc care at DCH, otherwise adult medical services 24/7 therapeutic support & crisis intervention Employment and life skills coaching Case 4 Outcome Pre May Last 5 Weeks 5 ED Visits Case 5 14 yo Type 1 Diabetes and Hypothyroidism History of poor management of diabetes Referred by endocrinologist A1C historically high (11-14) y g ( 4) 3 DKA events in 1 year 7
8 Intervention Collaboration with PCP & endocrinologist Weekly BFST over Skype Incentive for reporting normal glucose readings 24/7 therapeutic support Crisis plan and intervention Call when readings are high Support in following recommended medical treatment Consult with endocrinologist Support in decision making regarding ED visit Successfully avoided 2 ED visits Case 5 Outcome Pre Last 6 Weeks 1 ED Visits Aggregate Data January June Pre Last 6 Weeks ED 8
9 Future of 17 CareOregon patients enrolled since Jan patients total Average case load patients Currently serving Multnomah, Marion, Polk, Douglas and Coos counties Developing as part of CCO model for high-risk patients Adaptation of treatment model to serve other populations- Obesity Mental health emergencies in the ED and PICU Familys Advice for Medical Professionals Behavior as Adaptive Survival skills: ED manages crisis Hospital is safe and predicatable Predictable & stable context: 9
10 Comments Novel Interventions in Children s Healthcare Michael A. Harris, PhD Kimberly B. Spiro, PhD Matthew Heywood, MPH Dana Hoehn, MS David Wagner, MA Child Development and Rehabilitation Center Oregon Health & Science University October 212 1
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