Two Models of Pediatric Healthcare Integra6on: Approaching the Problem from Different Direc6ons Building Mental Wellness in Ohio Primary Care
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1 Two Models of Pediatric Healthcare Integra6on: Approaching the Problem from Different Direc6ons Building Mental Wellness in Ohio Primary Care Prac8ces Through a Quality Collabora8ve All- Ohio Ins8tute on Community Psychiatry Supported by the Ohio Colleges of Medicine Government Resource Center with funding from the Ohio Department of Health and the Office of Medical Assistance
2 Disclosure I have nothing to disclose. John C. Duby, MD, FAAP, CPE The NeuroDevelopmental Science Center Akron Children s Hospital jduby@chmca.org
3 Objec8ves Discuss the formamon of the Building Mental Wellness (BMW) Learning CollaboraMve Describe the 3 Building Mental Wellness Key Drivers Describe the 5 BMW Stars Highlight key outcomes Discuss Lessons Learned and Future Plans
4 BMW Sites Wave I Wave II Wave III 12
5 BMW s Global Aim To achieve opmmal mental wellness for all of Ohio s children and families as soon as possible
6 Needs Assessment Take Away Messages Review of NaMonal Survey of Children with Special Health Care Needs for Ohio, EDB issues are common ADHD, Anxiety, Depression, and DisrupMve Behavior are the most common EDB issues are under- idenmfied Families affected by EDB feel their care is less family- centered than other CSHCN EDB has major impact on family funcmoning
7 Building Mental Wellness (BMW) Based Upon IHI Breakthrough Series
8 IHI Model for Improvement Model for Improvement Part 1: Answers these three quesmons What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Set Aims Establish Measures Select Changes Part 2: Guides change to see if there is an improvement Act Study Plan Do Test the Changes The Improvement Guide Associates in Process Improvement
9 Office Culture PracMce Based Skills Integrated Models of Care
10
11 BMW Star Recogni8on Scale Updated:(2/10/2014(!! BMW!Star!Recognition!Program! Practice(sites(will(be(recognized(throughout(the(course(of(the(Learning(Network(and(earn(stars(for(implementing(systems(to(support(five(BMW(Key(areas.((A(star(will(be( earned(when(practices(can(demonstrate(completion(of(all(the(interventions(listed(under(a(bmw(key(area.(practices(may(earn(up(to(5(stars.(recognition(will(be(provided(on( the(bmw(online(community(and(promotional(materials(will(be(provided(for(display(in(the(office(and(on(the(practice(website.((as(practices(progress,(new(posters(that(reflect( their(advancement(will(be(provided.( Step!1:((Practices(will(be(evaluated(at(each(of(the(scheduled(site(visits.((( Step!2:((On(the(monthly(progress(report((Survey(Monkey)(practices(will(be(able(to(share(their(progress(towards(this(recognition(program.(( When(you(are(able(to(check(all(aspects(of(a(BMW(key(area(you(will(receive(that(color(star.(!!!! (!(Local(Mental(Health( Resource(Directory.((Updated( within(last(year(!(mental(health( Appointment(Reminder( System(!(Mental(Health(Education( materials(available(for( patients/families(!(mental(health(recall( system(for(missed( appointments(!(log(to(keep(track(of( patients(with(a(mental(health( concern(!(develop(a(system(of(ongoing( communication(with(referred( mental(health(providers( regarding(patient(&(family( mental(healthcare(plan(!(community(reception(is( hosted(!(staff(and(clinicians(complete( Common(Factors(Training(!(Mental(Health(Promotional( Materials(displayed(in(office(!(System(in(place(for( providing(anticipatory(guidance( for(healthy(sociall(emotional( development(in(early( childhood(!(system(in(place(postpartum( depression(screening(!(system(in(place(screening( development(in(early( childhood(!(advanced(1(or(more(levels( on(samsha(models(of( integrated(care( ( ( ( (!(System(in(place(for(Autism( ( screening(!(system(in(place(for(social( ( emotional(screening(for(school( age(through(adolescence.( Do(not(hesitate(to(contact(Sean(O'Hanlon(at(614L846L6258(or(sohanlon@ohioaap.org.( (!Clinicians(Complete( Psychopharmacology(Online( Learning(Module(!(A(crisis(plan(in(place(for( handling(of(psychiatric( emergencies,(including( suicidality.( ( (
12 BMW Wave Key Driver Diagram Culture Interven8ons INTERVENTIONS KEY DRIVERS A culture that supports the delivery of family- centered mental health services in primary care. Implement reliable processes that improve areas priorimzed in your Office Systems Inventory. Execute improvement plans incorporamng approaches from The Model for Improvement training. Incorporate systems to include evidenced- based developmental- behavioral surveillance and screening from infancy through adolescence, including an8cipatory guidance, postpartum depression, and au8sm. Make mental health resources available to families such as a list of local providers, mental health educamon materials, etc. Display mental health promomonal materials in the office Develop a log to track paments with mental health concerns. Develop a mental health reminder system for appointments. Develop a mental health recall system for missed appointments. Create a crisis plan for handling psychiatric emergencies, including suicidality.
13 BMW Wave Key Driver Diagram Skills Interven8ons INTERVENTIONS System in place to provide an8cipatory guidance KEY DRIVERS Skills to support the promomon, early idenmficamon and management of mental health concerns in primary care. for healthy social- emo8onal development in early childhood. Implement an evidenced based system of developmental- behavioral surveillance and screening from infancy through adolescence, including: screening for early childhood development, social emo8onal screening for school- age through adolescence, post- partum depression, and au8sm. Rou8nely u8lize Wissow s (2008) Common Factors including, managing rambling, agenda sewng, iden8fying possibili8es, responding to reluctance to try new things & asking permission to give advice. Demonstrate at least two of the seven first line advice techniques such as cogni8ve/coping methods, behavioral ac8va8on, problem- solving strategies, behavioral rehearsal, social skills building, assessment for suicidal thoughts and safety counseling. U8lize the E- learning modules to enhance medical knowledge, with a^en8on to the psychopharmacology module.
14 BMW Wave Key Driver Diagram Integrated Models Interven8ons KEY DRIVERS Integrated models of mental health services in primary care. INTERVENTIONS Host a community partners recepmon. Develop a system of ongoing communicamon with referred mental health providers regarding pament and family mental health care plan. UMlize the SAMHSA model as a resource to increase your pracmces level of collaboramon/integramon with local mental health providers.
15 Approach to Integrated Care INTEGRATED PRIMARY CARE OR PRIMARY CARE BEHAVIORAL HEALTH Combines medical & BH services for problems patients bring to primary care, including stress-linked physical symptoms, health behaviors, MH or SA disorders. For any problem, they have come to the right place no wrong door BH professional used as a consultant to PC colleagues Peek, C.J. (2013, p. 13). Integrated behavioral health and primary care: A common language. In M.R. Talen and A. Burke Valeras (eds.) Integrated Behavioral Health in Primary Care. New York: Springer.
16 WAVE I AND II OUTCOMES
17
18 Goal = 85% 80 % Charts with Documenta8on Post Partum Depression (n=83-182) Family Health Risks (n=96-185) Alcohol Use (n=89-155) Depresssion (n=88-154) Month of Par8cipa8on Figure 2. Run chart showing changes in documentamon of mental health screening during BMW parmcipamon.
19 Propor8on of Claims for Depression or Anxiety Month of Par8cipa8on Figure 3. Control chart showing changes in Medicaid claims for office visits related to anxiety and depression during BMW parmcipamon.
20 100 Goal = 85% % Appointments scheduled/completed Month of Par8cipa8on Wave I (n=3-39) Wave II (n=2-59) Figure 4. Run chart showing changes in scheduled (wave I) and completed (wave II) referrals during BMW parmcipamon.
21 100 Goal = 85% % Charts with Documenta8on Month of Par8cipa8on Wave I (n=0-10) Wave II (n=3-11) Figure 5. Run chart showing changes in documentamon of metabolic monitoring for paments prescribed atypical anmpsychomc medicamons by BMW pracmmoners.
22 100% Percent of Children With Mental Health Condi8on Prescribed Medica8on 90% 80% 70% 60% 50% 40% 30% 20% 10% Pre- Test Period Prescribed SSRI Prescribed AAM Age <6 Prescribed Psychotropic Drug Post- Test Period 0% Month of Par8cipa8on Figure 6. Control chart showing changes in Medicaid pharmacy claims for BMW prescribers before, during and aker parmcipamon.
23 Ensuring our patients schedule and keep their BMW Star Recogni8on mental wellness appointments Mental Health Promotion & Screening Ensuring we are screening for and providing guidance about mental wellness for our patients. 8/28 Integration Planning & Implementation Working to build bridges to promote mental wellness in our community. 3/28 Resources Providing Mental Health Resources for our patients and the public. Tracking Ensuring our patients schedule and keep their mental wellness appointments 12/28 12/28 Practice Based Interventions Ensuring our staff is trained appropriately in helping our patients during times of mental wellness needs. 6/28
24 Summary Mental Health IS mainstream pediatrics ADHD, Anxiety, Depression, and DisrupMve Behavior are the most common problems. Families with children with emomonal, developmental, and behavioral issues report significant disparimes in the quality of care and the impact on family funcmon when compared to other families with children with special health care needs Early adopter pediatricians are doing beler than the NSCSHCN data would suggest.
25 Summary Ohio s early adopters have been effecmve at making changes in anmcipatory guidance, screening and surveillance, and coordinamon of referrals Quality improvement science is a useful tool to help pracmmoners improve the care of children/families with mental health concerns
26 Lessons Learned ExisMng Challenges Presence of QI famgue Decreasing need for MOC Engaging all providers within a pracmce Using technology successfully Improving parental engagement and facilitamng behavior change Challenges around creamng a mental health network Limited mental health access in some communimes
27 Future Plans? BMW Online Learning Modules 11 Topics Pediatric and Family Medicine Residency Program BMW Learning CollaboraMve PracMce Based Assessment & IntervenMon Community CollaboraMon Integrated PracMce Models One Day Regional Learning Sessions
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