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Management of Pediatric Behavioral Health Disorders In
An Integrated Pediatric Medical Home
Stephanie Chapman, PhD, Assistant Professor Baylor College of Medicine, The Center for Children and Women
Arlene Gordon-Hollingsworth, PhD, Assistant Professor Baylor College of Medicine, The Center for Children and Women
Stephanie Marton, MD, Assistant Professor, Baylor College of Medicine, Associate Medical Director, The Center for Children and Women
Mudassar Tariq, MD, Assistant Professor, Baylor College of Medicine, The Center for Children and Women
Session #
CFHA 19th Annual ConferenceOctober 19-21, 2017 • Houston, Texas
Faculty Disclosure
The presenters of this
session have NOT had any
relevant financial
relationships during the
past 12 months.
Conference Resources
Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at http://www.cfha.net/?page=Resources_2017
Slides and handouts are also available on the mobile app.
Learning Objectives
Learners will be able to describe
• Clinic process that support successful
interdisciplinary and integrated treatment of
pediatric behavioral health care
• Interdisciplinary skill competencies and care roles
in the treatment of pediatric behavioral health
care
Management of Pediatric Behavioral Health Disorders In An Integrated Pediatric Medical Home
6
TCHP The Center for Children and Women
The Center for Children and Women
– A Hybrid Model
MinimalCoordinated –At a Distance
Co-locatedFully
Integrated
1) Independent outpatient behavioral health services2) Just in time behavioral health services during medical appointments
Medical Home Model
8
Capacity and Accountability
Provider Led Teams
Care Coordination& Integration
Whole Person Orientation
Safety and Quality
Continuity of CareEnhanced
Access
Center Patient Race/Ethnicity
67
25
41
0
10
20
30
40
50
60
70
80
Latino Black White Asian
Percentage
9
Funding – Capitated Payment
• Flat fee per patient member
• 100% Risk model
Value:
• No fee for service = ability to innovate
• Value on prevention and maintenance
• Incentives for reducing costs
10
Access
Hours
Pediatric Hours:
Sunday 9 AM – 7 PM
Monday 7 AM – 11PM
Tuesday 7 AM – 11PM
Wednesday 7 AM – 11PM
Thursday 7 AM – 11PM
Friday 7 AM – 11PM
Saturday 9 AM – 7 PM
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Integrated Care = Easy Access
OB/GYN PediatricsBehavioral
HealthOptometry
Speech Nutrition PharmacyHealth
Education
Dentistry Lab RadiologyCare
Coordination
OVERVIEW OF BEHAVIORAL
HEALTH
13
Interdisciplinary BH Team
14
5 FTE BH clinicians
2 social workers
1 psychiatrist
6 pediatricians5 nurse practitioners
BEHAVIORAL HEALTH CARE –
ADHD AND DEPRESSION /
ANXIETY
15
16
Screening
Care Coordination
Diagnostic Assessment
Medication Management
School Accommodations
Evidence-based Therapy
Care Interventions for ADHD at the Center
Use of Screening and Psychological Assessment Tools
18
19
Evidence-Based Treatments
Parent Management Training
– A brief (4-10 session) therapy
designed to teach parents skills to
change child behavior
– Effective for a variety of presenting
problems:
• Enuresis/Encopresis
• Sleep disturbances
• Feeding difficulties
• ODD, ADHD, and DBD
Thoughts
Feelings Behavior
Evidence Based Treatments –
Exposure Therapy
22
Evidence-Based Treatments -
Motivational Interviewing
Medication and Treatment AdherenceSubstance ReductionHealth Goal maintenance
Coordination of Care
Patient Registries
Staffed regularly by social work and care
coordinators
• ADHD Follow-Up
• 7 and 30 Day Psych Hospital Follow-up
• Maternal Depression Screen Follow-up
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Telehealth Increases Access
Telehealth = 7% of Psychiatry encounters
Contributes to 100% psychiatry template utilization
PCP – Medication Management
Psychiatry – Formal Consult Role
BH Clinician – Assessment & Therapy
Social Worker-Resources
Patient
Collaborative Medication
Management
• Protocols standardize care
• Increase timely access to care for medication titration
Medication Management
BH Clinicians and PEDI/OBGYN
providers partner to manage the majority of BH medications
• ADHD
• Anxiety
• Depression
• Sleep
Psychiatry - 30 % of time allocated to curbside consult
Psychiatrist only sees patients with complex psychiatric disorders
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Center PEDI Medication
Management
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Good Psychiatry Referrals• Patients with complex psychotropic medications• Patients with psychiatric histories other than
ADHD / depression/anxiety• Lack of progress with first line treatments• Children under 6 years
Psychiatry can always be consulted• Inbasket• Curbside consult• Patient office visit
Case Example – John
16 yo male who presents for his well child check
• PSC-17 is elevated; pediatric provider asks
further questions of child
– Concerned that child may be depressed
– Real time behavioral health consult
• Depression diagnosed at visit by psychologist
– SSRI started same day
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John returns
• Behavioral health team calls John in one week to
check on his symptoms, he is doing well with no
side effects noted
• At follow-up in clinic in 2 weeks John has had
some stomach aches and no real change in
mood
– Pediatric team increases SSRI dose
– Behavioral health team provides therapy same day
30
John continues to return
• Over next month behavioral health team sees
John twice
• He returns to pediatric clinic and reports he has
more energy but still does not see a change in
his mood
– Pediatric team briefly curbsides psychiatry to enquire
as to how long should John stay on same medication
with no change in his mood
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John returns
• John is maintained same dose of SSRI for an additional month with continued therapy
• After 2 months John reports he is having more energy and improved mood
• Therapy continues. Behavioral health team messages pediatric team that he is doing well and pediatrician team refills medication for an additional month.
• John stops coming to therapy; pediatrician continues SSRI and checks in with therapist when he comes for medication management visits.
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John
• John’s symptoms were caught early through annual
screening exam and he was never hospitalized.
• A team of multidisciplinary healthcare providers
were able to manage John’s symptoms; he was never
seen by psychiatry.
• John’s treatment was successful due to frequent
communications and a modifiable treatment plan.
• John received cost-effective, quality care.
33
CENTER OUTCOMES- ADHD
EXAMPLE
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ADHD / Depression/Anxiety
Screening Rates - % of Screening
Completed at Well-Child Checks
36
CENTER ADHD PATIENTS and VISITS 2016
Members with ADHD Treated
by PCP VS Psychiatrist
40%
22.80%
60%
77.20%
TCHP 2016 Center 2016
Psychiatry PCP
Use of Generic Pharmaceuticals
ADHD Meds
Center Psychiatry 42.30%
TCHP top prescribers 28.00%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
PEDIATRIC BH HEDIS METRICS
ADHD stimulant initiation
95th Percentile
ADHD continuation/maintenance
95th Percentile
7 Day psychiatric hospitalization follow-up 75th Percentile
30 Day psychiatric hospitalization follow-up 50th Percentile
RIGHT CARE / RIGHT PLACE -
BEHAVIORAL HEALTH Behavioral Health Integration Increases
Engagement in Underserved Communities
Thank you!
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