Pediatric Possibilities: An Examination of Integrated Behavioral Health Care for Children and Adolescents•Toni Watt, PhD, Professor of Sociology, Texas State University (San Marcos, TX)•Alejandra Posada, MEd, Chief Program Officer, Mental Health America of Greater Houston (Houston, TX)•Rick Ybarra, MA, Program Officer, Hogg Foundation for Mental Health (Austin, TX)

Session #G3, #8485679

CFHA 18th Annual ConferenceOctober 13-15, 2016 Charlotte, NC U.S.A.

Faculty Disclosure

The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning ObjectivesAt the conclusion of this session, the participant will be able to:

• Objective 1. Describe the evidence-base for pediatric IHC programs

• Objective 2. Identify several different models of care for children and adolescents at risk of emotional and/or behavioral health problems

• Objective 3. Develop an understanding of unique challenges to (and potential solutions for) implementing and evaluating pediatric integrated behavioral health programs

Asarnow, J., Rozenman, M., Wiblin, J., & Zeltzer, L. (2015). Integrated Medical-Behavioral Care Compared with Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatrics, 169(10), 929-937. doi:10.1001/jamapediatrics.2015.1141. Kolko DJ, Campo J, Kilbourne AM, Hart J, Sakolsky D, Wisniewski S. (2014). Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial. Pediatrics.133(4).

Kolko DJ, & Perrin E. (2014). The integration of behavioral health interventions in children’s health care: services, science, and suggestions. Journal of Clinical Child & Adolescent Psychology, 43(2), 216-228.  Pires, S., Grimes, K., Gilmer, T., Allen, K., Mahadevan, R., & Hendricks, T. (2013). Identifying Opportunities to Improve Children’s Behavioral Health Care: An Analysis of Medicaid Utilization and Expenditures. Center for Health Care Strategies, Inc. Faces of Medicaid Data Brief.  Richardson LP, Ludman E, McCauley E, et al. (2014). Collaborative care for adolescents with depression in primary care: a randomized clinical trial. JAMA.312(8):809-816. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau (2012).The AFCARS Report: Preliminary FY 2011 estimates as of July 2012. Washington, DC.

Bibliography / Reference

Learning Assessment A learning assessment is required for CE credit.

A question and answer period will be conducted at the end of this presentation.

•Question: What are some reasons why IHC has not been adopted or is not widespread in pediatric settings? We know how effective IHC is in a variety of settings...

•5 minutes small group discussion; select group leader; discuss question, select top three answers in rank order as agreed upon by your group; report out by each group by group leader (30 secs per group)

Group Exercise

• The 4Ps: Practice, Programs, Policy and Partnerships (local provider level; health systems; state; national) • Bring forth examples based on the limited literature, implementation efforts, and evaluation findings based on the work done evaluating pediatric IHC programs in Texas • Common themes anchored in the 4Ps of Practice, Programs, Policy and Partnerships

Framing of Presentation

Evidence base and examples of program

implementation efforts in pediatric IHC

• Much variation found in practice• Extent of integration/collaboration• Condition(s) and ages targeted• Recipient of intervention(s) – child and/or parent(s)

• Scant evidence base• Lack of rigorous designs with control groups• Small sample sizes, limited measurement & follow-up

• Meta-analysis by Asarnow et al. (2015)• Analyzed 31 RCTs• Overall summary effect for intervention vs. usual care

was small, statistically significant; wide range of effect sizes for individual studies

• Treatment vs. prevention trials• Level/model of integrated care• Condition(s) targeted

Example: The Center for Children and Women• Owned/operated by Texas Children’s Health Plan (Medicaid

MCO in Houston, Texas area)• Obstetrics/gynecology and pediatrics, with integrated

behavioral health for pediatric patients and pregnant/postpartum women

• BH staffing (Greenspoint location, serves ~14,000 patients): 2 social workers (non-licensed), 1 LCSW, 2 LPCs, 1 psychologist, ½ psychiatrist (psychiatric time primarily reserved for complex cases and consultation)

• Mental health & substance use services provided; services include individual and family therapy, CBT, motivational interviewing, parent education, assessment of social needs

• Accessibility: Pediatrics available 100 hours per week (BH available 80 hours per week)

• Communication: Team huddles, no staff offices, Voalte cell phones for texts/calls within building, information sharing via EPIC

• Global payment model allows for flexibility in staffing/services

Evidence base and examples – The 4 Ps• Practice

• Wide variation• Adaptation of collaborative care for a pediatric population• Training of PCPs and other providers• Engagement of parent(s)• Selection of EBPs for use with children and parents

• Program• Promising approaches…but more study is needed• Need for rigorous studies, including large, diverse trials

• Policy• Rigorous studies necessitate substantial funding• Reimbursement & financial sustainability• Availability/accessibility of services

• Partnerships• Provider partnerships/collaboration• Parent(s)/family as partners• Consider innovative partners beyond traditional providers –

e.g., schools, health plans

•Early Childhood Nutrition Intervention– Pregnancy through 12 month WCC

•Early Childhood Intervention to Mitigate Toxic Stress– Age 6-48 months (WCCs)

•Integrated Behavioral Health Care Program– School age children/adolescents

•Integrated Behavioral Health Care Program– Foster/Kinship Care

Evaluation: Four Pediatric IHC Programs in Texas

•Target– Pregnancy through 12 month WCC

•Programming– Vouchers, cooking classes, nutrition and lactation counseling

•Evaluation Design– Quasi experimental design-intervention and comparison

• Prospective study of pregnancy, 2, 6, and 12 mth WCCs– Outcomes

• Diet, depression, stress, weight, infant development (ASQ)

•Findings– High program participation– Improvements in diet, depression, and infant development

• Large effects-Cohen’s d

Early Childhood Nutrition Intervention

•Target– Age 6-48 months

•Programming– Universal messaging, screening for maternal depression, substance abuse, and/or

domestic violence, Circle of Security (COS) Attachment Intervention

•Evaluation Design– Quasi experimental design-intervention and comparison with propensity matching

• Prospective – Outcomes

• Parent-Child Dysfunctional Interaction (PSI) • Infant Social and Emotional Adjustment (ASQ:SE)

•Findings– Low program participation– Pilot project in progress (evolving)

Early Childhood Intervention for Toxic Stress

•Target– Age 6-17

•Programming– On-site and collaborative– Care management, psychiatric consult, therapy– Two sites

•Evaluation Design– Pre/Post (3-6 months follow-up)– Outcomes: Vanderbilt (parents and teachers), Phq-9 for older adolescents

•Findings– Data collection problems at one site

• Errors in Vanderbilt data entry• Only collected Vanderbilts from parents

– Medium effects for ADHD (teachers only), large effects for depression• Literature suggests control groups will have small effects

Pediatric IHC

•Target– Age birth to 17

•Programming– On-site and collaborative – Care management, psychiatric consult, therapy

•Evaluation Design– Qualitative (stakeholders and caregivers)– Pre/Post (3-6 months follow-up)– Outcomes: Child Well-Being (BERS-2)

•Findings– Small to medium effects– Care management is key– IHC needs to evolve to address

• Early childhood (0-5)• Trauma

IHC for Foster/Kinship Care

•Practice– Wide age range-start early

•Programming– Explore early childhood interventions

• Triple P, COS, VIP, etc.• Program uptake an issue

•Policy– Pediatric IHC in its infancy-Evaluation needed

• Baseline/comparison group data • Reliable, valid and easy to administer instruments• Qualitative• Effect sizes

•Partnerships– IHC team– Program staff, parents, teachers, community agencies– Program staff and evaluators-Assessment and internal evaluation capacity building

Evaluation: The 4 Ps of Pediatric IHC

•So we heard: •From Ale about the evidence base and examples of program implementation efforts in pediatric IHC & key take-aways related to the 4Ps•From Toni about what has been learned in the evaluation studies of program implementation efforts in pediatric IHC & key take-aways related to the 4Ps•Highlights from small group breakouts at start of presentation

4Ps Revisited

• Thoughts? Reactions? • Was there anything new presented?• What’s missing from what we covered?• For those working in pediatric settings or child serving

agencies, can you share what’s working or not in your setting? What have you learned?

• What components are doable and which are not? Why not? What are the barriers that would prevent implementing components or this program?

Q&A/Audience Engagement

Session EvaluationPlease complete and return the evaluation form before leaving this session.

Thank you!