Integrated behavioral health in

pediatrics: From practicalities

of practice to policy change

March 23, 2015

Maya Bunik, MD, MSPH

Ayelet Talmi, PhD

Christopher Stille, MD, MPH

Cody Belzley

GETTING STARTED,

PRACTICAL APPLICATIONS,

DISSEMINATION, & SYSTEMS

ISSUES

Maya Bunik, MD, MSPH

Associate Professor, Pediatrics

Ayelet Talmi, PhD

Associate Professor, Psychiatry and Pediatrics

Maya Bunik, MD, MSPH

Ayelet Talmi, PhD

No financial disclosures or conflicts

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PROJECT CLIMB:

CONSULTATION LIAISON IN

MENTAL HEALTH AND

BEHAVIOR

INTEGRATING BEHAVIORAL HEALTH INTO PEDIATRIC

PRIMARY CARE

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CLIMB…how we started

• Partnership of Psychiatry and Pediatrics

• Initial Health Foundation funding

Started with:

• Developmental screening (>85% rates)

• Added pregnancy-related depression

screening

• Built foundation of collaboration and co-

management of two disciplines

• Planned for sustainability

with funds from ASQ &

Dept of Peds making it whole

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Generously Funded By: with special thanks to Children’s Hospital Colorado Foundation and

Kathy Crawley and Jennie Dawe

• American Academy of Child and Adolescent Psychiatry Access Initiative Grant

• Rose Community Foundation: Access to Mental Health Services

CLIMB to Community

• The Colorado Health Foundation Pediatric Resident Education

• Caring for Colorado

• Walton Family Foundation CLIMB to Community

• Liberty Mutual

• Denver Post Season to Share

Our Team Administration:

Maya Bunik, MD, MSPH

Kelly Galloway, RN

Ayelet Talmi, PhD

Psychologists:

Melissa Buchholz, PsyD

Emily Muther, PhD

Kate Margolis, PhD Aurora Mental Health Clinician:

Cathy Danuser, LPC

Psychiatrists:

Kim Kelsay, MD

Celeste St. John-Larkin, MD

Postdoctoral Fellows: Shannon Beckman, PhD, Steven Behling, PhD, Anna Breuer, PsyD, Melissa Buchholz, PsyD, Bridget Burnett, PsyD, Dena Dunn, PsyD, Kendra Dunn, PsyD, Emily Fazio, PhD, Barbara Gueldner, PhD, Rachel Herbst, PhD, Jason Herndon, PhD, Jennifer Lovell, PhD, Kate Margolis, PhD, Dailyn Martinez, PhD, Christine McDunn, PhD, Brigitte McClellan, PsyD, Brenda Nour, PhD, Sarah Patz, PhD, Meg Picard, PsyD, Shawna Roberts, PsyD, Kriston Schellinger, PhD, Casey Wolfington, PsyD

Psychology Trainees: Dena Miller, MA, Keri Linas, MA, Emma Peterson, MA, Jessica Technow, MA, Crosby Troha, MA

Research Interns: Hamid Hadi, Traci Lien, MD, Iman Mohamed, Cody Murphy, BA, Molly Nowles, BA, Shagun Pawar, BA, Nick Pesavento, Clare Rudman, Danica Taylor, BA, Jen Trout, BA, Zeke Volkert, MD, Tyler Weigang, MPH

Pediatric Residents and Trainees:

Leigh Anne Bakel, MD

Scott Canna, MD

Jacinta Cooper, MD

Michael DiMaria, MD

Thomas Flass, MD

Adam Green, MD

Danna Gunderson, MD

Kasey Henderson, MD

Ashley Jones, MD

Sita Kedia, MD

Gina Knapshaefer, MD

Courtney Lyle, MD

Catherine MacColl, MD

Jennifer McGuire, MD

Michelle Mills, MD

Amy Nash, MD

Rupa Narra, MD

Nicole Schlesinger, MD

Teri Schreiner, MD

Heather Wade, MD

And many more…

Psychology Interns: Megan Allen, MA, Caitlin Conroy, MA, Tamie DeHay, MA, Barbara Gueldner, MA, Patrece Hairston, PsyM, Erin Hambrick, MA, Idalia Massa, MA, Jessican Malmberg, MA, Alexis Quinoy, MA, Ryan Roemer, MA, Justin Ross, MA, Cristina Scatigno, MA, Tess Simpson, MA, Michelle Spader, MA, Bethany Tavegia, MA, Crosby Troha, MA, Brennan Young, MA, Jay Willoughby, MA

CHC Faculty Mandy Allison, MD

Edwin Asturias, MD

Steve Berman, MD

Karen Call, MD

Mandy Dempsy, MD

Gretchen Domek, MD

Karen Dodd, PNP

Brandi Freedman, MD

David Fox, MD

Annie Gallagher, MD

Sita Kedia, MD

Allison Kempe, MD

Lindsey Lane, MD

Maureen Lennsen, PNP

Tai Lockspieser, MD

Dan Nicklas, MD

Steve Poole, MD

Bart Schmidt, MD

Chris Stille, MD

Christina Suh, MD

Meghan Trietz, MD

Shale Wong, MD

CHC Staff Liz Gonzales

Nicole Vallejo-Cruz

CLIMB Research Team Ryan Asherin, BA

Mandi Millar, BA

Iman Mohamed

Marianne Wamboldt, MD & Bob Brayden,

MD (original PIs)

Brian Stafford, MD, MPH (co-PI)

Child Health Clinic

• Children’s Hospital Colorado

• Large Urban Primary Care Teaching Clinic

• Low income= >90% Medicaid/SCHIP

• 29,000 visits per year

• 60% of visits for zero to 3 years

• 56% Hispanic, 40% Spanish Primary Language

• Pod based clinic design

• Dissemination to community based clinics

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Program and Services • Developmental Screening Initiative (Child)

• Pregnancy related depression (PRD) screening (Caregiver,

Child, Family)

• Healthy Steps for Young Children & MIECHV (Child, Caregiver,

Family)

• Baby & Me at the CHC (Child, Caregiver, Family)

• Case-based consultation (Child, Caregiver, Family)

• Care coordination, triage, and referral (Child, Caregiver, Family)

• Psychopharmacology consultations (Child)

• Counseling and brief therapy services (Child, Caregiver, Family)

• CLIMB to Community pilot (Child, Caregiver, Family)

• Training and education (Providers/Health Professionals)

Formal didactics

Precepting trainees

Collaborative care

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Clinician Identified Problem by Consultation

Type (%)

* Mothers of patients birth to 4 months were screened for pregnancy-related depression

CLIMB Initiatives

• Pregnancy-related depression

• Ages and Stages Developmental

Screening

• Healthy Steps for Young Children

Program

• Baby and Me Group visits

• Second Hand Smoke and Motivational

Interviewing

• Trifecta for Breastfeeding Management

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Pregnancy-Related Depression

• Formal screening at well-child visits from birth to four months using Edinburgh Postnatal Depression Scale (Cox et al., 1987)

• Primary care services

Training for providers

Psychoeducation

Support to mothers

Referral

Electronic medical record

• System changes

Capacity building

• (Caregiver, Child, Family)

PRD data • 89% of mothers seen for well child visits < 4

months of age get screened

• 10% of mothers scored ≥10 on at least one

visit.

• 60 % by CLIMB provider only, 4%

(21/508)social worker (SW), 11 %

• Those mothers who score high have more

clinic visits as part of their treatment

compared to those that do not (means 2.6

(1.1 sd), median 3.0 and 2.3 (1.1 sd),

median 2.0, respectively

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Developmental Screening and

Closing the Referral Loop

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Talmi A, Bunik M Pediatrics 2014

ASQ and EI Findings

• Developmental screening and referral is

necessary but not sufficient.

• Success of developmental screening

process depends on enhancing referral

completion.

• An intervention providing phone follow-up

and assistance with referral yielded

higher rates of referral and greater

provider knowledge of referral outcomes.

Talmi A, Bunik M Pediatrics 2014

Healthy Steps for Young Children

(www.healthysteps.org)

• Provide enhanced developmental services in pediatric primary care settings;

• Focus on developing a close relationship between the clinician and the family in order to address the physical, socioemotional, and cognitive development of babies and young children;

• Currently used in 18 residency training programs nationally

• MIECHV funding to expand our program and develop new sites across Colorado

• Baby & Me at the CHC

• (Child, Caregiver, Family)

Content analysis of well-child visits,

Healthy Steps vs. control (Buchholz & Talmi, 2012)

35% *

38% *

33%**

35%**

63%**

28%**

28% *

90% *

23% *

75%**

48%**

70% *

8%

3%

3%

0%

28%

6%

0%

56%

3%

6%

11%

17%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Language Development

Social Skills

Importance of Play

Daytime/Nighttime routines

Sleep

Promoting healthy eating

Temperament

Home Safety

Child Care

How parent is feeling

Postpartum depression

Breast Feeding

Control

Healthy Steps

* ≤ 0.03

**≤ 0.01

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Baby & Me at the CHC (Child, Caregiver, Family)

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26 Bunik M et al. Pediatrics July 2013

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Methods: MI Intervention

The pediatric provider offers a MI session to

help make a plan for cessation or reduction.

If yes, trained provider meets family for 20

minute session. CLIMB providers are

primary counselors for the intervention.

If no, reasons for refusal are solicited.

Results: Survey for

Satisfaction

• At the 1 week surveys, 81% (n=25/31)

reported MI definitely worth their time.

• 81% (n=25/31) felt MI educator understood

their situation very or fairly well.

• 77% (n=24/31) found the quality of the MI

program excellent or good.

• 70% reported that most or almost all of the

of the participants needs were met

(n=21/30)

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Summary of SHS Findings • The 'ONE Step' Quality Improvement

intervention was associated with a higher quit rate (14%) compared to Colorado 2008 state data for low SES population (5%).

• Most parent/caregivers reported reductions in smoking behaviors

• Addition of MI looks promising but need to talk to families ‘treat it as an MI emergency’

Bunik M et al. Pediatrics July 2013

Breastfeeding Management Evaluation earlier is better and support

from an infant mental health specialist is

crucial

It’s Complicated

• Pregnancy-related depression

• Paternal depression

• Sleep expectations/deprivation

• Sibling adjustment

• Financial stress

• Other family stressors

• Transition to parenthood

• Previous fertility or loss issues

31 Bunik M J Hum Lact 2014

What We Do: The Trifecta Model

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Baby

Breastfeeding Dyad 2. Psychosocial assessment

and support:

• Evaluate family adjustment

• Assess pregnancy-related

depression/Administer EPDS

• Acknowledge and support

partner’s involvement in

feeding routines

• Discuss sibling adjustment

• Self-care:

• “Baby out of the

building”

• Enjoyable activities

• Help with childcare

Family

Community

Intervention

Intervention

1. Comprehensive

functional

breastfeeding

assessment and

intervention:

• Physical exam

• Medical history

• Psychosocial history

• Pre-post feeding weights

• Assess latch

• Evaluate milk transfer

• Observe infant regulation

• Post hospitalization feeding

plan

• Evaluate baby growth and

milk supply

3. Follow-up

recommendations,

future planning, and

referrals:

• Communication with

medical home

• Discuss return to work

• Pumping

• Childcare

• Planning feeding and

sleep routines

• Community referrals if

needed:

• Fussy Baby

Network

• Mental health

referral

• Occupational

therapy

Lactation Consultant + Pediatrician + Psychologist

Bunik, Dunn, Talmi, & Watkins, 2012. Do not distribute without permission.

Dissemination:

CLIMB to Community • CLIMB to Community intends to implement and

evaluate the sustainability of integrated behavioral

health services in community-based pediatric

primary care practices serving publicly insured

children by disseminating the Project CLIMB model.

• Expansion of integrated behavioral health services

will improve the health outcomes for publicly

insured children ages 0-18 through increased

access to behavioral health services.

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Systems Isssues

• Maternal Infant Early Childhood Home

Visitation (MIECHV) federal funding

• State Innovations Model (SIM) - $65M

• Office of Early Childhood

• Regional Care Collaboratives

• Behavioral Health Organizations

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Questions?

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“I've learned that people will forget what you said, people will forget what

you did, but people will never forget how you made them feel.” Maya Angelou

INTEGRATED BEHAVIORAL HEALTH: A FINAL

PIECE OF THE MEDICAL HOME PUZZLE Christopher Stille, MD, MPH

Department of Pediatrics, UC Denver SOM/Children’s Hospital Colorado,

March 23, 2015

April 1, 2015

The Medical Home: definitions

• US MCHB definition: A Medical Home provides

care which is:

• Accessible

• Family-Centered

• Continuous

• Comprehensive

• Coordinated

• Compassionate

• Culturally Effective

• Robert Frost definition:

“Home is the place where

when you go there, they

have to take you in.”

• My definition:

The medical place where

the buck stops.

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Why focus on behavioral health services?

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We see this, many times, every day

4 year old boy for a 20 minute well child checkup

Previously healthy, few minor medical problems

Screen with PEDS: “behavioral problems”

Lives with mother (teen) and grandmother, father

incarcerated

Described as "a handful", "hard to manage" and "difficult"

since he started to walk. Referred for EI and behavioral

therapy in past

After 30 minutes of rambling history, they finally admit their

primary concern: he has injured two kittens that live in the

house and expresses no remorse over this practice. The

family is concerned for safety (his and theirs)

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Why does integrated care matter so

much? • Accessible

• Family-Centered

• Continuous

• Comprehensive

• Coordinated

• Compassionate

• Culturally Effective

Current challenges • Challenges unique to behavioral health that are addressed by integrated care: • Insurance “carveouts”

• Stigma

• Tradition of confidentiality

• Lack of continuity

• Interplay of physical and behavioral health

• Lack of awareness of the medical home as a source of mental health care (and other services)

• Accessible

• Family-Centered

• Continuous

• Comprehensive

• Coordinated

• Compassionate

• Culturally Effective

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Typical Medical Care System

Well-functioning Medical Home

Low

High

Watchful

waiting

Intervene with

resources

of the practice

Crisis and

emergency

services

Intervene with

specialty

mental health services Continuum of Needs

Thinking about MH

services in the

context of a patient-

centered medical

home:

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Child Mental Health: Opportunities for prevention

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But I’m just a primary care provider…?

• I see LOTS of behavioral health issues

• I think I am reasonably smart and caring

• I can’t do diagnostic interviews

• I can’t do therapy

• I can prescribe meds, but only so far…

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For the primary care team:

take a “Common Factors” approach • Tending to the alliance you build with families is a

treatment in itself, and facilitates the impact of other

treatment you provide

• Clarifying concrete concerns and making it clear that you

are working toward addressing those concerns is also

therapeutic

• A relatively small repertoire of brief advice may help many

families while waiting for more definitive diagnosis and

treatment

From Wissow et al. Adm Policy Ment Health. Jul 2008;35(4):305-318

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Step 2: Make use of your integrated

behavioral health colleagues… • After screening and identifying concerns, and clarifying

needs with patients and families, you are best prepared to

inform your behavioral health colleagues so they can get

a head start

• Later, you can best support what they do in followup visits

with the family

What About A Virtual Team?

• Consult liaison model • PCP as point of contact

• Phone consult with 30 minutes

• Single visit psychiatric consult within 2 weeks

• Care coordination for “hard cases”

• Funding secured to bring modified program statewide

• Open to all (MassHealth and private payers)

And It Has Caught On….

Alaska

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Illinois

Iowa

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Missouri

Nebraska

New Hampshire

New Jersey

New York

North Carolina

Ohio

Oregon

Pennsylvania

Texas

Vermont

Virginia

Washington

Washington, D.C.

Wisconsin

Wyoming

NNCPAP.org

National Network of Child Psychiatry Access Programs (NNCPAP.org)

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CPAP vs. integrated care

• CPAP more accessible especially at a distance

• Few of the benefits of integrated care but much better

than the “status quo”

• Bridge to an integrated care model

• Complements integrated care

• Psychiatry available by phone if not available in person

• Coordination of psychiatry and psychology essential

• This is not telehealth… but telehealth is being explored as

a way to improve it in some states

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And then,

the State

Innovation

Model: There is a

LOT going on

in Colorado.

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Colorado SIM grant: brand new

• Goal: 80% of people statewide have access to integrated

behavioral health

• Practice transformation

• Payment reform

• Measurement

• Challenge: aligning adult and child interests

• Pilot of a model like this ongoing in 8 practices using the

CLIMB model

The policy argument

April 1, 2015 Presentation Title 56

• Triple Aim (or just money): • Moving from episodic payment to whole

person care

• Any divides hurt this

• Mental illness begins in childhood • Early treatment saves money and improves

outcomes

• Children are not little adults • Need different systems

• Need better measures

• Need different payment

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Useful links AAP Mental Health Task Force http://www2.aap.org/commpeds/dochs/mentalhealth/mh1a.

html

National Network of Child Psychiatry Access Programs

http://nncpap.org or

http://web.jhu.edu/pedmentalhealth/nncpap.html

Center for Mental Health Services in Pediatric Primary Care

http://web.jhu.edu/pedmentalhealth/

My email: christopher.stille@childrenscolorado.org

Policy Change to Support Integrated Behavioral Health in Pediatrics Cody Belzley

Vice President, Health & Strategic Initiatives

Colorado Children’s Campaign Nonprofit, nonpartisan advocacy organization committed to realizing

every chance for every child in Colorado.

Grounding Data

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 or 2 3 4 5 6 7

Ch

ildre

n w

ith

Dev

elo

pm

en

tal D

ela

ys

Number of Risk Factors

Childhood Adversity and Developmental Delays

Source: Barth, et al.

Grounding Data

Initial Screenings

Further Evaluation

Services

Many children who are identified as having a developmental delay never receive intervention services

Source: PolicyLab, The Children’s Hospital of Philadelphia

Understanding Your Policy Audience

• Most elected officials are not health policy experts.

• Most elected officials are juggling very full agendas.

• Medicaid Directors have a huge job and limited capacity

Framing The Policy Discussion

• Children are Not Small Adults

• Whole Family Care Essential

• Focus on Prevention

• Focus on Community Settings

• Appropriate Evaluation

Policy Opportunities

Access and Delivery Models • Meet families where they are – reduce stigma

• Primary care doctors offices • Child care settings & schools

• Infrastructure for screening, referral & case management

• Standardized tools & protocol for screening • Unified data collection

• Resources for families in crisis

• Statewide crisis support line

Policy Opportunities

Financing • Paying for preventive services and non-medical supports

• Screening, referral, follow-up • Case management, transportation, food

• Family care, not individual patient care

• Multi-generational care from same provider

• Appropriate metrics for evaluating and paying for care

• Process metrics, if not outcome metrics

Policy Opportunities

Workforce • Addressing shortages in rural & underserved communities

• Recruiting and retaining providers in underserved places • Telehealth and innovative models to serving remote

communities

• Professional development and training

• Supporting continued training opportunities and career ladders for medical and education professionals

• Team-based approaches

• Scope of practice

• Educate and Engage Policy Makers

– Start with the basics

– Find personal connections to the issue

• Build Champions

– Invest time and resources in cultivating a few well-positioned champions

• Form Partnerships & Nurture Coalitions

– Look for existing networks to leverage

– Build new groups only when necessary or at critical junctures

Policy Strategies

• Capitalize on Opportunities

– Be opportunistic over the short term

– Find places to build a pediatric mental health component into existing work

• Create New Movements

– Be intentional and proactive over the long-term

– Build a multi-year agenda

Policy Strategies

Cody Belzley

(303) 620-4560, cody@coloradokids.org

More Info?