Transcript Childhood Mental Health

Childhood Mental Health:
Strategies for Rural NYS
9/10/07
Thomas C. Rosenthal MD
Director: NYS AHEC System
Editor: Journal of Rural Health
Professor and Chair
UB Dept of Family Medicine
1
Rural Challenge
• 1. Making the Diagnosis
– Requires team of family, school, primary care
physician and patient.
– PCPs diagnose psycho-social problems in 19% of
visits. (Koppelman, 2004)
• Specialty consult obtained for 50% of these cases.
• 2. Urgent Care
– Usually the primary care office or the ER.
• 3. Continuity and maintenance care.
– Requires integration of family, school, primary care
physician, mental health specialty support.
2
Rural Need
• Rural Pediatric Mental Health Visits
– 5% of child ER visits are for MH (rural ~ urban).
– 10% of psychiatric ER visits are children. (Hartley, 2005)
– Childhood mental health ER visits 102%. (Shah, 2006)
• Only 1 in 5 children receive definitive care.
(Rosenkranz, 2006)
• Rural adolescent rates of anxiety, depression,
thought problems, attention problems,
delinquency, substance abuse and aggressive
behavior are equivalent. (Hartley, 1999)
– Suicide is higher in rural America. (Hartley, 1999)
• Only 79% of Rural US Counties have mental
health services. (Hartley, 1999)
3
Agricultural Worker’s Need
Needs somewhat unique to farming
Problem:
Strategy:
Business Pressures
Poor problem solving,
rigidity, change.
Access to firearms.
 business and family
management resources.
Build professional
networks
Crisis services.
Alcohol, prescription
drug misuse.
Lack of knowledge of
mental health problems.
Access to recovery
programs.
Reducing stigma,
education.
Markets, regulatory, climatic
4
Source: American Farm Bureau
Solutions: Integrated Care (PCP)
• Mental Health Care in Primary Care
– Mental and physical health are indivisible.
– 50% of patients refuse referral. (Olfson, 1991)
• PCPs deal with mental symptoms as part of a
larger, more general problem:
– Mental symptoms are concentrated in patients who
visit their PCP for other reasons.
• Mental health symptoms are imbedded in a matrix of physical
symptoms.
– The Rural PCP remains “stuck” with difficult patients.
• Limited opportunity for “passing” the patient onto specialty
care. (Farley, 1998)
5
Disease and Illness
(Stewart, 1995;
Rosenthal, 2007)
Disease
The
Broken
Part
Illness
Feelings
Ideas
Function
Expectations
6
Bio-physiological Mechanism
Primary Care Model of Disease
Stress
Trauma
Predisposition Infection
Inflammation
Heterogeneous neuroendocrine-immune dysfunction
Aberrant central
pain mechanism
Pain
Fatigue
Depression/Anxiety
Mental stress
Sympathetic
Activity
Environmental
stimuli
Poor sleep Fatigue
Physical
deconditioning
Trauma
Poor posture
7
Why Primary Care? (PCP)
• “Distress” brings patients into the PCP Office
– An emotion that may arise out of physical or mental
trigger.
• 10-20% of people visit a PCP for a mental health
problem each year.
– 26% have a DSM diagnosis. (deGruy, 1996)
– 50% of high utilizers have significant distress.
– 8-15% of PCP Pediatric contacts are for psychosocial problems. (Costello, 1987)
• Team Care is inherent to Primary Care. (Rosenthal,
2001)
8
Why Primary Care? (PCP)
• Mind/Body Integration:
– Americans accept the inter-relationship of
mind and body more than clinicians. (Wolsko, 2004)
– 88% of patients accept management of
mental illness by their primary care physician.
(Smith, 2003)
• Patients expect their PCP to facilitate
referrals and consultations. (Rosenthal, 1991)
• Patients expect PCPs to continue
participation in their care after referral.
(Rosenthal, 1996)
9
Solutions: Expand the Team
• Advance Practice Psychiatric Nurses:
– Clinical outcomes of high quality.
• Both diagnosis and treatment (Merwin, 1995)
– Licensed with prescription authority in NYS.
• Their holistic framework is essential for rural
practice.
– 9.6% of NY’s APPNs practice in rural NY. (Hartley,
2004)
– 8% of NYS is considered rural.
• There are 40 APPNs in rural NYS as of 2004.
– Most training programs do not include rural
experiences. (Hartley, 2004)
10
Integrate Care: Examples
Chevy Version
• Bag Lunch Model:
– Letchworth Family Medicine, Perry, NY
• Established in 1978 as a solo (fee-for-service) practice.
• Now has 3 Family Physicians and 2 NPs.
– Friday noon lunch in PCP office:
• The physicians, NPs and nursing staff.
• Clinical psychologists, MHSWs from county mental health
office and private practices in county.
– Agenda: 1) referred cases, 2) problem cases, 3)
medically complicated cases, 4) un-referrable cases.
– Enhanced number of referrals, fewer visits per referral,
greater patient satisfaction, greater professional
comfort. (Rosenthal, 1990)
11
Integrate Care: Examples
Buick Version
• Tount, Texas (Federally Qualified Health Center est 1993.)
– Step 1: Established grant funded Family violence
intervention program.
– Step 2: Hired Clinical Psychologist (CP) initially
supported by grant.
– Step 3: Weekly Office PCP, CP and Staff conferences
focusing on patient care.
– Step 4: Referrals to CP expanded to other diagnoses.
– Step 5: Patient billings evolved to support CP.
– Step 6: Grant funding was no longer needed. (Farley,
1998)
12
Integrate Care: Examples
Cadillac Version
• Inter-professional Partners for Appalachian Children
(IPAC)
– Assessment and comprehensive treatment of behavioral and
developmental needs of children ages six and under
– 19 university and community health care organizations in
Appalachian Ohio participate.
– Access is through PCPs and schools.
– Provider participants:
• Primary physicians, psychologists, counselors, early child mental health
professionals, nurses, educators, and hearing and speech-language
pathologists from within the partnership.
• “No matter what door you enter, someone is going
to take a look at your child’s broad developmental
needs,”
• http://www.oucom.ohiou.edu/ipac.
13
Integrate Care: Examples
Systems Approach
• ~44 Child visits/yr/fp for psychosocial Issues.
– FP sees 102 patient visits/wk 46 weeks a year.(~4,600 visits/year).
– 19% (890) of FP visits are patients <19 yoa.
– 5% of pediatric visits are psychosocial.
• Swedish Sarcoma Model for non-common
conditions.
– Regionalize systems approach.
• Connect specialty surgical centers to office based PCP
practice.
– In-office “Academic” detailing.
– Regular “single message” teaching brochures.
– Improved outcomes and lowered recurrance rates by
2/3rds. (Gustafson, 1994)
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Why doesn’t the ideal just happen?
Competing Demands
• Competing demands confound PCP visits:
– Most pts have psychosocial and physical comorbidities.
• They present new problems at every visit
• Long problem lists interfere with providing prevention
and treatment of chronic disease. (Jaen, 1994)
• “The attention depression gets during a visit
is less associated with the severity of the
patient’s emotional symptoms than with the
number of other problems the patient has.”15
(Rost, 2000)
Strategies:
Bringing the PCP Into the Team
• 1. In-Office Training: Treatment of Child
Pscyho-social conditions:
– 6 hours proved feasible and acceptable to all
FPs in study.
• 93% FPs believed that learning were achieved.
• 82% felt more confident in care of complex
patients. (Morriss, 2006)
– Specific diagnoses were not essential to
management. (Clark, 2006)
– Lowers use of medications. (Salmon, 2006)
16
Strategies:
Bringing the PCP Into the Team
• 2. Re-imbursement:
– Dual Diagnosis Medical management fee:
• ~$5/month per patient per PCP. (Gold Choice)
• Saves $1m for every 1,000 enrollees. (Rosenthal, 1996)
• 3. Specialty communication:
– Tele-video:
• NY Statewide Tele-psychiatry Task Force (www.hysarh.org)
– Electronic transmission of EMR note.
– Visits with urban based specialists as needed.
• Tailored specialty/PCP interaction according to patient needs
and PCP participation.
17
Strategies:
Bringing the PCP Into the Team
• 4. Guided Pharmacologic Care:
– 85% of prescriptions for psychotropic meds in children
are written by Pediatricians and Family Physicians.
(Koppelman, 2004)
• Use of stimulants (i.e. Ritalin) for ADHD
• Use of selective serotonin reuptake inhibitors (SSRIs) for
depression.
• Use of clomipramine + fluvoxamine for obsessive-compulsive
disorders. (Greenhill, 1999; Emslie, 1999)
• 5. Support for Psychosocial Interventions.
– PCP encourages and facilitates family participation.
(Dore, 2005)
– Combined medical and cognitive care works best.
(March, 2004)
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Strategies:
Bringing the PCP Into the Team
• 6. Case Management:
– Advanced Practice Psychiatric Nurses
– Mental Health Social Workers
– Special service agencies
• 7. School performance:
– Semi-annual case conferences required.
– Each member of team may bill the equivalent
of an office visit for each patient conference.
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Solutions: Integrated Care (PCP)
• Key Feature: Case Management at Multi-levels.
– Overall Costs are significantly less. (Baldwin, 1993)
• Specialty and social services cost the same.
• Emergency and inpatient care costs were much lower.
– Outcomes measures better. (Schulberg, 1995; Katon, 1995)
• Most of the data is from adult care.
– Clinical Care Pathways develop. (Bertram, 1996)
– Specialty consultation is distributed.
• Impact is expanded to more patients.
• European model of health care. (Rosenthal, 2000)
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New York State AHEC System
www.AHEC.buffalo.edu
AHECs:
Brooklyn AHEC, Brooklyn
Bronx AHEC, Bronx
AHEC
Districts
Catskill-Hudson AHEC, New Palz
Central NY AHEC, Cortland
Erie Niagara AHEC, Buffalo
Hudson-Mohawk AHEC, Glens Falls
Regional Offices:
Manhattan/Staten Island AHEC
Northern AHEC, Potsdam
Western New York Rural-AHEC,
Warsaw
1998 Statewide Office, UB
1999 Central Region Office, Upstate Med. Univ.
2000 Eastern Region Office, Albany Med. Col.
2000 NY Metropolitan Region Office,
The Institute for Urban Family Health
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References
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deGruy F. Mental Health Care in the Primary Care Setting. In
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Dore M. Child and adolescent mental health. In G. Mallon and P.
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Suicide Rates in Rural America
• NY Times article:
– Social Isolation, Guns and a Culture of
Suicide. February 13, 2005.
• Byline: Fox Butterfield.
– “Americans in small towns and rural areas are
just as likely to die from gunfire as Americans
in Major cities. The difference is in who does
the shooting.”
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