Transcript Center for Integration of Mental Health in the Medical Home

Elise Fallucco, MD
Director, North Florida Center for Collaborative Care
Physician Scientist, Nemours Center for Health Care Delivery Science
Child Psychiatrist, Nemours Division of Psychiatry
Nemours Children’s Specialty Care
Adjunct Assistant Professor, Department of Psychiatry
University of Florida College of Medicine - Jacksonville
The Case for Collaboration
8, 000
CAPS1
15 million
youth2
 AACAP and AAP recommend collaboration3-5
○ Aaron
Overview

Challenges of Collaboration

The Collaborative Care Consultation Model
(CCCM)
 Clinical training for PCPs +
 Outpatient psychiatric consultation

Tips for implementing the CCCM
Barriers to Collaboration Between Primary
Care and Psychiatry
Primary
Care
Limited PCP mental health training6-9
Limited time, $ reimbursement??
Child and
Adolescent
Psychiatry
“Holding a Hot Potato”
Limited CAP time, availability
$$ reimbursement??
Few CAP-PCP networks
Fallucco EM, Robertson Blackmore E, Bejarano CM, Kozikowski CB, Cuffe SP, Landy R, & Glowinski AL. Journal of Behavioral Health
Services & Research, in press, 2016.
Slide Credit: Chelsea Kozikowski
Collaborative Models
Co-location1,10,11
Consultation10
MHP in primary care
PCP calls MHP
Examples: MCPAP, PAL
Challenges:
Challenges:
Collaborative Care Partnership
•
•
•
Clinical training for PCPs
PCPs access outpatient CAP consultation
PCPs and CAPs co-manage patients
Overview

Challenges of Collaboration

The Collaborative Care Consultation Model
(CCCM)
 Clinical training for PCPs +
 Outpatient psychiatric consultation

Tips for implementing the CCCM
Collaborative Care Partnership
3 – Patients
return to
PCP
2 – PCPs
refer
patients for
outpatient
consultation
1 - Train
PCPs
Potential Benefits


Use existing systems of payment
Efficiently use CAP resources without
subsidization

Limited extra-curricular CAP time required

More children access psychiatric services
= Model could be adapted and disseminated?
Overview

Challenges of Collaboration

The Collaborative Care Consultation Model
(CCCM)
 Clinical training for PCPs +
 Outpatient psychiatric consultation

Tips for implementing the CCCM
What is the best way to train PCPs about
adolescent depression and suicidality ?
A) Silly question. PCPs don’t need training –
they feel pretty comfortable prescribing
antidepressants
 B) Lectures are nice… and are sufficient to help
PCPs gain clinical skills
 C) Reform ACGME requirements for future
PCPs

Post-Training Pediatric Resident Confidence
Confidence Assessing Adolescents with
Suicidal Thoughts12
5
5 = very high
4= high
3= neutral
2=low
1 = very low
4.2
4
3
2.9
2.6
2.5
2
1
Control
Lecture Only
Fallucco EM, Hanson MD & Glowinski AL. Pediatrics, 2010.
SP Only
SP Plus
Lecture
2+1/2 hr Workshop Using Standardized
Patients
PHQ9 Depression Screen
3-Step Assessment: Depression13
1) Symptoms, Severity,
Stressors
2) Differential Diagnosis,
Comorbidity
3) Suicide Risk Assessment
Fallucco EM, Conlon MK, Gale G, Constantino JN, & Glowinski AL .Journal of Adolescent Health, 2012.
Depression: Triage
Symptoms
Plan
Acute psychosis, mania, and/or
suicidal intent/plan
Emergent ER evaluation
- Inpatient
- Partial Hospitalization
Suspect Bipolar or Psychosis
Refer to a psychiatrist
Depression of Moderate
Severity with/out anxiety
Consider initiating treatment
- Psychotherapy, SSRI
Training Tools
Local Resources
Casey:
Rebecca- https://youtu.be/7MqUEtw0Djk
Sarah- https://youtu.be/c68m4CjS5HE
Tips for Training
Challenges of Training
Ways to Overcome
CAP time required to develop
training content
Use academic setting
Don’t reinvent the wheel
Standardized Patients (SP)
involvement
Partner with the Office of Medical
School education
SPs cost $15/hr
Small grants vs. paid CME
Training outcomes: STL
Comments from PCPs about the SP Intervention
“I thought the patient interaction sessions were very helpful to pinpoint my weaknesses. I was given
helpful feedback. I think it will change the way I interview patients.”
“I received very constructive criticism concerning interview skills”
“I feel much more comfortable talking to teens about suicide and depression”
Fallucco EM, Conlon MK, Gale G, Constantino JN, & Glowinski AL . Journal of Adolescent Health, 2012.
Fallucco EM, Conlon MK, Gale G, Constantino JN, & Glowinski AL .Journal of Adolescent Health, 2012.
Training outcomes:
Adolescent patient reports
Fallucco EM, Seago RD, Cuffe SP, Kraemer DF, Wysocki T. Academic Pediatrics, 2015.
Training outcomes:
Adolescent patient reports
Baselin
e
2 years
after
training
Camille’s story
Adolescents at well-visits
diagnosed with
depression
Depressed adolescents
who discussed treatment
with PCP
3%
10%*
54%
86%*
Fallucco EM, Seago RD, Cuffe SP, Kraemer DF, Wysocki T. Academic Pediatrics, 2015.
Overview

Challenges of Collaboration

The Collaborative Care Consultation Model
(CCCM)
 Clinical training for PCPs +
 Outpatient psychiatric consultation

Tips for implementing the CCCM
Patient Progress
Refer for consult to CPCC
Primary Care
Provider
Child and
Adolescent
Psychiatrist
Return to PCP care
Intake and follow up
Consult Clinic is NOT an HOV Lane!
Consult request
Clinic Operation
PCP
Referral for
Consult
Schedule a
Consult
• +/- 3 Follow
up visits
Intake
Coordinator
• Verify
Insurance
CAP Triage
• Review
Eligibility
Characteristics of 81 Referred Patients
Reason for Referral
Depression
57 %
Anxiety
41 %
ADHD
33 %
PCP-prescribed medication
None
38%
SSRI
33%
Stimulant
28%
Age
12.1±3.6 (1-17)
Primary Diagnoses
Depressive Disorder
24 %
Anxiety Disorder
22 %
ADHD
20 %
CAP-recommended treatment
Therapy + Medication
82 %
CAP-prescribed medications
Antidepressants
50 %
Stimulants
32 %
.
Fallucco
EM, Robertson-Blackmore E, Bejarano CM, Kozikowski CB, Cuffe SP, Landy R, & Glowinski AL. Journal of
Behavioral Health Services & Research, in press, 2016.
Child Psychiatry Consultation Model (CPCM)-Referral Patient Flow
PCP Satisfaction with
CC Outpatient Consultation Clinic
Consultations improve access
to child psychiatry
Consultations improve PCP
skills in mental health care
% Agree
Consultations help meet the
needs of patients
Consultations are useful
0
20
40
60
80
100
“FREE SERVICE”
Fee-for-service $$$
Triage consultation
requests
Outpatient consultation
(9924x)
Quarterly Meetings with
PCP groups
Breaking Barriers through Collaborative Care
Improved Patient Care
Primary
Care
PCP gains clinical skills  SUPER PCP
Resource
Lists
MH Reimbursement Codes
Create partnerships with CAPs,
no “hot potato”
Improved Access
Training helps PCP mange patients in
primary care
PCPs have expedited access to
consultation
Consultation helps maintain Enhanced
Access
Child and
Adolescent
Psychiatry
Public Health Impact
CAP
PCP
PCP
PCP
200 – 300
Adolescents
200 – 300
Adolescents
200 – 300
Adolescents
Lessons Learned
POSITIVE PUBLIC HEALTH IMPACT:
89 Florida PCPs from 22 practices
 25,000+ adolescents screened annually6

Choosing PCPs:
○ Large practices
○ Physician champions

Choosing CAPs:
○ Liaison work, education
○ Strong communication skills
○ Open to consultation model vs. ongoing care
○ FLEXIBLE!!!!!!!!
THANK YOU!!!




Substance Abuse and Mental Health Services
Administration
Nemours Foundation
Hall-Halliburton Foundation
Collaborators and Mentors!!!





Tim Wysocki, PhD
Steve Cuffe, MD
Anne Glowinski, MD, MPE
John Constantino, MD
CCCM staff
 Chelsea Kozikowski, BA
 Lauren James, MA
References
1.
2.
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8.
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11.
12.
13.
Child and Adolescent Psychiatry Workforce Crisis: Solutions to Improve Early Intervention and Access to Care. Published
2013. Available at: https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap
workforce_crisis_201305.pdf. Accessed September, 2015.
Costello EJ, Mustillo S, Erkanli A, Keeler G, & Angold A. Prevalence and Development of Psychiatric Disorders in
Childhood and Adolescence. Archives of General Psychiatry. 2003; 60(8), 837-844.
American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics, Task Force
on Mental Health. Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to
Access and Collaboration. Published 2009. Available at:
https://www.aacap.org/App_Themes/AACAP/docs/Advocacy/policy_resources/cap_workforce_crisis_201305.pdf.
Accessed September, 2015.
American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and Task Force on
Mental Health. Policy Statement-The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care.
Pediatrics. 2009; 124(1): 410-421.
American Academy of Child and Adolescent Psychiatry Committee on Collaboration with Medical Professionals. A Guide
to Building Collaborative Mental Health Care Partnerships in Pediatric Primary Care. June 2010.
Fallucco EM, Seago RD, Cuffe SP, Kraemer DF, & Wysocki T. Primary Care Provider Training in Screening, Assessment,
and Treatment of Adolescent Depression. Academic Pediatrics. 2015; 15(3): 326-332.
American Academy of Pediatrics, Task Force on Mental Health. Strategies for System Change in Children's Mental
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Horwitz SM, Kelleher KJ, Stein RE, Storfer-Isser A, Youngstrom EA, Park ER, Heneghan, AM, Jensen, PS, O’Connor, KG
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Nasir A, Watanabe-Galloway S, DiRenzo-Coffey G. Health Services for Behavioral Problems in Pediatric Primary Care.
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Briggs RD, Racine AD, Chinitz S. Preventive Pediatric Mental Health Care: A Co-location Model. Infant Mental Health
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Kautz C, Mauch D, Smith S. Reimbursement of Mental Health Services in Primary Care Settings (HHS Pub. No. SMA-08–
4324) Center for Mental Health Services. Substance Abuse and Mental Health Services Administration, Rockville, MD.
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Fallucco EM, Hanson MD, & Glowinski AL. Teaching Pediatric Residents to Assess Adolescent Suicide Risk with a
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Fallucco EM, Conlon MK, Gale G, Constantino JN, & Glowinski AL. Use of a Standardized Patient Paradigm to Enhance
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