Integrated Strategies for Integrated Care: Building the DC Collaborative for Mental Health in Pediatric Primary Care Lee Savio Beers, MD Children’s National Health System American Association of Directors of Child and Adolescent Psychiatry Annual Meeting 2016

Learning Objectives Describe the local experience with developing a collaborative approach to systemically improving mental health-primary care integration Discuss components of this approach which may be replicable in other communities Discuss existing and potential barriers and how they were addressed

Washington, DC – Geographic scope Metro area population of 5 million (DC, MD, VA) DC population: 650,000 DC children 0-21years: 120,000+ DC Medicaid enrolled children (0-20): 90,000+

May 2012 Recommendations include -Routine screening for mental health concerns at pediatric well visits -Implementation of a “Child Psychiatry Access Program” -Routine screening for perinatal mood and anxiety disorders in primary care

Collective Impact— A model of sustainable and impactful community change

And so it began…. Winter 2012—informal collaboration which became the DC Collaborative for Mental Health in Pediatric Primary Care Children’s Law Center Children’s National DC Chapter of the American Academy of Pediatrics DC Departments of Behavioral Health, Health and Health Care Finance Georgetown

Spring/Summer 2013—Awarded grant funding Title V funds to develop infrastructure for a child psychiatry access project Private funding to focus on early childhood mental health State behavioral health agency funding to develop and implement a longitudinal quality improvement learning collaborative to implement routine mental health screening in primary care

Infrastructure Development

Policy- Advocacy Integrated Services Education & Training Support for Practices Support for Families Resource Guide Child BH Access Program Integrated Evaluation & Treatment Routine, Universal Screening Payment Reform Access to Services Coordinated Systems of Care Peer to peer support Activities - Initiatives Evaluation - Research

Community Needs Assessment: Beliefs & Practices PCPs spend a lot of time addressing MH but they feel they could do a better job PCPs serve as gatekeepers of children’s MH, helping to identify, guide, and co-manage 96% of PCPs and 70% of MH providers said that PCPs are expected to address MH problems Few PCPs implement routine universal MH screening; 25% have office protocols in place to manage youth with common MH problems ~33% of PCPs said they have access to up-to-date information about MH diagnosis, treatment, and community-based resources 79% of PCPs reported that their comfort level and knowledge about identifying and addressing MH problems was worse for children < 5 years than for older children

Community Needs Assessment: PCP-MH Provider Relationships There is variability in PCP-MH communication, but it is generally poor Even within the MH community, communication is poor across different providers There is a desire among both PCPs and MH providers to improve collaboration PCPSMH Providers Of families I connect to mental health specialists, I receive some sort of consultative feedback for most. (I typically provide some sort of consultative feedback to PCPs) 16%52%* The PCPs I reach out to are receptive to my feedbackn/a60%* Improving collaboration between MH providers and PCPs would improve patient care 100%89% * Psychiatrists more likely to endorse than other MH clinicians

Comprehensive Resource Guide

QI Learning Collaborative Two parts (9 mos + 6 mos) Learning sessions (1 hour webinars) Monthly team leader conference calls Monthly practice team meetings Monthly chart audits to measure progress Routine PDSA cycles to facilitate change Technical assistance from QI and MH coaches

Project Map

Project Aims Increase practice readiness to implement and sustain mental health screening at well visits using a standardized tool Increase the number of well visits where a mental health screen is administered, documented, addressed and billed

Participating Practices Total practices enrolled in either or both Rounds; n=16 14 located in Washington DC, 1 located in Maryland, 1 located in Virginia Total practices participated in both Rounds 1 & 2; n=10 (~150 providers) 6 community health centers affiliated with academic health centers 2 Federally Qualified Health Centers 2 private practice pediatric offices

Results DHCF Claims 96110/96127 FY13 : 4,632 FY14 : 9,553 FY15: 22,648

Child Behavioral Health Access Program Infrastructure development funded by state health agency May 2013-Sept 2015 Contract from state behavioral health agency awarded in February 2015 Collaboration between Children’s National and Medstar Georgetown Pilot began in May 2015 Full roll out in Sept 2015—over 200 calls to date

DC MAP (Mental Health Access in Pediatrics)

Policy and Reimbursement Mental health screening reimbursement Payment per screen, no limit to number of screens Addition of billing modifier to begin to track at risk screens Linked with EPSDT provider education Behavioral Health System of Care Act of 2014 Legislatively mandates implementation of a Child Psychiatry Access Program through state behavioral health agency Addressing issues related to payment for psychological evaluation and treatment by Fee-for-service Medicaid

Next steps Individualized technical assistance for practices on: Mental Health Screening For practices who did not participate in Learning Collaborative Early Childhood Perinatal Mood and Anxiety Disorders Identifying and addressing adverse experiences Linkages to community programs such as Home Visiting Education and training Greater focus on trainees Increase number and types of educational opportunities, with focus on case based and interactive learning

Challenges Collaborative infrastructure Early on—many ideas but little capacity to implement them Changing scope and refining of priorities Varied engagement and agenda of stakeholders Management of complex team Project implementation Primary care providers were nervous about the lack of resources available to them Practices faced variable but sometimes significant workflow challenges Much harder to engage practices who didn’t have senior level commitment to projects

Lessons Learned Interdisciplinary, multi-agency collaboration critical Early involvement/awareness of key stakeholders Recruit and engage champions—clinical, policy, funding Start small and work towards tangible “wins” Dedicated team makes all the difference Primary care providers need sustained support In person Longitudinal and metrics oriented Policy and advocacy are critical to success but are more effective when paired with clinical and quality improvement initiatives and infrastructure

Questions?