Kristi Kleinschmit, MD Associate Professor, Dept of Psychiatry Adjunct Associate Professor, Dept of Pediatrics University of Utah

Mental Health in Primary Care  75% of mental health treatment occurs by primary care physicians  There will never be enough mental health providers  I.e, 7,000 child psychiatrists nationally, need is 30,000  1 in 5 children with mental illness  Only 25% get treated, untreated have long-term morbidity  US Preventive Services Task Force has recommended screening of adolescents ages and adults for all ages for major depression to ensure accurate diagnosis, psychotherapy, and follow up.  Insufficient evidence to recommend screening 7-11 y/o  Treatment within primary care with collaborative care shown to be equal in quality  Improved delay to treatment, decreased time in treatment, decreased number of appointments, decreased stigmatization

Care “As Is” Currently  Johnny is struggling, makes appointment with PCP  10 minute “sick” visit turns into minute crisis visit  Often, no clear answer known by PCP  Referral to psychiatrist  Wait is 2-3 months at times  Child worsens during wait  Hospital, ED, school failure, social failure

Consults As Is  Ideally, co-located mental health professionals  MHI program through IHC  Not enough providers for this to be universal  With Collaborative Care Models in other states:  Phone in system  Fax in system  Time intensive for PCP  Without Collaborative Care Models:  “Sidebar” consult with friend or colleague, informally.  Even more time intensive for the PCP  Referral to psychiatrist  Long wait  Poor communication and feedback  Care outside the medical home

What is GATE?  GATE stands for “Giving Access To Everyone”  It is an interactive web-based tool to facilitate professional to professional consults between pediatricians/PCP’s and psychiatrists  It was designed with a busy primary care practitioner in mind, to support care in the medical home.  It utilizes the family/patient to obtain most of the information, thereby decreasing time spent by the primary care physician.  Different than other models across the country  A new method of mental healthcare delivery

What GATE is NOT:  It is not meant to replace traditional mental healthcare delivery, only to compliment it.  Some patients will still need a traditional psychiatric visit  It is not a “fast track” to a psychiatric visit

The Consultation Process: 1.Go to and log in with unique provider name/passwordhttp:// 2.Fill out a quick consult form and obtain a log-in number for the family Alternatively, for really quick questions (would take a paragraph for us to answer them), can use the quick question link 3.Give the log-in information to the family, letting them know that the consult can be done only when they are finished Remind them not to use names, as it has to be de-identified!

4.Families fill out the electronic psychiatric assessment tool. 5.Once it is completed, an is sent to the GATE assistant 6.GATE assistant will call physician’s office to set up phone appointment 7.GATE physician will call primary care physician to discuss recommendations 8.Re-consult in future, if still need guidance To obtain a consult (cont.)

Objectives of GATE  Increase access to psychiatrists for primary care doctors  Improve ability to refer to other levels of care  Include education and supervision of cases to improve primary care physicians’ confidence in treating mental illness in their primary care medical home  Reduce health care costs and redundancy, by offering timely interventions that minimize morbidity and time spent in clinics dealing with crises  Be virtually scalable to care for large populations

Anticipated Cost Savings To Healthcare System  Decreased lag time to treatment, thereby preventing expensive ED visits or psychiatric hospitalizations  Improved efficiency of primary care physician  Improved functioning of kids and adults, allowing them to participate in life  Decreased medical costs in general  Decreased pharmaceutical costs (more informed, targeted medication choices)  More targeted mental health visits (not all-comers need to see the psychiatrist)  Over time, decreased mental health costs,  Maintenance of care in the medical home

GATE utilization  GATE started July 2011  434 consults to date  Poor survey completion was issue  Partnership with U of U Community Clinics has increased utilization dramatically!  Added Social workers into clinics starting in July  3,294 social work patient visits  128 crisis interventions, only 25 admitted  116 GATE consults

Short-Term Therapy Sessions (3-5 sessions) Groups Community Resources/ Referral to specialized services Coordinate with Care Management GATE Consult Triage Assessment and/or Input GATE Eval Mental health needs discovere d No mental health needs Social worker + patient Real-Time Care Team Coordinati on

Feedback so far from Families  54 completed surveys; (5 is excellent, 1 is poor)  Ease of using web site: 4.7  Time it took: 4.3  Quality of advice: 4.4  Functioning before: 2  Functioning after: 3.2  Overall rating of GATE service: 4.3  What did you like?  “Easy. No travel. No pressure.”  “Great to get connected through our pediatrician to a trusted psychiatrist  ”It sped up a process that was taking months”  Comments  “Great experience and would highly recommend it!”  “You were there to help when we needed it.”  “Gave us help with behavior via medication we have been lookin for for over a year”  Criticisms  Still had to wait to see psychiatrist  Wish I could have talked with the psychiatrist

Provider Surveys  24 initial surveys  25% felt comfortable treating mental health  50% would have referred >50% of kids with MH concerns to psychiatrist  13 Follow up surveys  44% felt comfortable treating mental health  16% would have referred >50 % of kids with MH to psychiatrist  92% were very satisfied with the system.

Current Funding  Per member per month with ARUP  Utilization has decreased with consistent use by providers  Adult and child consults  U of U Community Clinics  Fee for service  Physicians’ group decided to pay as a service  No billable encounter.  Small grant funding for ongoing pilot programs

Future Directions  Implementing “GATE Plus,” based on our experience in the community clinics, with virtual social work/case management, and tele-consultations for diagnostic clarification

Funding issues with current system  De-identified patient encounter  Funding for both time spent by PCP and Psychiatrist  I’m a pediatrician and a psychiatrist. If I’m in a primary care clinic, seeing a patient one-time, to keep care in primary care, what do I bill as?  Tele-health visits  Variable reimbursement  Rural versus urban visits