Pregnancy Related Depression (PRD) Screening in the Pediatric Setting: Operational Considerations Bridget Burnett, PsyD Kathryn Jantz, MSW, MPH Sue Williamson, JD In collaboration with: Colorado Department of Public Health and Environment (CDPHE) Colorado SIM Office ENSW/SIM Collaborative Learning Session – Golden, CO June 2, 2017

Learning Objectives for Presentation Summarize the literature review and key informant interviews around the operational challenges of performing the PRD screening within the pediatric setting Identify findings on billing and coding for Medicaid and commercial payers for the PRD screening Describe approaches and best practices used among pediatric practices (where to document within the EMR, consent forms, policies, and procedures) Operational only-sue

Colorado Pregnancy Related Depression (PRD) Facts According to the DSM, Pregnancy Related Depression is a form of Major Depression that occurs within four weeks of delivery Prevalence: Ten percent of Colorado mothers experienced frequent PRD symptoms (2011) (1) Significant impact on children: Infants of parents with PRD often have delayed cognitive and psychological development, delayed motorized skills, lower vocalizations, and increased resource use Screening is reimbursed: Medicaid (federal and state) supports and reimburses screening by the child’s medical provider under the child’s Medicaid ID CDPHE and others don’t use DSM diagnosis Behavioral health clinicians are moving to PMADs. In setting up strong processes and procedures around PRD, practices are preparing for a more holistic, PMADs approach. (1) Colorado Department of Public Health and Environment Pregnancy Risk Assessment Monitoring System (PRAMS)

American Academy of Pediatrics (AAP) Position Includes “assessment and consideration of parental and family environmental factors that may affect children’s health”, maternal depression being one of these. Include bullets about importance- Sue

Additional Recommendations United States Preventive Services Task Force (USPSTF) – depression in general adult population including pregnant and postpartum women Centers for Medicare and Medicaid (CMS) – identifies importance of PRD screening and encourages child’s provider to refer mothers for appropriate care

Policy Perspective Encouraged to administer PRD screenings in a pediatric setting SIM initiative – PRD screening is a Clinical Quality Measurement (CQM) Medicaid and other payers reimburse PRD screening in pediatric setting

Mom is Not My Patient: Pediatric Worry List??? Do I need mom to sign consent form to administer PRD screen? Where do I record the results in my EHR? In the child’s (patient’s) records? Am I responsible for ensuring Mom has received appropriate referral to services? To what extent can I release child’s records to outside party when it includes Mom’s information? Do I have to let my risk management (malpractice) carrier know I’m doing this? Is my risk/liability greater if I do nothing? How do I know if Mom connected to the referral I made?

Findings: Notifications and Informed Consent No clear consensus what type of notification a mother or father should receive about assessments or interventions directed at them within pediatric setting Informed consent a construct for “treatment” although HIPAA defines it broadly Gray area as to whether “treatment” defined broadly enough to include administration of PRD screening to mom How to effectively and appropriately “close the loop” on referrals?

Recommendations: Notifications and Informed Consent Consider revising standard forms to notify parents that mental health screening will occur Consider notifying parents of the process for referring to other community or mental health providers Consider written policies and procedures related to the maintenance and release of mental health related data Obtain an ROI to coordinate the referral and “close the loop” with external systems Ask the group whether they have done this

Findings: Liability Treating adults not within traditional scope of pediatric practice Absence of clear standard of care for pediatrician Inference that policy recommendations serve as a proxy for standard of care Case law/risk management: insufficient evidence that addressing maternal mental health outside the scope of pediatric practice Seems reasonable that pediatricians may perform these activities Operational Only

Emergency Protocols Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child?

Recommendations: Liability Limit liability by establishing carefully defined screening, documentation of results and referral policies and procedures

Findings: Privacy and Data Management Guidelines around data management based on maintaining personal health information (PHI) for a single patient and releasing that information based on clearly defined rules No consensus about how best to document screening results and follow-up related to mental health status of the parent of the patient One legal analysis: presence of information in the child’s chart results in it becoming the child’s PHI Typically behavioral health confidentiality held to higher standard by courts

Data Management Key Decisions Where: Record information in the main EHR or in an area intended to have greater security? What: What information is retained (screening score, follow-up plan, conversations at future visits)? Release: How and when is the information released. Does it appear on your patient portal? Kathryn- Operational only Poll how many people put in their main EHR

Recommendations: Privacy and Data Management Consider establishing clear written polices about data points provided or not provided when the child’s record is solicited by another entity (including another caregiver who may have no relation to the mother)

Findings: Billing and Coding Private insurers have range of policies and coverage for PRD screening in practices Colorado Medicaid (NEW!): 3 times a year Billing and coding report

Emergency Protocols Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child?

Identified Gaps Trainings for staff on PRD Referral lists for all communities and clinics Reimbursement that supports comprehensive services and prevention associated with screening in a pediatric perspective Official guidance around policies and procedures on consent, and data management, privacy

Acknowledgements CDPHE Denver Public Health Colorado SIM HealthTeamWorks Project CLIMB Children’s Hospital Colorado