Pregnancy Related Depression (PRD) Screening in the Pediatric Setting: Clinical and Operational Considerations Western Slope ENSW/SIM Collaborative Learning Session – Grand Junction, CO Dec 2018

What we think motherhood looks like . . . When we think about a mother’s feelings associated with the birth of her newborn child, we think of joy, excitement and wonderment

The reality for many Colorado mothers . . . 2012 – 2014 Nearly 1 in 10 (9.6 percent) women who had a recent live birth reported experience of postpartum depressive symptoms since their new baby was born 196,000 live births = 19,000 children For many mothers in Colorado, this is not always the reality. Pregnancy-related depression and anxiety are the most common complications of pregnancy and yet it is estimated more than 75% of new mothers remain untreated Nearly 10% of women in Colorado reported symptoms of post-partum depression

Adapted from the National Scientific Council of the Developing Child Sources of toxic stress in young children . 13% 14% 7.5% We know untreated post partum depression is not good for the caregiver, but it also has a profound impact on young children. It represents 13% of the sources of toxic stress in young children. It is also important to note that there may be overlap in these areas as some mothers who have postpartum depression may also have substance use disorders or may be neglecting or abusing their children. Postpartum Depression Source: O-Hara & Swain (1996) Parental Substance Abuse Source: SAMHSA (2009) Neglect & Maltreatment Source: Finkelhor et al. (2005) Adapted from the National Scientific Council of the Developing Child

Maternal Depression: Central Role in Wellbeing Over a Lifetime Outcome Impact of Depression on Children Adverse Birth Outcomes Premature delivery: 3.4x more likely Low birth weight baby: 4x more likely Developmental Milestones Height-for-age at age 5: 40% increased odds of being ≤ 10th percentile Emergency Dept Visits - Child Asthma: 2-3x more likely to have visit in the past year School Readiness & Performance 30% less likely to be Kindergarten ready Adult Health Smoking: 1.8 – 2.8X more likely Poor general or mental health: 1.3 – 2.3x more likely Limited activity: 1.8 – 3x more likely Untreated depression and anxiety can have lasting impacts on children as they grow into adulthood Because of your focus on early childhood, it is important to highlight that 30% of young children whose mothers suffered from untreated maternal depression were less likely to be kindergarten ready

Focused Impact Medicaid mothers and children 0-5 – greatest at- risk population and greatest opportunities for moving the needle 45% of live births (66,581) covered by Medicaid – 30,000 moms 10% prevalence pregnancy-related depression – 3,000 moms 34% of children on Medicaid (560,000) are aged 0 – 5 (206,351) Nationally, pediatricians provide a majority of all office visits for children aged 0 -5 (80%) CCHAP’s has extensive experience and knowledge of the Medicaid program and for the initial implementation of the pregnancy-related depression toolkit, we are focused on the Medicaid population. All women, irrespective of age, race, and income, are at risk of pregnancy-related depression and anxiety; however, younger and low-income Colorado women report even higher rates of postpartum depressive symptoms than their older, higher-income counterparts. If you look at the numbers, we believe there is real opportunity to impact the lives of mothers and their children and reinforces the idea that the pediatric setting is the right setting to do this work.

AAP pushes 2Gen approach for providers Pediatrician – first responder Changing outcomes for children facing adversity requires transforming the lives of adults who care for them Screening moms for pregnancy-related depression was not traditionally viewed as the role of the pediatrician However, the American Academy of Pediatrics now strongly recommends that pediatrics consider family and environment factors that impact a child’s health – this is commonly referred to as a 2-generation approach The AAP’s recommendations include screening for maternal depression in the pediatric setting Pediatric primary care providers are often seen as first responders in primary care as they are often a mother’s first and most frequent contact with the healthcare system after delivery

The Operational Gap for Providers: My training didn’t cover this! WHO Do I screen? Is their OB/Gyn also screening? WHAT Do I tell moms? Tool do I use? PHQ-2/9 EPDS GAD WHEN Do during the visit do I screen? How frequently? WHERE Do I refer patients? HOW do I… Bill? Create a workflow? Get clinical training? Align my clinical work with my claims? Close the loops on referrals? Pediatricians are heeding the recommendations of the AAP but pediatricians face some unique challenges because mom is not a patient of the practice On the clinical side, a pediatrician hasn’t been trained on the available screening tools. A pediatrician must also address and respond to the screening itself, as well as appropriate referrals to resources or treatment for the mother. Underneath the surface of the clinical challenges are the business considerations such as ethics, consent, risk management/liability, privacy, documentation and data management issues. risk management~liability~consent~EHR

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?” Child is the patient of the pediatrian

Operational Components Prior to Screening Notifications and Informed Consent Screening frequency Screening Workflow Introducing the screener to caregivers Documentation Liability

Screening Frequency The AAP recommends integrating postpartum depression surveillance and screening at the 1-, 2-, 4-, and 6-month visits. Universal screening can normalize PRD, normalize the screening process and assure families that their pediatric office is a safe and appropriate place to talk about how things are going.

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 How to effectively and appropriately “close the loop” on referrals? Consider ROI to effectively coordinate care with external systems

Introducing the Screener Workflow and Consistency are key Caregivers may feel more comfortable completing the screen on pencil and paper Caregivers may feel more comfortable completing the screen once roomed Who is present during the visit may impact validity of the score. Assess and monitor dynamics and culture Culture and language may impact the validity of the score The verbal and written introduction is an important part of normalizing the PRD screen Can assure mothers that PRD is common and there are effective treatment options available

Documentation and Data 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? 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)

Billing and Coding Medicaid: use G codes for positive and negative screens Commercial: CPT code 96161 caregiver screen Medicaid: Reimburses 3 screens in the child’s first year

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

Clinical Considerations Choosing a Tool Scoring the tool Clinical conversations Emergency Protocols Referrals and tracking

Choosing a Tool The Edinburgh Postnatal Depression Screen (EPDS) The Edinburgh Postnatal Depression Screen is recommended by the Colorado Department of Public Health and Environment (CDPHE) for screening in pediatric settings Recommended in Ped setting by AAP, American Academy of Family Physicians, the American Congress of Obstetricians and Gynecologists, and the US Preventive Services Task Force The Patient Health Questionnaire-9 (PHQ-9), which is a diagnostic tool for general depression

EPDS Scoring Positive items receive a score of 1-3 10+ Indicates risk for Depression 14+ Considered a Positive Screen Item 10 Self Harm Clinical Judgement always supersedes scoring Score of Zero can be just as concerning as 14+ The EPDS is available in both a ten question and a three question format.   One study of the three question survey (n=199) found the EPDS-3 form had a sensitivity of 95 percent, a negative predictive value of 98 percent and identified 16 percent more depressed women. In a larger subsequent study (n=914), the EPDS-3 identified 40.1 percent more women with potential depression, including all of the women who were identified in the longer form  Suggest deleting as this makes it sound like the 3-question is a screener for only anxiety and not depression.

PHQ-9 Scoring Positive items receive a score of 1-3 Intended to assess symptoms within the past 2 weeks Always review with the patient and assess for risk, especially if item #9 is endorsed.

Screener Review and Starting the Conversation Stigma “Many women feel anxious or depressed during pregnancy or postpartum” “A woman deserves to feel well” “Many effective treatment options are available” https://www.colorado.gov/pacific/sites/default/files/HTW_PRD_Pregnancy-Related-Depression-Guideline_09-30-2013.pdf

Screener Review and Starting the Conversation Explore Expectations: Pregnancy and postpartum experiences and expectations vary “How are you feeling about being pregnant/a new mother?” “What has surprised you about being pregnant/a new mom?” “What has it been like for you to care for your baby?” “What beliefs or practices related to pregnancy or soon after the baby is born are especially important to you?” https://www.colorado.gov/pacific/sites/default/files/HTW_PRD_Pregnancy-Related-Depression-Guideline_09-30-2013.pdf

Screener Review and Starting the Conversation Explore Social Support “Who can you talk to that you trust?” “How have your relationships been going since becoming pregnant/a new mom?” “Who can you turn to for help?” https://www.colorado.gov/pacific/sites/default/files/HTW_PRD_Pregnancy-Related-Depression-Guideline_09-30-2013.pdf

Sample with Scripting https://www.colorado.gov/pacific/sites/default/files/HTW_PRD_Pregnancy-Related-Depression-Guideline_09-30-2013.pdf Talmi, 2007 Project CLIMB Children’s Hospital Colorado. Do not replicate without permission

Emergency Protocols Do you have a written protocol for when a mother indicates she may be at risk for harming herself or her child? Practices should develop and test guidance for emergency situations prior to screening Utilize existing referral and emergency protocol tools

Community Referrals What resources, services and programs are available in your community? What kind of partnerships have you created in your community? What are the gaps in your community with respect to resources, services and programs? What is needed to close those gaps?

https:// Make a handout https://www.colorado.gov/pacific/sites/default/files/HTW_PRD_Pregnancy-Related-Depression-Guideline_09-30-2013.pdf

CCHAP Readiness Checklist Tool Property of CCHAP; do not use, replicate, or disseminate with CCHAP permission

Coming Soon! CCHAP Pediatric PRD Toolkit Assessment Workflows Legal Forms Referrals and Resources Coding and Billing CCHAP has identified the development and implementation of a pediatric-focused pregnancy-related depression toolkit. This toolkit is a comprehensive guide to supporting the prevention, identification and treatment of depression in pregnant and postpartum women. Screening Tools Data & Outcomes

Questions??