The Partnership Access Line Enhancing the Capabilities of Primary Care Mental Health Services Terry Lee, MD University of Washington Evidence Based Practice Institute

PAL Program Funded By: ► WA Medicaid (DSHS/HRSA) ► WA State Legislature

Our Call to Action ► Primary Care Providers (PCPs) are the Front Line of mental health care  Nationally PCPs reported to provide about half of all common mental disorder care  1 in 5 child PCP appointments are for a behavioral health chief complaint ► PCPs are typically uncomfortable with this role  Simply were not trained in mental health W Gardner and K Kelleher, 2000 New Freedom Commission, 2003

Why do all of these kids see their PCP instead of a psychiatrist? ► 6.6 child psychiatrists per 100,000 WA children ► This calculates to 1 child psychiatrist for every 820 children with serious emotional disturbance (GAF <50) in Washington C Thomas and C Holzer, 2006 Shaffer et al (SED rate 5.4%)

Lack of Access to Child Psychiatrists ► Rural area access is abysmal, and is not likely to improve  US mean of 0.3 child psychiatrists per 100,000 youth ► We will not train our way out of this bind by producing more child psychiatrists  No significant increase in trainees for years  Average age of a child psychiatrist is >50 WJ Kim, 2003 C Thomas and C Holzer, 2006

Access to Mental Health Therapists ► Psychiatrist access not the only problem ► National shortage of skilled child therapists ► It’s why you’re all here—our therapist workforce needs both expansion in numbers, and training in current best practices New Freedom Commission, 2003

How Can Mental Health Become Part of the Child’s Medical Home? ► Provide PCPs with:  Mental health education  Rating scales/tools  Resource finding assistance ► When PCP wants to engage outside resources, it must be a real option  Rapid consultation for any difficult cases  Care collaboration with specialists

Telephone Based Consultations ► Get “just in time” processing  offer assistance only when provider wants it ► Teachable moments  “problem based learning” on provider’s own patient ► Reach a large audience with few resources  use our limited specialist resources more efficiently  In-person consults are less resource efficient ► Match intervention to the level of primary care provider engagement  call as often as they want  “raise all the boats”

Design of PAL ► “PAL” stands for “Partnership Access Line” ► Started April 2008  PCP develops any MH question about a child  PCP or assistant calls the PAL toll free number ► PALS (7257)  PAL assistant answers, asks basic questions  Child psychiatrist on duty picks up line, or is paged ► “When in Doubt, Call Your PAL”

PAL: How It Works Continued ► PCP and child psychiatrist talk  if a FFS Medicaid client, PCP can get reimbursement  Diagnosis/therapy/medication recommendations ► If questions remain, a rapid patient consult appointment is offered (Medicaid/Healthy Options)  Patient can come to Seattle Children’s Hospital ► Or new office in Spokane for PAL program  When more convenient, a telemedicine appointment is offered ► Olympia or Longview

PAL Consult Appointments ► Consultant will not prescribe, or take on case themselves ► Referral to other specialists for ongoing care  MSW on our team now an expert on the regional referral process  provide bibliotherapy and other resource recommendations

Care Guide, Distributed to all PCP’s:

PAL Site Assignment

Calls Are Slowly Increasing

Continuing to Recruit New Users

Getting the Word Out ► Mailings ► Phone calls ► Office visits ► Conferences ► Word of Mouth ► Building professional relationships takes time

Types of PAL Calls ► Calls tend to be about difficult cases  86% had estimated GAF <60 ► Topics are all over the map  medications part of the question for 2/3 rd ► About 1 in 10 calls lead to in person consults

Age of PAL Call Subjects Age 6-12 Age 12+ Age 0-6

Medicaid Impact ► Despite the open invitation to call us, most calls are about Medicaid clients  37% of all the state’s children are enrolled in Medicaid  64% of calls to the PAL program have been about DSHS clients

Therapy ► ½ the time when a provider called to discuss a medication, the call ended with recommendation to start a new evidence based psychotherapy ► Now employ 2 social workers who assist providers with connecting to therapists

Satisfaction Measures ► PCP and family satisfaction very high  Average 4.8 on 5 point scale ► Collected testimonials have all been positive

Research ► Need quality research done on impact of PAL to justify its continued existence ► DSHS IRB approved study  Evaluation by EBPI

Take Home Points ► PAL is a primary care provider service ► Therapists might want to encourage PCP’s to utilize the PAL service ► PAL makes referral recommendations ► PAL makes referral recommendations  based on information provided to us by therapists  i.e. someone doing CBT gets a CBT referral  call Lauren or Jessica at to let them know your referral preferences

Contact PAL program

Collaborating with Psychiatrists ► HIPAA ► Exchange information