1. 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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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

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

11. 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.

12. 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

13. 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

14. 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)

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

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

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

18. 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

19. 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.

20. 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.

21. 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”

22. 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?”

23. 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?”

24. Sample with Scripting
Talmi, 2007 Project CLIMB Children’s Hospital Colorado. Do not replicate without permission

25. 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

26. 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?

27. https:// Make a handout

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

30. 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

31. Questions??