1. Behavioral Health Screening & Referral in Pediatric Clinics
Brigette Vaughan MSN, APRN, PMHNP-BC
University of Nebraska Medical Center

2. Setting the stage…
Nebraska has 27 “rural” psychiatrists (only 9 see children), 20 psychiatric nurse practitioners, 61 psychologists, and 0 developmental pediatricians.
Outside of Omaha and Lincoln, only 4 counties have a child psychiatrist
Rural mental health providers are spread over 70,000 square miles and 900,000 lives
There are few resources for children and families, as well as schools and primary care providers for managing behavioral health concerns

3. NAMI Report Card (“Grading the States”, 2006)
Infrastructure D-
Information Access F
Services D
Recovery Supports C-
Overall grade: D

4. Updating the System
The family physician or pediatrician is often the FIRST person consulted regarding behavioral health issues. They have become “defacto” behavioral health providers.
>60% of psychotropic medications are prescribed by primary care providers
Many providers surveyed indicate they are not comfortable prescribing these medications

5. Research has demonstrated that behavioral health issues are “missed” greater than 53% of the time in primary care.
The use of behavioral screening tools in primary care can increase recognition and diagnosis of behavioral disorders up to 70%.

6. LB556
Provides that a trained staff person must be available if a child is receiving telehealth services
The trained staff will create a safety plan if a safety threat results during therapy
Behavioral health screenings should be offered by physicians during physicals

7. The Behavioral Health Center of Nebraska will provide training on children’s behavioral health care for educators serving clinics that provide behavioral health screenings (with parental consent) during physicals and offer integrated child psychologist services on site.
Right now this includes the Valentine, Omaha Children’s Physicians Dundee, and Columbus areas. These areas are engaged in a pilot integrated clinic program (as set up by LB556) to measure effectiveness of routing screenings

8. Establishes consultation services for primary care clinicians caring for children with behavioral health issues in integrated pilot site clinics
The bill establishes regulations on how the integrated clinics will run, and what data will be collected
The bill addresses various reimbursement issues under Title XIX, to include medicaid reimbursements for services provided via telehealth

9. The Vanderbilt Scale
A 55-question assessment tool. It reviews symptoms of ADHD according to the DSM-IV criteria. It also screens for co-existing conditions such as conduct disorder, oppositional-defiant disorder, anxiety and depression, and more.

10. Current Screening Data
Total Screens All Ages (3-18) 1029
Positive
259 (25.2%)
All Ages
Inattention 10.4%
Hyperactivity 8.2%
Combined 6.5%
Older Children 6-18
Inattention 11%
Hyperactivity 7.3%
Combined 5.7%
ODD 10.6%
Conduct 3.5%
Anxiety/Depression 6.9%
Younger Children 3-5
Inattention 9.0%
Hyperactivity 10.0%
Combined ADHD 8.3%
143 f/u Calls
51 successful phone contact
34 psychology service referrals/consults
17 declined services
25 NP referrals/consults
Negative
770 (74.8%)
+ screen-met threshold on scale or requested help
Psych referral includes recommendations given over phone, already a current patient in psychology or scheduled new appt
NP consult includes referrals (primarily Columbus) and phone med consults

11. Number of Areas Scored Above Cut-off (children 6-18 years)

12. ADHD Comorbidity Often Complicates the Diagnosis and Treatment of ADHD
ADHD alone
31%
31%
Oppositional
Defiant
Disorder
40%
Tic Disorder
11%
ADHD
n=579
Conduct
Disorder
14%
38%
Anxiety/Mood
Disorders
Jensen P, et al. Arch Gen Psychiatry 1999;56:

13. LB556 & School Nurses
Integrated care is the goal for behavioral health care in the future. This will reduce stigma, increase access, and reserve more severe cases for psychiatric nurse practitioner and child psychiatrist care.
If a school nurse notices a child is exhibiting symptoms of a behavioral health disorder, this condition should be brought to the teacher and parent’s attention using school policy. The parents should then be referred to a primary care clinic for care, preferably one that offers integrated care (psychologist in-house).

14. Encourage physician colleagues to encourage the use of valid and reliable screening tools in their clinic as a routine part of child physicals.
Encourage parents and physicians to refer to child psychologists/behavioral therapists for combined treatment.
Reach out to MMI and BHECN for needed educational programs to meet knowledge gaps.

15. BHECN http://www.unmc.edu/bhecn/
Howard Y. Liu, M.D.
Medical Director Behavioral Health Education Center of Nebraska (BHECN)
Office Phone: 
Direct Line: 
Pager:  
Heidi J. Keeler, PhD, RN
Asst. Professor, Community Based Health Dept.
Nurse Planner, Continuing Nursing Education
Director of Educational Design, BHECN
Phone: (w)
Fax:
For more information regarding CNE opportunities please visit:

16. Munroe Meyer Institute
Munroe Meyer Institute
Joseph H Evans, Ph.D.
Professor, MMI and Pediatrics
Associate Clinical Director, Behavioral Health Education Center of Nebraska
Munroe-Meyer Institute
University of Nebraska Medical Center

17. Brigette Vaughan MSN, APRN-BC, NP
Nurse Practitioner, Munroe Meyer Institute
UNMC Developmental and Behavioral Pediatrics
Nurse Coordinator, Department of Psychiatry
Child & Adolescent Psychopharmacology Research

18. Questions?