1. “THE NEW MORBIDITY”: ADDRESSING CHILDHOOD BEHAVIORAL AND PSYCHO- SOCIAL PROBLEMS IN PRIMARY CARE COS - 2015 Rangel Family: PFAs: Betty Reyes Taina Sanchez Rebecca Osei Elizabeth Santiago MAs: Wendy Acosta Amarilis Carrera Louisa Soriano Kenia Jones Nurses: Clara Paris Michelle Coleman Carlton Tate Cindy SW: Jessie Rosado Nadia Vasquez Providers: Evelyn Berger Hetty Cunningham Christine Krause Alvin Teodoro Nisha Broodie Kenny McKinley Hong-Ann Nguyen Ashish Ankola Jennifer Cohen Eileen Mercurio Wee Chua Pooja Desai Sylvana Hidalgo Ashley Blanchard Erin Cahill Andrew Wehrman

2. Behavior Problems? Our family unit.

3. Rangel AIM Statement Improve screening and intervention surrounding behavior and psycho-social health in our well-child visits at Rangel  Work with PFA’s, MA’s and RN’s to pre-screen at least 50% of all well children ages 6 mo-11 yrs  Secondary goal to document in our Electronic Medical Record That screens were completed That problems were addressed in 75% of children with positive screens  Standardize and improve our delivery of guidance for specific problem behaviors

4. Why Screen?  The top 5 reasons for child disability are now all mental disorders or developmental disabilities. 1  Nearly 20% of the pediatric population has a DSM disorder, and nearly 50% of those have severe impairment.  Only about 50% of children with emotional and/or behavioral disorders are identified by their primary care physicians. 2  Compared with providers, screens identify twice as many patients with moderate symptoms and nearly 28% more patients with high symptoms. 3 1. Anita Slomski. Chronic Mental Health Issues in Children Now Loom Larger Than Physical Problems. JAMA, July 18, 2012—Vol 308, No. 3 2. http://abpeds.wordpress.com/2014/07/11/mental-health-crisis-among-americas-children-what-should-we-do/http://abpeds.wordpress.com/2014/07/11/mental-health-crisis-among-americas-children-what-should-we-do/ 3. Brown, Jonathan D., and Lawrence S. Wissow. "Screening to identify mental health problems in pediatric primary care: Considerations for practice. " The International Journal of Psychiatry in Medicine 40.1 (2010): 1-19.

5. Baseline Data  Before project, 0 patients/year with behavioral pre-screening prior to MD visits.  Concerns among residents/providers that there is no standardized way to proactively address & then document behavior

6. Identifying a useful tool  Pediatric Symptoms Checklist (PSC-17)  Assesses cognitive, emotional, behavioral problems  17 items – “never, sometimes, often”  Parent (and child when > 8y) complete the screen  Designed for ages 4-18y  Survey of wellbeing of young children (SWYC) includes a Baby-PSC and Preschool-PSC (0-5yrs)  Extrapolated from PSC  Integrates behavior and development with family context/risks (ie toxic psycho-social stressors) Development Behavior Family Risk

9. AIM Statement: Provider performs appropriate intervention Key Drivers: Interventions: QUALITY IMPROVEMENT KEY DRIVER DIAGRAM Improve screening and interventions for child behavior and psycho-social health in our well-child visits at Rangel: 1.Work with PFA’s, MA’s and RN’s to pre-screen ≥ 50% of all well children 6mo-11yrs w/ the Pediatric Symptoms Checklists 2.Document screen and problems addressed in 75% of positive children. 3.Standardize and improve delivery of guidance for specific problem behavior(s) Screens completed Create folders with behavior screens to be distributed by MAs/PFAs Educate Mas/PFAs on work-flow Create box in resident room to collect completed screens after review Educate providers on scoring the screens via lecture Place algorithm on how to interpret/respond in each provider room Educate providers on giving guidance for specific problem behaviors Effective communication between providers and parents Interpretation and documentation of screen Create acronym expander to document screen results Add behavior screen to task column on Eclypsis AND in development section of follow- up notes Make guidance (TIP sheets, etc.) available in each room Schedule appropriate behavior-only f/u visits Develop easy to use database of parent education handouts & referral sources

10. Percentage of Patients Screened MAs trained on handing out screens 16325 Cycle

11. Screening Results Number (%) Total – 88 Positive for behavior problem 29 (33) Positive for parental concern 25 (28) Positive for psycho- social (“Toxic”) stressor 20 (23) Positive for at least one area 44 (50)

12. Percentage of Screen Documented Posted algorithm for interpreting screens in exam rooms

14. Social Work Visits 2014 v. 2015 One Social Worker’s qualitative experience: Patients have had increased show rates for appointments since the beginning of this QI project. New patients who are being referred now are more medically and socially complex. However, these patients have complicated social challenges that may have been missed before a standardized screen. 112 100

15. Pilot feedback on new handouts: Did you get any information sheet from the doctor today? 4/7 Parents were given sheet All 4 who received paper agree that this guidance is helpful If you received a sheet, is this more helpful than information available on the internet? 2/4 believe information from doctor is safer than internet 1/4 believes information online is more helpful given more pictures, videos, and more information available in general

16. Developing of library of resources

18. Conclusion  Achieved our goal of pre-screening for behavioral and psycho-social health issues  Screens have high positive rates  Providers are able to document appropriately, but incorporating fields for behavior screens into EMR will increase this further  Some evidence of increased and improved SW referrals  Resident education has begun:  Providers at Rangel are giving specific didactics on mental health as part of continuity clinic talks  Dr. McGurk will use CDC parent handouts in her talks on normal behavior and development

19. References  “Pediatric Symptoms Checklist.” Massachusetts General Hospital. 2014. Accessed from:http://www.massgeneral.org/psychiatry/services/psc_research.aspxhttp://www.massgeneral.org/psychiatry/services/psc_research.aspx  “Mental Health Crisis Among America’s Children- What Should We Do?” Blog of the American Board of Pediatrics. Posted in Mental Health by abpeds July 11 2014. Accessed from: http://abpeds.wordpress.com/2014/07/11/mental-health-crisis- among-americas-children-what-should-we-do/http://abpeds.wordpress.com/2014/07/11/mental-health-crisis- among-americas-children-what-should-we-do/  The Pediatric Symptoms Checklist. Accessed from: http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst. pdf http://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst. pdf  Survey for the well being of young children (SWYC). Floating Hospital for Children. Tufts Medical Center. http://www.theswyc.org/http://www.theswyc.org/  “Positive Parenting Tips.” CDC National Center Home Page. Child Development. Last revised May 21, 2014. Accessed from: http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/ http://www.cdc.gov/ncbddd/childdevelopment/positiveparenting/  “Materials.” Connected Kids: safe, strong, secure. American Academy of Pediatrics. Accessed from: http://www2.aap.org/connectedkids/material.htmhttp://www2.aap.org/connectedkids/material.htm