1. Behavioral Health Issue Screening and Use of Health Services Deena J. Chisolm, PhD Columbus Children’s Research Institute & The Ohio State University

2. The TARAA Research Team Kelly J. Kelleher, MD, MPH – Principal InvestigatorKelly J. Kelleher, MD, MPH – Principal Investigator William Gardner, PhD - Co-InvestigatorWilliam Gardner, PhD - Co-Investigator Jack Stevens, PhD - Co-InvestigatorJack Stevens, PhD - Co-Investigator Deena J. Chisolm, PhD - Supplemental Co-InvestigatorDeena J. Chisolm, PhD - Supplemental Co-Investigator Lindsay BuchananLindsay Buchanan Teresa Julian, CNP, PhDTeresa Julian, CNP, PhD Jennifer McGeehan, MPHJennifer McGeehan, MPH Funded by NIDA grant #R01MH078629-01Funded by NIDA grant #R01MH078629-01

3. Background Routine screening for behavioral health issues in primary care is recommended by the AAP.Routine screening for behavioral health issues in primary care is recommended by the AAP. Standardized screening is not regularly done because of:Standardized screening is not regularly done because of: –Limited time in the clinical encounter –Limited resources and increased cost for referral and care Computerized self-interviews can help with the first limitation and yield information superior to that in face-to-face interviews for sensitive topics.Computerized self-interviews can help with the first limitation and yield information superior to that in face-to-face interviews for sensitive topics.

4. Trial of Automated Risk Assessment in Adolescents Goal: To improve recognition and treatment of behavioral health problems in adolescents in primary care through:Goal: To improve recognition and treatment of behavioral health problems in adolescents in primary care through: –Risk screening in the primary care waiting room using wireless web-tablets –Immediate provision of scored screening results to clinicians (3 day delay as a control condition) –Motivational Interview follow-up calls for substance users (phase II) Setting nine urban primary care clinicsSetting nine urban primary care clinics

10. Preliminary Results 95% were satisfied with their experience and satisfaction did not vary by race, payor, computer experience, or risk status.95% were satisfied with their experience and satisfaction did not vary by race, payor, computer experience, or risk status. Clinicians in the immediate results group were more likely to recognize behavioral health issues than those who received delayed results.Clinicians in the immediate results group were more likely to recognize behavioral health issues than those who received delayed results.

11. Research Question Do youth who screen positive for behavioral health issues in primary care use more services in the following 6 months than those who screen negative?Do youth who screen positive for behavioral health issues in primary care use more services in the following 6 months than those who screen negative?

12. Methods Independent Variables Mutually exclusive behavioral health issue categories:Mutually exclusive behavioral health issue categories: – None – depression – score of >=25 on the CES-DC – suicidal thoughts – serious thought of ending life past 30 days (PHQ-A) – violence risk – physical fighting or carrying a weapon (YRBS) – substance use – alcohol, marijuana, or inhalants (CASI-A) – multiple risks Potential Confounders: age, gender, service use in previous six months, payorPotential Confounders: age, gender, service use in previous six months, payor

13. Methods Outcome Variables Used data warehouse to gather all visits six months before and six months after screening.Used data warehouse to gather all visits six months before and six months after screening. Service Use VariablesService Use Variables –Any visit –Mental Health related visit – any visit with a diagnosis code included in Clinical Classification Software (CCS) Codes 66-74

14. Methods Analysis Relationships between behavioral health issues and probability of use were tested using chi-squared and logistic regression.Relationships between behavioral health issues and probability of use were tested using chi-squared and logistic regression. Multivariate relationship between behavioral health issues and number of visits were tested using negative binomial regression.Multivariate relationship between behavioral health issues and number of visits were tested using negative binomial regression.

15. Sample Characteristics 1,524 youth ages 11-201,524 youth ages 11-20 72% under age 1672% under age 16 57% female57% female 65% non-white65% non-white 76% covered by Medicaid76% covered by Medicaid

16. Positive Screens

17. Probability of Service Use Within 6 Months By Risk Category

18. Adjusted Odds Ratios for Service Use (reference=no risk) Behavioral Health Issue Any Use* Mental Health* Suicidal Thoughts 2.93 (1.22-6.98) 3.83 (1.38-10.58) Depression 1.06 (0.66-1.69) 2.76 (1.43-5.35) Substance 1.02 (0.51-1.04) 0.53 (0.07-4.02) Violence 1.18 (0.88-1.59) 1.61 (1.01-2.57) Multiple 1.01 (0.75-1.37) 1.79 (1.12-2.87) *Odds ratios adjusted for gender, age group, prior use, and study arm

19. Six Month Visit rate per 100 Youth Behavioral Health Issue Any Visit Rate Mental Health Visit Rate None131.621.5 Suicidal Thoughts 138.738.7 Depression205.6*39.2* Substance142.08.0 Violence153.434.7* Multiple162.842.5* *Difference in visit counts (reference=none) tested using negative binomial regression controlling for age group, gender, use in previous 6 months, and study arm

20. Conclusions Self-reported behavioral health issues factors are common in adolescents seen in primary care.Self-reported behavioral health issues factors are common in adolescents seen in primary care. Youth who screen positive for depression, violence, or multiple risks have higher mental health service use after screening than those with no behavioral issues.Youth who screen positive for depression, violence, or multiple risks have higher mental health service use after screening than those with no behavioral issues. Mental health services use in those who screen positive for depression are still below optimal.Mental health services use in those who screen positive for depression are still below optimal.

21. Implications Primary care screening programs may increase treatment for behavioral problems while creating limited additional burden in the health care system.Primary care screening programs may increase treatment for behavioral problems while creating limited additional burden in the health care system. Systems should consider developing case management approaches for youth with identified behavioral health problems to ensure appropriate use of services.Systems should consider developing case management approaches for youth with identified behavioral health problems to ensure appropriate use of services.

22. Thank You Questions?