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Implementing Innovations in Primary Care
As was observed by several workshop participants, primary care is a universal access point for health care. When families seek care for their infants, children, or adolescents, an opportunity occurs for medical home-based interventions intending a trajectory for lifelong health.
One panel at the workshop looked specifically at the primary care setting. Models for care touched on by the panelists include preventive services obtained at regularly scheduled well-health supervision visits, connecting mental health practitioners with pediatricians remotely or in colocated practices, seeing parents as well as children in the same practices or health centers, and using information technology to help integrate care for children, adolescents, and their families.
A PRIMARY CARE PROGRAM IN THE BRONX
Montefiore is the largest health care system in the Bronx and a pioneer ACO. Ten years ago it started an integrated early childhood two-generation mental health initiative under the Healthy Steps program, with an effort to identify families at risk during the prenatal period. Interviews with women who are pregnant or within 5 years of giving birth focus on trauma, toxic stress, and the parent–child relationship and attachment, all within primary care pediatrics. Parents have their own clinicians within the program, so parents and children can receive care at the same time.
From these mandated visits in the early years has emerged a fully lifespan integrated behavioral health system in the primary care network, with 21 practice sites across the Bronx seeing about 300,000 patients overall each
year, said Rahil Briggs, associate professor of clinical pediatrics at Albert Einstein College of Medicine, director of Healthy Steps at Montefiore, and director of pediatric behavioral health services at Montefiore Medical Group. Every newborn visit has trauma screening followed by annual screening in the first year of life for both parents and children. Universal screening for mental health is a part of every well visit. For adolescents, the program has developed short-term modules for depression, anxiety, attention, conduct, and trauma and is working on modules on obesity and substance use and misuse.
Workforce development is a challenge, said Briggs, with her biggest challenge being to find qualified psychiatrists and psychologists, despite being in New York City. “If I hire a bunch of child psychologists, social workers, and child psychiatrists who are used to working in an outpatient mental health clinic and ask them to do short-term population-based health care for a clinic with 10,000 kids, it’s not going to happen.” Briggs noted that she has just 1 child psychiatrist for every 20,000 children in the system. They are colocated and integrated into the biggest sites and consult to the smaller sites. They have monthly collaborative office rounds where they train pediatricians, starting with what is ADHD and progressing to the psychopharmacology of treatment.
Another issue is the need to move away from fee-for-service approaches. New York State is a carve-out state, which has been very challenging for integrated behavioral health, Briggs said. Providers have long lists of phone numbers to call for preauthorizations, and major payers in the state can have different behavioral health carve-outs. Within a fee-for-service framework, the concept of medical necessity becomes problematic. “Is medical necessity enough to be the infant child of a mother with postpartum depression? . . . I would argue that it is, but it’s not where we are right now.”
Finally, Briggs pointed out that if prevention works, children will not receive a diagnosis, “and nobody is paying for that still” as we operate in a payment system based on diagnosis. Another challenge is to do more peer support and group-based interventions around parenting in primary care settings.
PREVENTION USING THE BRIGHT FUTURES GUIDELINES
The Bright Futures Guidelines, currently published by the American Academy of Pediatrics, dates to the early 1990s, with a vision of health supervision in the context of family and community. Goals of Bright Futures include enhancing the delivery of well-child care to infants, children, and adolescents with a focus on lifelong health, consistent with the attitude
toward health envisioned in the ACA. Bright Futures seeks to translate that vision into work that can be done in pediatric and family medicine practices.
The soon to be published fourth edition of The Bright Futures Guidelines features increased emphasis on the social determinants of health and life course health, observed Joseph F. Hagan, Jr., a clinical professor in pediatrics at the University of Vermont College of Medicine and Vermont Children’s Hospital. The ACA designates Bright Futures as the standard of care for preventive services from birth to 21 years of age. Hagan said that the ACA requires that insurance carriers reimburse for services called for in Bright Futures, thus its contributors and editors have set a high standard for evidence for what is recommended for practice. Historically many primary care preventive services did not have evidence for effectiveness because they had not been studied, he pointed out. Now new study and evidence is being applied to preventive services recommendations.
Hagan noted that some clinicians push back on some of the guidance offered by Bright Futures by saying they already have too much to do and cannot provide services that are not reimbursed. They ask why they should screen for something if they perceive they have nothing to offer to address what they might find. Hagan added that clinicians note chronic difficulty finding consultants for children and adolescents, especially for mental health services. The ACA seeks to remedy these concerns, Hagan explains, and Bright Futures suggests a system of care that is community based to enhance services.
ACCESSING MENTAL HEALTH EXPERTISE IN MASSACHUSETTS
The Massachusetts Child Psychiatry Access Project (MCPAP) is a program that connects pediatricians and child psychologists with primary care to improve children’s access to mental health care, said Barry Sarvet, medical director for the project, chief of child and adolescent psychiatry at Baystate Medical Center, and clinical professor at Tufts University School of Medicine. A statewide project that is about a decade old, MCPAP is for all pediatricians and children regardless of payer and is publically funded. Teams staffed with child psychiatrists operate a hotline that is open to pediatricians in a catchment area. Almost all of the pediatricians in the state are affiliated with the teams, which allows them to use the hotline, and they can call whenever they have any kind of question related to mental health and talk with a child psychiatrist. The psychiatrist can provide advice, answer questions, see the patient for an expedited psychiatric evaluation, and work with a care coordinator on the team to try to find services that the child needs:
It’s a preceptorship model of primary care provider education, in which a resident comes out of the exam room to present the case to a clinical preceptor and ask questions. With MCPAP, this conversation occurs through a dedicated hotline, and the child psychiatry consultant is also available, when necessary, to follow-up with a face-to-face evaluation, resulting in more detailed recommendations to the pediatrician.
MCPAP is focused on secondary and tertiary prevention, but it also recognizes maternal depression to be a critical area for primary prevention and has spun off a program to address this issue as well. In addition, the project provides educational programs.
About 30 child psychiatrists in Massachusetts have been involved with the project, with six teams located in academic medical centers covering six regional areas. It is not a colocated model, Sarvet noted, which places some limits on what can be done. Many practices have integrated colocated therapists providing care coordination and engaging with families around mental health needs, with the MCPAP child psychiatrist providing additional consultation on the case. One goal is to reduce the unnecessary use of medication, so consultation questions regarding medication treatments often lead to discussion on the use of psychotherapy as preferable treatment plan, he added. “The purpose of MCPAP consultation is to improve knowledge of best practice guidelines for children’s mental health, including a wide range of therapeutic interventions beyond medication treatment,” Sarvet said.
The project is scalable, because it spreads a small workforce over a large population, tries to optimize the use of child psychiatrists to train other people to extend the resource further, and identifies children who need to be referred to specialists. It also has been successful in getting legislation approved to have insurance companies operating in Massachusetts provide support for the program. “The mechanism is the same as the mechanism for paying for immunizations, so we’ve become part of the public health infrastructure.”
A challenge with the project is that it uses a “pull” rather than a “push” model, said Sarvet. Pediatricians have to call to get the service rather than the service automatically provided within their practices. Practices also need to have the motivation and internal workflows to follow the advice that is offered, Sarvet observed. “Beyond training and consultation, there is enormous need for process improvement efforts to help practices incorporate attention to mental health within their primary care workflows.”
A large number of states are developing similar models, which is leading to a national network of child psychiatry access programs. However, each program is funded differently, Sarvet noted, and more standardized funding streams would help promote these kinds of efforts.
A MEDICAL INFORMATICS SYSTEM IN INDIANA
The Child Health Improvement through Computer Automation (CHICA) system is a clinical decision support system layered on top of an existing electronic medical record (EMR) system that has been developed over the past decade by Steve Downs, Jean and Jerry Bepko Professor of Pediatrics and vice chair for general pediatrics at Indiana University School of Medicine, and his colleagues. When a child comes into the clinic, CHICA downloads that patient’s EMR, runs hundreds of rules, and selects 20 yes or no questions to ask that family. The questions are displayed on an electronic tablet that is given to parents as they come into the clinic. They answer the questions and return the tablet to the medical assistant or nurse when the child is brought back to be roomed. Their answers to those questions are added to the EMR system, another set of hundreds of rules is applied to the enriched data set, and six reminders are provided to the pediatrician. “It’s not 12 reminders, and it’s not 8 reminders, it’s 6, because that’s what they will tolerate getting in a busy primary care pediatric practice,” said Downs. Each alert is associated with a checkbox with which physicians can document how they have responded to the alert.
The guidelines come primarily from the American Academy of Pediatrics, with contributions from the U.S. Preventive Services Task Force (USPSTF), the Centers for Disease Control and Prevention, and other organizations. The idea is to quickly ask high-sensitivity, low-specificity, or moderate-specificity surveillance questions in the waiting room and focus the physician’s attention on important if not salient issues that need to be dealt with for that child. For instance, the system screens for maternal depression, domestic violence, autism, food and utility insecurity, symptoms of school failure, attention deficit hyperactivity management, and environmental tobacco smoke. Television watching, tuberculosis, immunization, and lead screenings are also conducted. In this way, the system not only improves the quality of care but captures data that are not captured in other systems.
CHICA does not create another information system, Downs said. Rather, it is layered on existing EMRs to add functionality. Furthermore, randomized controlled trials of the system have demonstrated improvements in the quality of care, he said.
Downs is working on what he calls CHICA for all. “We would like to make this a service that is available to anyone through their existing EMR systems.” But enormous barriers exist, including developing the workforce for health care and for medical informatics, the expense of developing and connecting systems, and the existing rules around meaningful use, which have distracted from creative ways to use health information technology, he said.
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