Pediatric Residency Training and Behavioral Health

Transcription

1 Session # F6 Pediatric Residency Training and Behavioral Health Models and Outcomes from a Multi-site Study Jeffrey D. Shahidullah, PhD, Assistant Professor, Rutgers University, New Brunswick, NJ Paul W. Kettlewell, PhD, Director of Pediatric Psychology, Geisinger Health System, Danville, PA Mohammed H. Palejwala, MA, Doctoral Student, Michigan State University, East Lansing, MI Kathryn A. DeHart, MD, Pediatrician, Geisinger Health System, Danville, PA CFHA 19 th Annual Conference October 19-21, 2017 Houston, Texas

2 Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3 Conference Resources Slides and handouts shared in advance by our Conference Presenters are available on the CFHA website at Slides and handouts are also available on the mobile app.

4 Learning Objectives At the conclusion of this session, the participant will be able to: Identify current training needs related to behavioral health in pediatric residency programs Describe existing models of behavioral health training and the advantages/weakness of each Discuss how aspects of the enhanced training curricula discussed in this presentation may be tailored/adapted for implementation in other training programs across the country

5 Bibliography / Reference 1. American Academy of Pediatrics. (2009). Policy Statement The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care, Pediatrics, 124, Horwitz, S. M., Storfer-Isser, A., Kerker, B. D., Szilagyi, M., Garner, A., O Connor, K. G., Stein, R. E. (2015). Barriers to the identification and management of psychosocial problems: Changes from 2004 to Academic Pediatrics, 15, Stancin, T., & Perrin, E. C. (2014). Psychologists and pediatricians: Opportunities for collaboration in primary care. American Psychologist, 69, McMillan, J. A., Land, M., & Leslie, L. K. (2017). Pediatric residency education and the behavioral and mental health crisis: A call to action. Pediatrics, 139, Horwitz, S. M., Caspary, G., Storfer-Isser, A., Singh, M., Fremont, W., Golzari, M., & Stein, R. E. (2010). Is developmental and behavioral pediatrics training related to perceived responsibility for treating mental health problems? Academic Pediatrics, 10,

6 Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

7 Key Points 3 behavioral health training curricula Assessing residents response to curricula 1 st year outcomes/next steps

8 Background PCPs positioned to serve increasing number of youth w/ BH concerns in PC 50-70% of patients seen in PC have BH referral concerns (Belar, 2008; Gatchel & Oordt, 2003) 1/4 of pediatric visits involve discussion of BH concerns (Cooper et al., 2006)

9 Background National shortage of specialty BH providers (Kim, 2003) often difficult for PCPs to make external referrals When specialty providers are available lack of follow through by patients to these externally referred services (Cummings & O Donohue, 2011) Resultedly, PCPs often tasked w/ managing BH care inhouse PCPs report difficulty in evaluating & treating BH conditions (Steele et al., 2010)

10 Background Oft cited barrier to providing effective care lack of training for PCPs in BH (Serby et al., 2002) Most PC medicine residency program directors report BH training is important & should be emphasized more (Chin et al., 2000) Most directors of accredited PC residency training programs in internal medicine & pediatrics report suboptimal training on topic (Leigh et al., 2006)

11 Background Numerous calls for improved biopsychosocial training for physicians: o Goldberg et al., (1980). The Lancet o IOM (2001). Crossing the Quality Chasm o Healthy People 2020 (2010) AAMC added large behavioral & social sciences section to MCAT in 2015 Due to lack of formal training in BH that medical providers receive AAP (2009) highlighted key aspirational BH competencies for pediatric PCPs o AAP attainment of competencies requires innovations in residency training

12 Background Several BH training initiatives developed in past 10 years varying levels of intensity & results o Didactic focused (talks, seminars, readings, vignettes) o Varying levels of results, intensity, & feasibility

13 Overview Describe an innovation in residency training by delivering a BH curriculum to pediatric residents in setting in which BH services are integrated w/ pediatric PC Obtain data from 1 st -, 2 nd -, & 3 rd -year residents Attitudes, Knowledge, & Skills in BH service delivery Data from 3 pediatric residency programs in Northeastern United States Findings may support rationale for innovation in BH servicedelivery that also aims to improve BH competencies for pediatric PC Implementation science framework Most effective dosage (training intensity) from 3 relatively feasible options?

14 Dependent Variables Attitudes/Comfort Knowledge/Skills in behavioral health

15 Independent Variables Innovation in residency training formal behavioral health curricula 3 different dosages (intensity levels) 1) Integrated Service-Delivery + Didactic focus 2) Didactic focus only 3) Control (training as usual)

16 Site 1 Service-Delivery + Didactic Exposure Service-Delivery Components Requiring an embedded BH provider Warm hand-offs On-site BH provider (psychologists) Direct patient care in well and sick-child visit Behind-the-scenes consults On-site behavioral health providers (psychologists) Indirect patient care in conjunction w/ a well-/sick-child visit Observation/Performance Feedback Feedback provided for ADHD, anxiety, depression, and/or suicide risk assessments Direct observations by embedded psychologists Feedback provided Joint Precepting Psychologist precepts residents and psychology fellows in shared space Psychologist also precepts the resident in conjunction with medical preceptor Didactic Components Not requiring an embedded BH provider Lectures on BH topics 18 lectures throughout AAP/AACAP practice parameters Readings and quizzes AAP/AACAP practice parameters Evidence-based evaluation of ADHD, anxiety, depression, suicide/crisis intervention; Quizzes over readings with feedback Vignettes Vignettes describing behavioral health concerns Identify course of treatment based practice parameters Feedback provided 16

17 Performance Feedback ADHD Components Inquire about inattention, hyperactivity, impulsivity, academic/behavior problems More than one setting Data regarding: Duration of symptoms Severity of symptoms Degree of impairment Physical exam Screen for sensory impairments (vision/hearing) Administer parent/teacher rating scales Determine diagnosis Symptom criteria met in IA and/or HI domains Age of onset Impairment in multiple settings Process Components Components Completed? 1 Allowed for performance feedback to occur in a setting preferred by Yes No the resident 2 Clearly stated that the performance feedback conversation would Yes No remain confidential and it would not be used for formal performance evaluation within residency program 3 Asked/allowed time for resident to self-assess their performance Yes No before completing checklist and receiving feedback from observer 4 Completed checklist of practice parameter steps completed by resident Yes No 5 Provided positive feedback for checklist items completed and Yes No observed strengths 6 Provided feedback on interpersonal and communication skills Yes No 7 Provided suggestions for improvement that were accompanied by rationales for why changes are important and how changes will improve outcomes 8 Allowed residents time to reflect on/ask questions about suggestions, if they so chose 9 Summarized performance feedback session in the form of major take-aways and/or upcoming action steps Yes No 10 Performance feedback session lasted between 5 and 15 minutes Yes No Yes Yes No No

18 Site 2 Didactic Exposure-Only Service-Delivery Components Requiring an embedded BH provider Not provided Didactic Components Not requiring an embedded BH provider Lectures on BH topics 18 lectures throughout the year AAP/AACAP practice parameters Readings and quizzes AAP/AACAP practice parameters Evidence-based evaluation of ADHD, anxiety, depression, suicide/crisis intervention Quizzes over readings with feedback Vignettes Vignettes describing behavioral health concerns Identify course of treatment based practice parameters Feedback provided 18

19 Date Behavioral Health Seminar for Pediatric Residents Topic 10/16 The Behavioral Health Referral 10/23 Pediatric Behavior Management: The Basics 11/6 Pediatric Behavior Management: The Skills 11/20 ADHD: Evaluation (AAP) 12/4 ADHD: Treatment (AAP) 12/18 Anxiety: Evaluation (AACAP) 1/8 Anxiety: Treatment (AACAP) 1/22 Motivational Interviewing in Primary Care (1) 2/5 Motivational Interviewing in Primary Care (2) 2/19 Depression: Evaluation (AACAP) 3/4 Depression: Treatment (AACAP) 3/18 Suicide/Crisis Response (AACAP) (1) 3/25 Suicide/Crisis Response (AACAP) (2) 4/1 Sleep 4/22 Feeding 5/6 Toileting 5/20 Child Abuse 6/3 Schools (SPED system & bullying) 6/17 Medically unexplained physical symptoms 19

20 Examples of Readings AACAP & AAP Practice Parameters American Academy of Child and Adolescent Psychiatry. (2007). Depression Practice Parameters. American Academy of Child and Adolescent Psychiatry. (2007). Anxiety Practice Parameters. American Academy of Child and Adolescent Psychiatry. (2001). Suicidal Behavior Practice Parameters. American Academy of Pediatrics. (2011). ADHD Practice Parameters. Pediatrics in Review articles Resources from AAP s Mental Health Toolkit

21 21

22 Quizzes

23 Vignettes What are your treatment recommendations? V-1: Mom reports severe ADHD symptoms; teachers say pt is an angel ; clearly does not meet DSM criteria for diagnosis V-2: Mom reports severe and persistent ADHD symptoms; teachers report severe and persistent ADHD symptoms; clear impairment V-3: Mom and teachers report borderline severity ADHD and borderline impairment

24 Site 3 Control Group; Treatment as Usual Service-Delivery Components Requiring an embedded BH provider Didactic Components Not requiring an embedded BH provider Not provided Not provided 24

25 What to Measure? AAP (2009) - Policy Statement Call for innovations in BH training of pediatricians Need to address attitudes, knowledge and skills in BH service delivery

26 How to Measure? What did we consider? What had previously been used? What to do when there is no gold standard?

27 Guiding Principles Goal not primarily to develop a measure(s) Address attitudes, knowledge and skills with Frequently occurring BH problems that pediatricians deal with Those for which there are some published (well accepted) standards of care Which categories did we select?

28 Our Response Qualitative and Quantitative Approach Quantitative 1. Self-reported Knowledge Their views about how skilled or competent they considered themselves to be 2. Measured Skills in Behavioral Health key categories: ADHD, anxiety, depression, suicide risk assessment

29 1 st Year Outcomes Must use caution to not overstate results Pilot study Small sample size Difficult to detect significant differences Feasibility of implementation of curricula Utility of assessment tool for tracking response to curricula

30 Background: Participants/Sites Variable Training as Usual (TAU) (n = 12) Didactic Only (DO) (n = 20) Didactic + Integrated Primary Care (DIPC) (n = 24) Mean age, y (SD) (2.29) (2.41) (2.29) F=1.74, p=0.19 Males, n (%) 1 (8.33%) 2 (10%) 6 (25%) χ 2 =2.50, p=0.33 Hard science major, n (%) 10 (83.33%) 12 (60%) 21 (87.5%) χ 2 =5, p=0.11 MD degree (vs DO), n (%) Weeks in medical school on mental health rotation, w (SD) 1 (8.33%) 12 (63.16%) 12 (50%) χ 2 =9.27, p=0.01 DIPC > TAU DO > TAU 4.83 (2.33) 5.75 (1.74) 5.08 (1.95) F=1, p=0.38 Completed mental health training (outside of medical school/ residency, n (%) 12 (100%) 19 (95%) 20 (83.33%) F=3.32, p=0.21 Clinical rotations in primary care in medical school, n (%) 6 (100%) 20 (100%) 16 (100%) Did those primary care practice(s) have an embedded behavioral health provider on site 5 (83.33%) 10 (50%) 2 (12.5%) χ 2 =10.53, p=0.004 TAU > DIPC DO > DIPC What type were they? Psychologists 2 (40%) 7 (70%) 2 (100%) χ 2 =2.55, p=0.48 What type were they? Social Workers 4 (80%) 9 (90%) 1 (50%) χ 2 =1.86, p=0.66 How likely are you to go into primary care? (1-10) 3.67 (3.78) 6.90 (3.38) 5.06 (3.71) F=1.61, p=0.22 Would you be more likely to go into primary care pediatrics if it was an integrated practice with embedded behavioral health providers? Current residency year, n (%) PGY-1 PGY-2 PGY-3 1 (16.67%) 16 (80%) 9 (56.25%) 5 (41.67%) 2 (16.67%) 5 (41.67%) 9 (45%) 4 (20%) 7 (35%) 13 (54.17%) 5 (20.83%) 6 (25%) χ 2 =8.2, p=0.01 DO > TAU χ 2 =1.17, p=0.89 Completed DBP rotation, n (%) 2 (33.33%) 4 (36.36%) 4 (25%) χ 2 =0.43, p=0.88

31 Self-reported Knowledge in Behavioral Health Evidence-based Practice Parameter Training as Usual (TAU) Didactic Only (DO) Didactic + Integrated Primary Care (DIPC) Significance Pre (n = 12) Post (n = 9) Pre (n = 20) Post (n = 17) Pre (n = 24) Post (n = 27) ADHD Evaluation Treatment Anxiety Evaluation Treatment Depression Evaluation Treatment Time*DO (p=0.02) Knowledge scores range from 1 (least confident in knowledge of evidence-based practices) to 10 (most confident in knowledge of evidence-based practice)

32 Measured Skills in Behavioral Health Evidence-based Practice Parameter Training as Usual (TAU) Pre (n = 12) Post (n = 9) Didactic Only (DO) Pre (n = 20) Post (n = 17) Didactic + Integrated Primary Care (DIPC) Pre (n = 24) Post (n = 27) Significance ADHD Evaluation Treatment Anxiety Evaluation Treatment Depression Evaluation Treatment Time*DO (p=0.04) Possible scores ranged: ADHD evaluation, 0-16; ADHD treatment, 0-9; anxiety evaluation, 0-11; anxiety treatment 0-3; depression evaluation, 0-15; depression treatment, 0-8

33 Conclusions/Next Steps IBH is promising approach to training/learning enhancement of pediatric residents Knowledge vs. Skills Dunning Kruger Effect? Continue to track outcomes over 3 years of residency More research/advocacy needed for yet another benefit that IBH may provide (in addition to access, costs, clinical care improvement)

34 Session Evaluation Use the CFHA mobile app to complete the evaluation for this session. Thank you!