Perspectives On Integrated Child and Adolescent Mental Health Care in Oregon

Transcription

1 Perspectives On Integrated Child and Adlescent Mental Health Care in Oregn Tan Ng MD Fellw, PGY-5 Child and Adlescent Psychiatry Oregn Health and Science University March 5 th, 2013

2 Objectives Describe the basic levels f care in the current cmmunity mental systems in place fr children and adlescents in Oregn Analyze varius perspectives frm mental health rganizatins f the ptential impact f the frmatin f Crdinated Care Organizatins (CCO s) n these systems Describe different mdels f integrated mental health care fr children and adlescents that may becme mre imprtant in the future Take perspective n the evlutin f the rles f a child psychiatrist with the emergence f integrated care Discuss new ideas abut hw t implement these new rles in training

3 Least restrictive Spectrum f Services Preventin Outpatient And everything else in between Intensive Children s Treatment Services/Wraparund Day Treatment Residential/Behaviral Rehabilitatin Services Sub-acute Inpatient Secure Child/Adlescent Inpatient Prgram Acute Inpatient

4 Spectrum f Services Mental health and addictins services fr thse with OHP are currently being prvided by: Mental Health Organizatins cunty r grups f cunties e.g. Jeffersn Behaviral Health Cs, Curry, Duglas, Jacksn, Jsephine, Klamath Cunties Cmmunity Mental Health Agencies e.g. Trillium Family Services, Kairs Cmplex interweaving between these rganizatins and their services depending n cntracts with OHP

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6 Rise f CCO s Triple Aim IMPROVE the verall HEALTH f the ppulatin Prvide BETTER QUALITY CARE REDUCE COSTS f health care service delivery Oregn legislatin 2011 Crdinated Care Organizatins reginal ACO (Federal) prvider-driven CCO (Oregn nly) all players invlved in sharing risk Representatin frm Primary Care, Specialty Care, Mental Health, Addictins, RN/NP s, Dentists, Cmmunity Members, Reps frm majr health systems

7 Hpe f CCO s Meet the Triple Aim develp integrated systems f health care Definitin f Integrated Care (fr this talk) Mental health and addictins within primary care and cmmunity

8 Hpe f CCO s Align and integrate care reduce administrative csts, waste, and duplicatin Primary care hmes centralized crdinatin hub fr physical, mental, and dental health, as well as addictins Fcus n utcmes rather than services Encurage preventin Engage cmmunity t address its wn health needs Address disparities

9 Hpe f CCO s Start with Medicaid, then mve int Medicare, then PEBB/OEBB Single budget fr CCO Flexible and nt tied t services prvided (i.e. fee fr service) Sharing risk all tgether

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11 Targets fr CCO s At least fr HealthShare Align strategic initiatives t address high-risk ppulatins lw hanging fruit Highest acuity (and utilizers f resurces) patients with cmbined physical health, mental health, and addictins issues divert away frm the hspital NICH prgram is addressing these kinds f kids and their families Maternal and early childhd health Rughly 50% f all kids brn in Oregn are brn int Medicaid Nt as much fcus has been placed n child and adlescent mental health EXCEPT recent push by Oregn Senate President Peter Curtney

12 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study by Felitti et al. (1998) Lked at adult ppulatin Cmpared # f adverse childhd events (ACE s) and adult risk behavir, health status, and disease ACE s Psychlgical abuse Physical abuse Sexual abuse Substance abuse in husehld Mental illness in husehld Mther treated vilently Criminal behavir in husehld

13 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study (1998) ACE s, risk fr disease in adulthd Odds ratis fr disease with 4+ ACE s Mental Health and Addictins Physical Health Depressed 2 weeks in last year 4.6 Ischemic Heart Disease 2.2 Hx f suicide attempts 12.2 Cancer (any) 1.9 Alchlism 7.4 Strke 2.4 Smker 2.2 Obesity (BMI 35) 1.6 Used illicit drugs 4.7 COPD 3.9 IV drug use 10.3 Diabetes 1.6 Sexually-Transmitted Infectin 2.5 Hepatitis r Jaundice 2.4

14 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study (1998)

15 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study (1998) Interventin by child and adlescent mental health prviders Preventin

16 Gals: What I did with my elective time T understand hw child and adlescent mental health services play int the develpment f CCO s and int integrated care systems T understand what the rle f a child and adlescent psychiatrist will be with these new develpments Prcess: Interviewed administratrs and staff f varius mental health rganizatins and cmmunity mental health agencies, as well as thers invlved in CCO s and plicy, t see what they thught Face t face r by phne Attended talks abut CCO s and integrated care Explred current mdels f integrated care being practiced with yuth Fcus n hmeless yuth system (HYC in Multnmah Cunty)

17 What d cmmunity mental health prviders think f CCO s? Cncerns abut what services will lk like CCO s will have t recnstruct the mental health system t fcus n cmmunity-based care Many physicians are nt used t thinking in public health mdels There is ging t be less traditin child mental health services and mre emphasis n educating primary care Child psychiatrists are ging t need t practice at the tp f their license A lt f this is ging t be incumbent n us ging ut and shaking hands There will never be enugh child psychiatrists t be able t staff these integrated mdels

18 What d cmmunity mental health prviders think f CCO s? Cncerns abut funding Payment needs t be aligned with hw care is delivered What mdels f care will be paid fr? Will preventin actually be funded by the CCO s r will we still have t rely n grants? Will child psychiatry have t fight ther specialties fr funding? Will MHO s really want t share their budgets? When is this all ging t stabilize s that we can make ur budgets?

19 What d cmmunity mental health Hpes prviders think f CCO s? Cmmunicatin shuld be better, and that shuld make it easier t treat kids Walls are ging t be made mre permeable Over time, there shuld be mre delineatin f what can be managed by a PCP and what shuld be managed by a child psychiatrist CCO s shuld be able t prvide fr mre creativity in terms f having patients and family access a wide cntinuum f care within a cmmunity base CCO s shuld be able t help with cvering mre kids and prviding mre resurces We might actually be able t effectively d preventin!

20 What d cmmunity mental health prviders think f CCO s? My verall impressins Nbdy knws hw this will all shake ut with CCOs Great discmfrt with change Wary, but hpeful Everybdy recgnizes that mdels f care (and f reimbursement) will need t be changed

21 Least restrictive Spectrum f Services Preventin Outpatient And everything else in between Intensive Children s Treatment Services/Wraparund Day Treatment Residential/Behaviral Rehabilitatin Services Sub-acute Secure Child/Adlescent Inpatient Prgram Acute It s at these levels where there is high fcus n integrated care

22 Mdels f Integrated Care C-lcatin in primary care clinics Behavir specialist n-site Child Psychiatrist n-site Telepsychiatry OPAL - K

23 Mdels f Integrated Care Schl-Based Health Centers primary care hme set up inside f schl Mst (but nt all have sme c-lcatin mdel)

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25 Mdels f Integrated Care Outreach mdels Fcusing n assertively engaging yuth and families where they are at Nvel Interventins in Children s Health (NICH) prgram Medical ACT team Hmeless Yuth Cntinuum (Multnmah Cunty)

26 Elements f Integrated Care Establishment f stable, safe, psitive, and trusting relatinships with child and adlescents is the highest pririty The mre relatinships, the better N services withut engagement Outreach is critically imprtant Cnnect t services Circumvent barriers t accessing care Avid having yuth get stuck in ther systems (e.g. plice, legal, gangs)

27 Elements f Integrated Care Cnnecting at-risk kids t a cmmunity is als a high pririty Helping yuth make cntributins t their sciety in what ways they can, e.g. art, music, educatin, jb training, etc. Cnnecting with thers wh have been able t vercme similar bstacles, e.g. bullying, addictins, etc. Empwerment f members f a cmmunity t engage with ther members t prmte the health f their wn Peers can help reach ut t thse wh are afraid f the systems Trained staff n-site within the cmmunity Knw hw t help kids (and families) transitin int mental health r addictins treatment when they are ready

28 Elements f Integrated Care Need fr higher level cmmunicatins within and acrss rganizatins Accessible and centralized data system Vertical and hrizntal flw f cmmunicatin Cmmn framewrk and language

29 Elements f Integrated Care Flexible funding Sharing and redistributin f resurces t thse services that need it the mst Need t develp sme way t keep the system selfsustaining There is a need fr advcates fr integrated systems f care fr at-risk yuth ppulatins n a plitical level

30 Schl-Based Health Centers

31 Schl-Based Health Centers Integratin f mental health int schl-based health clinics has high ptential Schls are where the kids are at de fact mental health treatment centers Reduce barriers t accessing care Less disruptive t schl day Built-in cmmunity Outreach and preventin effrts at schls can reach ut t the wider cmmunity Empwerment f students t help their wn peers Training f schl staff t be aware f the scial and emtinal develpment f their students and t guide them t services when needed

32 Schl-Based Health Centers Difficulties fusing cultures f medicine, mental health, and academia Child and adlescent psychiatrists will need t be culturally-cmpetent Need t find ways t make these sustainable financially Get ff reliance n grants Advcacy

33 Rles f a Child & Adlescent Psychiatrist in an Integrated System f Care Traditinal ffice-based delivery may nt serve the needs f certain ppulatins r f integrated care systems Need t utreach t bth patient ppulatin and t system f care t maximize effectiveness Mre cnsultative/supervisry rles Liaisn with physicians, case managers, therapists, and CADC s t prvide supervisin and recmmendatins Fr mre cmplex patients, evaluate and treat mre thrughly as needed

34 Rles f a Child & Adlescent Psychiatrist in an Integrated System f Care Rle as part f a treatment team will be mre peripheral Limited direct treatment with ptentially less n-ging psychtherapeutic wrk Fcus n cnsultative management f the patient with gal f returning treatment t manageable level fr ther team members Likely increased administrative rles Wrking with system t ptimize quality f care QI prjects, utcme measuring, training, versight, utilizatin review

35 Rles f a Child & Adlescent Psychiatrist in an Integrated System f Care Need t be mre active in advcacy and leadership Desired by ppulatins and integrated care systems On-ging participatin can help shape the delivery f care as it evlves Must be able t prmte need fr mental health and addictin services n systemic and plitical levels The ability fr a child and adlescent psychiatrist t prvide a culturally-cmpetent develpmental perspective within a bipsychscial mdel is a strng cmmdity when develping new systems

36 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study (1998) Interventin by child and adlescent mental health prviders Preventin

37 Why Child and Adlescent Mental Health Needs t Be Addressed by CCO s ACE Study (1998) ***Child and Adlescent Psychiatrists can advcate and guide bth interventin AND preventin effrts*** Interventin by child and adlescent mental health prviders Preventin

38 Impact n Child and Adlescent Psychiatry Training Need t set up pprtunities t wrk in integrated mdels f mental health care Learn hw t be cnsultants t pediatricians and family practitiners Learn hw t be cnsultants t systems f care Allw pprtunities fr utreach t cmmunities learn abut preventin Mdel and prmte advcacy effrts frm a hspital level t a cmmunity/state/natinal level

39 Integratin in ur relatinships create integratin in ur brains. -Daniel Siegel

40 Special Thanks Ajit Jetmalani MD, prject supervisr and Divisin Directr, OHSU Mike Franz MD, supervisr David Jeffery MD, Trillium Family Services Drew McWilliams, COO, Mrrisn Child and Family Services Margie MacLed, Directr f Quality, Prgram Develpment and Preventin Services, Mrrisn Child and Family Services Beth Putz, Directr f Services fr Children, Albertina Kerr David Pllack MD, OHSU Lisa Kaskan MD Jhn Gale MD, Medical Services Directr, LifeWrks NW Mary Mnnat, CEO, LifeWrks NW; Member, Bard f Directrs, HealthShare Dennis Mrrw, Executive Directr, Janus Yuth Prgrams Jhn Duke, Clinical Directr, Outside In C. Wayne Sells MD, MPH, Medical Directr, Outside In Mllie Janssen, Prgram Manager, New Avenues Fr Yuth Ashley Thirstrup, Direct Services Manager f Yuth Services, NAYA