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      Marsha Raulerson, MD, MEd, FAAP
I have no relevant financial relationships with
the manufacturers of any commercial products
and/or provider of commercial services in this
CME activity.

I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation
     The World Health Organization has made the
      point that “there is no health without mental
      health” since “health is a state of complete
      physical, mental and social well-being and
      not merely the absence of disease or
      infirmity.”---This is the goal of the patient-
      centered Medical Home.

World Health Organization. Mental Health Strengthening Our Response. Available at: Accessed June 20, 2011.
     More than 14 million children and
      adolescents in the U S ( 1 in 5) have a
      diagnosable mental health disorder that
      requires intervention or monitoring.
     Up to ½ of all lifetime cases of mental illness
      begin by age 14
     Only 20 to 25% receive treatment

Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. The Future of Pediatrics:
Mental Health Competencies for Pediatric Primary Care. Pediatrics. July 2009; 124:1 410-421; doi:10.1542/peds.2009-1061
   Results in adults who use more health services
    and have higher health care costs.
   Mental illness is the number one cause of
    disability in adults.
   Mental health issues often lead to a downward
    spiral of school failure, poor employment
    opportunities, and poverty
   The consequences of mental illness for the
    individual and for society are staggering:
    Unnecessary disability, unemployment, substance
    abuse, homelessness, incarceration, and suicide.
   In the US, ,the cost of untreated mental illness is
    more than 100 billion dollars each year.
   Suicide is the 11th leading cause of death in
    the US and the 3rd leading cause of death
    among those 10-24 years old.
   On average, 45% of suicide victims had
    contact with a primary care physician within 1
    month of suicide!
   Access
   Lack of Transportation
   Financial constraints
   Child mental health professional shortage (In
    Alabama there are 20 child psychiatrists)
   Stigma related to mental health disorders
   Appropriate training and collaborative
    relationships so primary care pediatricians
    can deliver mental health services to children
   Colocation of mental health professionals in
    the primary care setting
   Enhance coordination between primary care
    and psychiatry using electronic
    communications including telemedicine
   Much of the burden of identifying and treating
    child and adolescent behavior disorders falls on
    primary care pediatricians
   Primary care initiates services for ADHD,
    depression, anxiety disorders and substance
    abuse as well as behavior problems that do not
    meet the criteria for a coded DSM-IV diagnosis
    (crying baby, temper tantrums, oppositional
    behavior, the teenager with an attitude, etc)
   70 to 80% of all psychotropic medications are
    prescribed by primary care physicians
   Increasing access to outpatient Mental Health
    Services does not significantly increase
    healthcare costs because it reduces
    psychiatric hospitalizations.
   Getting policy makers to believe this is a
    challenge especially with current budget crisis
   Allow primary care clinicians to provide and
    authorize services for common mental health
   Compensate primary care for the mental
    health services they provide
   Implement procedures to fully support parity
    in benefit packages
   Support the principle of diagnostic parity.
    (Mental health disorders result in distress and
    functional impairment just as medical
    illnesses do)
   Support the principle of procedural parity For
    example, children’s mental health
    professionals, as well as primary care
    clinicians should be paid appropriately when
    reporting evaluation and management
    Current Procedural Terminology (CPT) codes
   Remove disincentives for appropriate and
    accurate diagnostic coding by allowing
    primary care clinicians to be paid for services
    on reported mental health diagnostic codes
   Support the use of standardized tools by
    paying for mental health screening at routine
    medical visits
   Recognize treatment-planning and treatment
    team meetings that may not include the
    patient or his family
   Support payment for primary care or mental
    health professionals for sessions with parents
    or care givers
   Restructure networks providing Mental
    Health services to include primary care
   Support colocation models of mental health
    professionals working with the Medical Home
   Support payment for evidence-based
    psychosocial interventions as well as
    psychopharmacologic therapy
   Support payment for non-face-to-face care
    such as communications with community
   Enhance coordination between primary care
    and mental health providers (electronic
    communications including telemedicine)
   Develop a risk-adjustment system that takes
    into account the complexity of the child’s
   If concerns addressed early may not lead to
   Maternal depression affects 1 in 7 new
    mothers. If symptoms are severe and not
    treated, the mother’s mood disorder can
    ultimately harm her child. Since the baby’s
    doctor is usually the professional she will see
    the most in her child’s first year, it is
    important for him to screen for maternal
   Last Forever: the adult a child will become is
    shaped by aggregate experiences of daily life
    over the long term
   Bonding with a care-giving adult is crucial
    during those years
   So what’s a pediatrician to do? We are usually
    the only health care professionals to see the
    child with his care givers—we see problems
    now and coming
   Third Party Payors to encourage and support
    pediatricians in screening for maternal
    depression and for childhood mental disorders

   Third Party Payors to encourage and support
    pediatricians to diagnose and treat or co-
    manage with a child psychiatrist: ADHD,
    depression, anxiety, substance abuse, and
   Support continued collaboration between mental
    health professionals and primary care clinicians
    to integrate mental health services into the
    Medical Home.
   January 2004 1st Child psychiatry Institute at
    Point Clear. Al. Chapter AAP President Invited
   CATCH planning grant applied for and started
   Stake Holders Focus groups held
   Research done to identify the needs
   Program launched with local hospital, mental
    health at state and local level and local
   State Child psychiatry Institute held yearly for
    next 6 years. More than 100 pediatricians
    have participated
   Child in need of evaluation/treatment identified
    by primary care physician( 4 pediatricians 3
    family practice physicians)
   15 page history and identified concerns
    completed by caregiver
   Child and family register with local mental health
   Secretary in Pediatric office sends all paper work
    to psychiatrist (Dr. Tom Vaughan at Children’s
    Hospital, Birmingham) and makes appointment
   After child seen, psychiatrist emails full report to
    both primary provider and mental health
   Primary care physician writes prescriptions,
    follows up with patient, when needed
    arranges for prior approval for medications
    and communicates with family and
   Mental health provides counseling, and case
   Counselor sees patient at school whenever
   Turf Issues
   Payment
   Telecommunications infrastructure T-Lines vs
   Personnel changes
   Lack of available counselors trained in
    Cognitive Behavioral Therapy
   General lack of understanding of mental
   The Main Thing is to remember The Main
    Thing: That the Main Thing is the Main Thing
    (Yogi Berra)
   Over 200 patients seen
   Show rate about 90%
   Kids like the television format
   Services provided locally with decreased
   Joy in seeing children with serious mental
    illness getting on with their lives
 Anxiety               Oppositional   defiant
 Anorexia   nervosa     disorder
 ADHD                  Panic disorder

 Autism                PTSD

 Bulimia               Schizophrenia

 Depression            Trichotillomania

 Impulse   control     Tourette’s syndrome
  disorder              Fetal Alcohol
 OCD                    syndrome
 Fragile X syndrome    Separation Anxiety
               The Massachusetts Child
               Psychiatry Access Project
                    A Platform for Integrating Child
                     Psychiatry with Primary Care
                                         Barry Sarvet, MD
              Baystate Health, Tufts School of Medicine

AAP Future of Pediatrics Preconference

I have no relevant financial relationships with the
manufacturers of any commercial products and/or
provider of commercial services in this CME activity.

I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation.
Collaborative Mental Health Care for
Children in the Primary Care Setting
The sustainable provision of direct and indirect clinical
consultation, education, and care coordination
assistance to a primary care practice by a consistent
group of children's mental health professionals on a
real-time basis.
Enabling the primary care practice to provide an
appropriate level of assessment and mental health
treatment and to coordinate the care for children who
require the services of specialists.
            Child Psychiatry
            Workforce Issues
       •   Estimated 1.6 child and adolescent psychiatrists per
           1,000 children and youth with DSM IV rated severe
       •   Overall rate of 8.6 child psychiatrists per 100,000
           children and youth (range Alaska 3.1 to MA 21.3)
       •   Poorly distributed throughout country
       •   Inverse relationship between # of child psychiatrists
           and percentage of youth in poverty
       •   No increase in number of child psychiatrists trained
           per year between 1995 and 2006(census~700)

Thomas and Holzer, JAACAP,
Suitability of Primary Care
Providers for Mental Health
•   Patients and families often feel more
    comfortable and trusting of primary care
•   Primary care providers have the
    opportunity for prevention and screening
•   Primary care providers know the
    developmental context of symptoms
•   Addressing psychiatric issues in primary
    care setting can reduce stigma
    Pediatrics and Mental
•   Costello E et al: Psychopathology in pediatric primary
    care: the new hidden morbidity, Pediatrics, 1988
    ‣   routine care, pediatricians sensitivity=17%
•   Pediatricians prescribing 84.8% of the psychotropic
    meds in large national office-based practice survey
    (Goodwin et al, 2001)
•   Organized medicine gets behind mental health in mid-
    90’s to present
    ‣   Bright Futures in Mental Health
    ‣   AAP Mental Health Task Force
    ‣   AACAP Initiatives 2005 through 2008
Child Psychiatrists and PCPs:
Why is it so hard for us to work
• Managed Care: Carving Out of Mental
• Scarcity
• Time-intensiveness of traditional CAP
  practice not matching up with high
  volume primary care operation
• Confidentiality concerns
• Stigma/Marginalization of Psychiatry
  from Mainstream Healthcare
            MCPAP Goals
•   Improve access to treatment for children
    with psychiatric illness
•   Promote the inclusion of child psychiatry
    within the scope of practice of primary care
•   Restore a functional primary care/specialist
    relationship between pcp’s and child and
    adolescent psychiatrists
•   Promote the rational utilization of scarce
    specialty resources for the most complex
    and high-risk children
           Program Design
•   Dedicated teams deployed regionally across state
•   A state governmental program, through the MA
    Dept of Mental Health, administered by the
    Medicaid MCO.
•   Serves all children and families in MA regardless
    of insurance status
•   Teams hosted by prominent children’s healthcare
    institutions with existing networked relationships
    with pediatricians
•   Operating budgets of teams are fully funded,
    subject to reconciliation of third party
  6 MCPAP “Hubs                                                                   Mass General Hospital
                                                                                        Lauren Hart
                                                                                   Leah Grant, LICSW
                                                                                   Jeff Bostic, MD EdD
                                                                                    Susan Swick, MD
                     UMass Memorial Med Ctr
                            Kelly Chabot
                      Martha Moore, LICSW
                                                 Northshore Children’s Hospital
                                                   Catherine Elizabeth Walsh
                                                                                      Lisa Price, MD
                                                                                     Betty Wang, MD
                                                                                       Bruce Masek
                      Deanna Pedro, LICSW             Lisbeth Costa, LICSW
                      Mary Jeffers-Terry, CNS   Patricia Gardner-Goodof, LICSW
                     Matthieu Bermingham, MD           Jefferson Prince, MD              Tufts Med Ctr
                          William O’Brien                Lisa D’Silva, MD          Children’s Hospital Boston

                                        *             Michele Reardon, MD
                                                         Joseph DiPietro
                                                                           *           Jessica Thompson
                                                                                    Alexis Hinchey, LICSW
                                                                                       John Sargent, MD
                                                                                     Smita Srivastava, MD
                                                                                   Christopher Bellonci, MD

                                                                 *                     Kayoko Kifuji, MD
                                                                                        Mimi Thien, MD
     Baystate Med Ctr
        Arlyn Perez
   Jodi Devine, LICSW
                                       *           *             **
                                                                                        Brian Kurtz, MD
                                                                                        Greg Brownstein
                                                                                        Mary Ahern, RN
     Barry Sarvet, MD
    Bruce Waslick, MD
    Shadi Zaghloul, MD
     Sara Brewer, MD
     John Fanton, MD
                      *                                          *                McLean Hospital/Brockton
Marjorie Williams-Kohl, CNS                                                          Amanda Medeiros
                                                                                   Emily Loomis, LICSW
                                                                                    Charles Moore, MD
                                                                                     Jeanne Dolan, MD
                                                                                       Mark Picciotto     *
    Additional MCPAP
• Urgent Child Mental Health Information
• Network mapping, resource directory
• Mental health system advocacy
• Organized CME programs
• MCPAP website (
• 407 practices (enrolled)
• 1440 FTEs of primary care providers
• 84,439 encounters as of June 30, 2011
• Over 20,322 encounters in FY 2011
• 81% utilization
• Over 1,465,000 children (98% of state)
  now covered
• Cost = $.18 per child per month
             Utilization through FY10
All six regions
up and running
                  Number of MCPAP Encounters by Month
                              All Regions


                                  Behavioral health screening
                                  tool mandate- Dec 31, 2007

                    All six
                    regions up
                    and running



                   MCPAP Encounter Types

                                             FY05 –
                                FY2010       FY 10
             Activity          n=18,527    N=65,604

•Phone Consultation with PCP     39%         39%

•Care Coordination               31%         27%

•Face to Face Evaluation         10%         11%

•Phone Member/Family             10%         10%

•Follow Up Visit                 2%          4%

•Other                           8%          8%
Percentage of Encounters by Age FY 2008

       Percentage of MCPAP Phone PCP Encounters by Age
                    Category FY 2010 n=6668

 45%              44%




 15%   13%                               14%


       0-5        6-12       13-16      17-21        >21
  Reason for contact (% of total
                                             FY 2010   April 08 – June 10
Reason for Contact                           n=6,709       N=14,938
Resources –Community Access                    38%           37%
Diagnostic                                     36%           40%
Medication Question                            26%           27%
Medication Evaluation                          25%           26%
Parent Guidance                                 7%            7%
School Issues                                   5%            4%
Second Opinion                                  2%            3%
Crisis                                          2%            2%
* Reason for contact field added in April of 2008
                                                                                Mean MCPAP Satisfaction Survey Responses
                                                                             Baseline, FY 2008, FY 2009, FY 2010 (n=385 at baseline)


Mean response (1 = Strongly Disagree, 5 = Strongly Agree)

                                                                                                                                       access to child
                                                                                                                                       psychiatry for
                                                                                                                                       my patients

                                                                                                                                       Usually able to
                                                                                                                                       meet needs of
                                                            3                                                                          children with

                                                            2                                                                          Able to receive
                                                                                                                                       child psychiatry
                                                                                                                                       consult in timely

                                                                Baseline   FY 2008              FY 2009               FY2010
                                                                              MCPAP Satistaction survey

          Outcomes of MCPAP PCC Screening Tool Implementation
                     Number of surveys mailed = 828
             Number of respondents who did not use MCPAP = 15
                    Number of responses analyzed = 288
                                FY 2009
                      Strongly                                   Strongly
                      Disagree   Disagree   No Opinion   Agree    Agree

I have increased my
  ability to use
  behavioral health
  screening tools      4%         14%         25%        48%      9%
            AACAP Access
            Initiative Project
   Promoting Best Practice in the Detection, Assessment, and
   Treatment of Adolescent Depression in the Primary Care
   Setting: Implementation of the GLAD-PC in Two
   Large Primary Care Practices

Campaign for America’s Kids
Disease management project for
Adolescent Depression with two large
primary care practices
 • Utilizing GLAD-PC recommendations
 • Includes broad mental health
    screening at well-child visits with PSC-
 • PCP’s trained in diagnostic
    assessment, treatment selection,
    initiation and monitoring of treatment
 • Enabling role of MCPAP: practical and
School MCPAP Pilot
• Enrolling 6 schools as MCPAP
• Change in consultation role
• Linkage with primary care: Interaction
  with primary MCPAP relationships
• Adjustment counselors, principals,
  school RN’s, school psychologists,
  guidance counselors

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