Your child’s health is our #1 priority. MISSION • To serve the whole child, recognizing her/his relationships in the family, school, community. • To provide a medical home to the children and adolescents whom we serve Achieving the Mission GCH is a public-private partnership between: • Hospitals: The two community health systems. • Pediatric Teaching Program (Greensboro AHEC). (The pediatric residents come from UNC-Chapel Hill.) • Guilford County (Department of Public Health and the Department of Social Services). GCH Is A Private Practice… …serving children and adolescents whose families live at, or below, 200% of the Federal Poverty Level– accounting for 60-70% of the children with Medicaid in Guilford county. Insurance status of our patients: 87% Medicaid 6% NC SCHIP 7% uninsured (undocumented immigrants) Visions for GCH • “Cutting edge”: best practices, evidence-based protocols • Comprehensive: especially for children with complex/ chronic conditions • Medical Home: facilitate referrals, assist with logistics, and track referral completion Visions for GCH • Access and Continuity: meet family (as well as practice) needs • Community: be visible in the community and available/responsive to our community resources • Prevention: screen for developmental/behavioral and psychosocial risks and intervene Visions for GCH • Integrate & develop mental health services • Welcome different cultures: appropriate interpretive services. • Affect policy: eg, state Medicaid and SCHIP • Leadership and dissemination Structure: Collaboration • Specialty Staff: co-located and integrated into protocols and processes (including Wraparound services) Asthma/Allergy, D&B Pediatricians, LCSW’s, Neurologist, PhD Psychologist, Child &Adolescent Psychiatrist, Speech & Language Pathologist • GCH Staff: Community Liaisons arrange and track referrals, and link to community resources Quality: Commitment • Participant/pilot for initiatives and best practice protocols for Medicaid (NC Community Care Network) • Leader in local network: – Protocols: ADHD, asthma, dental varnishing, developmental screening & surveillance, diabetes, ED utilization,Take Charge Weight Initiative - Mental Health Integration - Medical Home Project – Reach Out and Read – Advanced Access Scheduling (IHI) Quality: Commitment • On-site specialty care: Asthma/allergy, development & behavior, LCSW’s, neurology, nutrition, psychology, psychiatry • Regular compilation of process and outcome data and biannual chart audit of performance. Quality: Outcomes • 17% decrease in ED utilization for asthma in first year of collaborative protocol • Decrease in no-show rate from 40% 20% • Change in state policy in Medicaid and Public Health (ABCD project at GCH) • Adoption of GCH processes in other practices (e.g. developmental screening tool and community liaison type staff) Leadership and Dissemination • Locally • Statewide • Nationally – AAP – AHRQ – NICHQ – NASHP – Commonwealth Fund ABCD Project – APA Healthcare Delivery Award The Challenges: 44% of children in NC live in low-income families. The use of “the most common and familiar” developmental screening tool was untenable in primary care practice (Denver). The AAP recommends formal screening and surveillance at well child visits. Limited access to professionals with 0-5 expertise: psychiatry, psychology, counselors. The Challenges Continue… Division of MH, SA, and DD Reorganizing: “target” population not inclusive of children atrisk or with mild to moderate problems. Mental Health and Primary Care “Silos” The number of children served by early intervention (EI) is low (1999 Legislative Study indicated between 8-13% of the total 0-3 population could qualify and benefit from EI services - only 2.6 % were served.) Across Medicaid systems of care the average rate of developmental screening was low: (approximately 15.3%) ……… North Carolina Opportunities Statewide promotion of screening and surveillance in Pediatric and Family Practice offices (ABCD, NCPS, NCAFP, Health Check) Early Intervention recognizes Established Risks (includes Reactive Attachment Deprivation) 18 regional CDSA’s (Children’s Developmental Services Agencies) Promotion of co-location models of MH staff in primary care practices. Opportunities continued…. Division of Child Development 5 Star Childcare Licensing System Smart Start Partnerships statewide Regional Child Health Consultants 18 Regional Resource and Referral Centers County Childcare Nurses through Public Health and Smart Start Opportunities continued…. Both Health Check (EPSDT) and Health Choice (SCHIP) allow 26 MH visits annually, with a non-specific diagnosis code allowed for the first 6 visits. Directly-enrolled Medicaid Mental Health providers available to PCP for referral and/or co-location. Social/Emotional Screens for children identified “at risk” from personal/social on developmental screen-facilitated by case managers within local community networks. NCCCN Mental Health Integration Pilots Practice Process SUMMARY OF SOCIAL-EMOTIONAL/BEHAVIORALPROTOCOLS & FLOW PROCESSES visit screen/concern 2nd screen/by referral variation problem AGE 0-5 YEARS 2 mo. & 4 mo. Edinburgh CareManager support LCSW or Maternal Depression or LCSW brief counsel MH provider 6,12,18 or 24, ASQ - at-risk score on Personal- ASQ-SE support 36,48,60 mos. Social CareManager parent educ. LCSW or or LCSW Head Start MH provider any At-risk psychosocial situation ASQ-SE " " (I.e. mat dep, DV, SA) CareManager or LCSW any Parent concern ASQ-SE " " CareManager or LCSW AGE 6-18 YEARS every PE Pediatric Symptom Checklist Depressive symptoms CDI by support LCSW or provider/SW brief counsel MH provider and/or psychiatry Learning/School Behavior packet by School for screening Problems school, then packet completion sent to PCP CDI = Children's Depression Inventory Co-located MH Services in Primary Care Not just a mental health clinic in a primary care practice: more flexible services, may be brief sessions • MH provider partners with PCP during course of regular visits: as needed or crisis. • MH provider involved routinely in visits for children with chronic/complex conditions • MH provider sees child and family for several visit course Benefits of Co-location • Reduction of stigma • Greater convenience for family • Enhanced communication between PCP and MH provider, with opportunity to encourage therapeutic goals. • Improved adherence to treatment • “Cross fertilization” learning for PCP and MH provider • Interdisciplinary team: reintegration of mind and body Community Networking • Attendance at Advisory meetings of LME • Inventory of Resources • Mixer: PCP’s, Psychiatrists, Psychologists, and therapists • Meetings with psychiatrists • Meetings with school personnel, DSS, Juvenile Justice, etc. State & National Activities • NCPS Mental Health/School Health Committee • AAP Task Force on Mental Health • Rethinking Well-Child Care • Commonwealth Fund ABCD Projects • Commonwealth Fund State Technical Assistance Resources • Earls, M, Hay, S, “Setting the Stage for Success: Implementation of Developmental & Behavioral Screening and Surveillance in Primary Care Practice-The North Carolina Assuring Better Child Health & Development (ABCD) Project,” Pediatrics, Vol. 118, No. 1, July 2006. • Foy, J, Earls, M, “A Process for Developing Community Consensus Regarding the Diagnosis and Management of Attention Deficit Hyperactivity Disorder,” Pediatrics, Vol. 115,No. 1, January 2005. • Foy, J, Earls, M, Horowitz, D, “Working to Improve Mental Health Services: The North Carolina Advocacy Effort,” Pediatrics, Vol. 110, No. 6, December 2002.