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Francis E. Rushton , M.D. F.A.A.P.

Adding Community Services to Your Pediatric Practice Gain KNOWLEDGE OF STRATEGIES FOR ADDING OR ENHANCING COMMUNITY SERVICES WITHIN YOUR. Francis E. Rushton , M.D. F.A.A.P. “I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider

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Francis E. Rushton , M.D. F.A.A.P.

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  1. Adding Community Services to Your Pediatric PracticeGain KNOWLEDGE OF STRATEGIES FOR ADDING OR ENHANCING COMMUNITY SERVICES WITHIN YOUR Francis E. Rushton, M.D. F.A.A.P.

  2. “I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.” I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

  3. What we plan to cover • Screening for those families at risk of poor mental health outcomes • Adding services within the practice • Mental Health Professionals • Care Coordinators • Positive Parenting (Reach Out and Read) • Linking to Services outside the practice • Home Visitors • Parenting Programs • Developing new services collaboratively • Well Baby Plus

  4. What do Parents Want Discussed?From 2000 National Survey of Early Childhood Health

  5. Family Experience with Primary Care Physicians and Staff • Families emphasized that having a primary care pediatrician ask about development, emotional and behavioral issues during well care visits was important and would help normalize mental health issues. It also helps to make families feel more comfortable discussing these issues. They also stressed the importance of having primary care pediatricians use mental health screening tools, questionnaires and checklists as part or routine clinical practice • National Alliance on Mental Illness May 2011

  6. Home Visitation Formal Social Capital Programs Child care School Systems Medical Home Parks Early Intervention Social Service Transportation Other health care WIC Program Informal Social Capital Extended family Friends Neighbors Housing Education Housing Information needs Cultural beliefs Language Child development outcomes -optimal intellectual growth -safe and healthy -motivated for learning -capable of reciprocal relationships -capable of emotional self regulation -sense of conscience And responsibility Family characteristics 1.Family Mental Health 2.Child characteristics 3.Socioeconomic Status 4.Family Connectedness

  7. Screening is the first step • Developmental Screening • Maternal Depression Screening • Socioeconomic distress • Language issues • Social Capital and Supports • Social Isolation • Domestic Violence • Familial Substance Abuse • Family Mental Illness • Autism • Child Mental Health Status • Special Health Care Needs

  8. Many psychosocial screens available • 2 Question screen • Edinburgh Depression Screen • Domestic Violence Screen • Dubowitz PSC Screen • Kemper/Kelleher protocol • Orr’s A Social Environment Inventory (SEI) and pre-natal form (PSEI) • Our Beaufort screen

  9. Kelleher/ Kemper Protocol • Parental depression • Parental substance abuse • Domestic violence • Parental history of abuse as a child • Housing instability • Family Health Habits • Inadequate social support

  10. Pediatric Screening Questionnaire (PSQ) (Dubowitz) • Easy to read • Easy to answer (yes/no) • Brief • Convenient, time to complete • Voluntary • Part of SEEK Program at Maryland

  11. During the past month, have you often been bothered by feeling down, depressed or hopeless? ?

  12. □ Yes □ No In the last year, have you been hit, slapped, kicked, or otherwise physically hurt by a partner (for example, a husband, boyfriend, or other intimate partner)? □ Yes □ No Do you think your partner has a problem with alcohol or drugs?

  13. Comparing the PSQ to Standardized Measures PSQ Standardized Measures Depression Beck Depression Inventory II Domestic Violence Revised Conflict Tactics Scale Substance Abuse CIDI – Drug and Alcohol Sections Food Security USDA – Food Sec./ Hunger Core Module Caregiver Stress Parent Stress Index – Short Form

  14. Prevalence RatesPSQStandardized Measure • 19%depression - past month 18% • 13% abused by a partner – ever 9 - 79% • 5% drug/alcohol abuse - past year 17% • 33% food insecurity - past year 31% • 30% high levels of stress 21%

  15. Other Screens • Child Health and Development Interactive System (CHADIS) Developed by Barbara Howard and Ray Sturner at Johns Hopkins University, Computerized version www.childhealthcare.org • ASQ-SE (Ages and Stage Socio-Environmental)

  16. BEAUFORT PEDIATRICS, PA • In house mental health counselor (MSW) • Care coordinator for children with special health care needs • Parent coordinator • Strong links to local health department and PT/OT • Joint staffings for home visitor services • Oldest ROR program in SC

  17. Beaufort Stress Index • Modified from Orr’s Prenatal Social Environment Inventory (PSEI) Orr ST, James SA, Caspter R: Psychosocial stressor and low birth weight: development of a questionnaire. Journal of Developmental and Behavioral Pediatrics: 1992; 13 (5): 343-47 • Available online in “A Practical Guide for Improving Child Developmental Services”: http://www.cmwf.org/usr_doc/mod3_Sample_PsychosocialScreen_Stresstest.pdf

  18. Beaufort Stress Index • Family characteristics: illness, death, personal health, living arrangements, financial worries, employment, substance abuse, school, • Informal social supports: marital arrangements, other family members • Maternal mental concerns: concerns about pregnancy, ability to be a parent, fears. Positive scores correlate with depression • Child Characteristics

  19. Beaufort Stress Index • is quick and easy for families to complete • has been assessed for reliability and validity • the individual questions on the screen identify specific social issues that can be addressed • the screen is less intrusive than others

  20. A Stress Index: Beaufort Pediatrics Modified PSEI Social Inventory] • Have any of these things happened in your life in the last year? Yes No • A family member died. • You worried about the safety of your children. • Someone close to you was in an accident. • You were hospitalized for something besides having a baby. • You worried about a health problem (such as high blood pressure, diabetes, etc.). • You worried about how your neighborhood affected your children. • Your husband or boyfriend lost his job. • One of your children was in an accident. • You were ill for longer than a week. • You worried about your children’s emotions. • You worried about the baby’s health when you were pregnant. • You had to put off starting prenatal care because of money. • You lost your job • Your husband or boyfriend had a drinking problem. • Someone close to you got in trouble with the law. • You worried about being able to be a good parent. • You worried about how breaking up with your husband or boyfriend would affect your children. • One of your children had a chronic health problem.

  21. 19. You worried about spotting, bleeding or pain when you were pregnant. 20. Your home was too crowded or needed repair to be safe. 21. One of your children had a serious illness. 22. You worried that other children might be a bad influence on your own. 23. You worried about having enough money to pay your bills. 24. You and your husband or boyfriend broke up. 25. You worried because you had problems with an earlier pregnancy. 26. Someone in your family was sick for longer than a week. 27. A family member had money problems. 28. A family member was using drugs. 29. Caring for the baby or your children all the time was a problem for you. 30. You had problems with your mother or father. 31. A family member had a drinking problem.

  22. 32. You and another family member didn’t get along. 33. You worried when you were pregnant about how your drug use would affect the baby. 34. You were sick to your stomach a lot with your pregnancy. 35. You wanted to go back to school but you couldn’t 36. You were unhappy in your job. 37. You worried about labor and childbirth. 38. Your husband or boyfriend was without a job for more than a month. 39. You were without a job for more than a month.

  23. Screening Medicaid Newborns in Beaufort, SC With Stress Index • 100 total patients • Low risk 0-6 47 positive responses • Medium risk 7-9 26 positive responses • High risk > 10 27 positive responses automatically referred

  24. Beaufort Pediatrics Screening Protocol

  25. Community ConnectednessCo-location of services • Mental Health services in pediatric medical homes more common • Hall way consults • Links counseling, talk therapy with drug management • Less threatening environment • Common charts • Supports the medical home concept/ healer-patient relationship • School sites • Quick mental health services for staff • Funding issues • Rural health clinic status • Patient compliance issues • Focused on treatment, not on prevention

  26. Co-Location of Case Managers/ Care Coordinators in the office • Publicly funded? care coordinators for children at risk, including those who are environmentally at risk • Knowledge of referral services • Able to communicate with other early childhood providers.

  27. Joint Staffing • Jointly staffs those families at risk to make sure appropriate services offered • Meets monthly • Beaufort Pediatrics • School System • First Steps Program • Health department • Social Services • All home visiting programs

  28. Develop better care coordination mechanisms

  29. Well Baby Plus: Collaborative Approach to the Parent Child Relationship • Beaufort Pediatrics • BJHCHS • Beaufort Elementary • Beaufort County School District FACES Program

  30. Well Baby Plus intervention • Group well child visits staffed by a private pediatric practice (8 clinicians), who provided other medical home services at their office. Group visits were scheduled using the AAP periodicity schedule • Utilized a school-based home visitation program (“Parents as Teachers” curriculum). Home visitors provided assistance with coordination, appointment reminders, transportation and post visit reinforcement. Home visitors attended the group well visits. • Visits were provided on a school site where other auxiliary services were present

  31. Features of Well Baby Plus Evaluation Group • 119 Families offered WB+ • 91 families enrolled • 70 families still engaged at 15 months of age • 51 families completed exit questionnaire • Lived east of Battery Creek

  32. Comparison Group Features • Received traditional pediatric care within the medical home • Lived west of Battery Creek • Matched retrospectively one to one with WB+ patients by maternal age, marital status and SE stress (Orr SES)

  33. Completed all Well Child Visits • Children in the WB+ intervention group (65%) were more likely than comparison group (37%) children to attend all scheduled well-child visits • ( p= 0.006)

  34. Immunization UTD as recorded in Patient Chart • 92% of WB+ children were fully immunized vs. 78% of comparison children (p= 0.01)

  35. Trend towards Lower ER Utilization • Well Baby Plus children showed a trend towards lower ED usage with an average of 1.0 visit vs. 1.45 visits in the control population (p=0.18) • Not statistically significant

  36. Family Spacing: Well Baby Plus Mothers more likely to be using birth control • WB+: 25/41 using birth control (61%) • Comparison: 17/43 using birth control (40%) • p = 0.03

  37. When child was 15 months, parents recalled their clinician had discussed: • WB+: • P: Poisoning : 65% (p=0.003), • D: Discip.:69% (p<0.001), • L: Literacy: 87% p=0.16) N: Nutrition: 8%(p=0.17) • T: Toi-train:35%(p=0.01) • Control Group: • P: Poisoning: 41%, • D: Discipline: 31% • L:Literacy: 75% • N: Nutrition: 78% • T:Toilet-Training 12%

  38. Impact on Obesity?: Were Well Baby Plus patients less like to be obese at 15 months of age? • WB+ • weights> 90 percentile: 8% • Average 50 percentile • Control Group • weights>90 percentile: 24% • Average 55 percentile • p=0.03 • This difference disappeared when Weight vs. Height percentiles used (p=.3)

  39. Home Visitation Formal Social Capital Programs Child care School Systems Medical Home Parks Early Intervention Social Service Transportation Other health care WIC Program Informal Social Capital Extended family Friends Neighbors Housing Education Housing Information needs Cultural beliefs Language Child development outcomes -optimal intellectual growth -safe and healthy -motivated for learning -capable of reciprocal relationships -capable of emotional self regulation -sense of conscience And responsibility Family characteristics 1.Family Mental Health 2.Child characteristics 3.Socioeconomic Status 4.Family Connectedness

  40. Conclusion: Coordinating Care in the Medical Home • Recognition of need: Screening • Developmental • Psychological • Social Connectedness • Knowing community resources and linking to appropriate services • Team-based approach to care: Care coordinators, mental health, development specialists, social workers, lactation consultants, early childhood educators • Impacts both physical and mental health outcomes

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