Child Mental Health Consults for Quality Improvement

Robert Hilt, MD Director Partnership Access Line, MDT Consult,

and 2nd Opinion Consult Services in WA and WY

Associate Professor of Psychiatry, University of Washington

August 27, 2012

Practicalities of QI programming Will describe three types of state

Medicaid consult programs which address: rising medication use increasing costs questionable or dangerous prescribing inappropriate foster care treatment planning poor child psychiatrist access community need for more assistance

To address outlier prescribing

Mandatory Medication Reviews#1

Medication Review Triggers Medicaid’s review “flags”

Created by WA and WY workgroups of experts Prescription arriving at pharmacy triggers reviews Examples:

stimulants under age 5 (WA and WY) methylphenidate (Ritalin) at >120mg/day (WA) or

>135mg/day (WY) risperidone (Risperdal) at >2mg/day for 3-5 year old (WA)

or >5mg/day in any age child (WY)

(all flags in “DUR” section of care guide at wyomingpal.org and in “DSHS” section of care guide at palforkids.org)

Medication Review History Washington

ADHD medication reviews started 2006 Antipsychotic medication reviews started 2009 reviews for >5 meds starting this month

Wyoming ADHD and antipsychotic med reviews started

2011

~1900 reviews completed since 2006

Running a Medication Review Program

Lesson 1: Prescriber’s written rationale is usually insufficient to support an authorization doc-to-doc reviews for better communication more able to teach best practices

Lesson 2: If do a “stop” at the pharmacy, rapid processing time is vital Delays undermine collaboration, can interfere

with best patient care

Running a Medication Review Program

Lesson 3: Delivering a consistent message is a major challenge Initial multi-center design had to be abandoned

Audits kept finding diverging approaches Collaborative/educational approach more

valued than just “approve vs. deny” Teaching best practices

Found a review leader needs to be regularly present

Quarterly audits ensure consistency

Running a Medication Review Program

Lesson 4: Even high risk regimens can be fiercely defended i.e. methylphenidate 450mg, or using 9

medications Lesson 5: Even if well run, many will

resent having required reviews Second Opinion program feedback surveys:

Review was “useful” 53% of the time Review was “not useful” 27% of the time

(other s reported a “neutral” opinion)

To assist the primary care medical home

To efficiently leverage use of child psychiatrists in rural areas

Elective Consultation Services

#2

PCP callsPAL consult team with a

mental health question on any patient(8AM-5PM)

PAL CAP provides a

rapid access phone consult

PAL rapid televideo consult scheduled if both A) desired by PCPB) Medicaid child

PAL CAP EMR entered

advice is faxed to PCP (by next day)

PAL SW offers resource assistance or a phone consult

(by PCP or CAP request)

Same day PCP feedback, then a

dictated note

PCP=primary care providerPAL=Partnership Access Line

CAP=child & adolescent psychiatrist

SW=social workEMR=electronic medical record

PAL Consult Process

Telemedicine Equipment

Other Aspects of PAL Services Free psychiatric care

education conferences 4 times a year in WA 3 times a year in WY

Free, expert reviewed care guide At palforkids.org and

wyomingpal.org Quarterly fidelity audits and

team consult approach to ensure advice is consistent

PAL Program Lessons Learned Lesson 1: PCPs manage very complex

issues in rural areas Usually call PAL at a point of crisis in care Complex problems

~2/3rd with “Serious Emotional Disturbance” (CGAS < 50)

~3 MH diagnoses per patient Major mental illnesses like true bipolar, schizophrenia

Rural PCPs often don’t feel they need/want that full consult appointment but DO want to know it is available

Note: more specific/detailed PAL information is coming soon in an Archives of Pediatrics & Adolescent Medicine article

PAL Program Lessons Learned Lesson 2: Despite high complexity, care often

can remain in the medical home ~2/3 of the time, we recommended care to remain

with the PCP (± a therapist) Lesson 3: Care coordination is necessary

component ~½ of all callers receive PAL Social Work assistance

Connect to therapists and other resources Lesson 4: PAL program impacts different part

of care system than Second Opinion Reviews minimal patient overlap

PAL Program Lessons Learned Lesson 5: Actually recruiting providers to

use the service is a challenge in rural, very underserved states i.e. impractical to set up lunchtime meetings to

meet all PCPs CME meetings and word of mouth among

colleagues recruit participants Lesson 6: A small “virtual” team can work

2 PAL offices, 300 miles apart, televideo connected Using 2 child psychiatrist FTEs to serve a 1.7

million child region

PAL Program Lessons Learned Lesson 7: PCPs that use the service love it

(though not everyone will use it) Very positive PAL feedback survey data after the calls

Increased the PCP’s mental health care skills Helped the PCP to manage their patient’s care More PAL contacts → higher feedback survey scores

Lesson 8: Consults steer kids into more psychosocial services (EBP therapies)

~9/10 calls recommend new psychosocial treatments Significant increase in foster children utilizing

psychotherapy appointments after the PAL call (WA FFS Medicaid data)

PAL Program Lessons Learned Lesson 9: If open the door to accepting all

calls, Medicaid issues still predominate ~2/3 of calls about Medicaid kids

Lesson 10: PCPs usually call because they seek medication advice ~½ PAL recommended to start a medication ~¼ PAL recommended to stop a medication Example: PAL gave PCPs advice to change

antipsychotic prescriptions >200 times (2008-2010)

Do Consults Change Antipsychotic Prescribing?

PAL & 2nd Opinion Medication Reviews Did Influence AP Prescribing

Fewer kids now on antipsychotics in WA decrease of 8.6% in all Medicaid children

receiving antipsychotic medications (2007-2010) decrease of 34.7% in the subset of foster care

children decrease in expenditure of ~$300,000 per

month on antipsychotics in first 2 years of PAL (2008-2009) and first year of antipsychotic med reviews During that same 2 years, antipsychotic

expenditures increased unaltered for adults in WA

Data provided Dr. Jeff Thompson

2007 20100200400600800

10001200140016001800

3400360038004000420044004600480050005200

1456

952895

669

187 122

4979

4551

Foster Care children receiving antipsychotics (35% decrease)Multiple Antipsychotic Use for >60 days (25% de-crease)Medicaid Age under 5 years receiving antipsychotics (35% decrease)Medicaid Children (All Cat-egories) receiving antipsy-chotics (8.6% decrease)

Antipsychotic Use Changes in Washington Medicaid

(from 2004-2007, use had been increasing annually)

To improve dependent child care planning through telemedicine

Wyoming MDT Consultations#3

Foster care and CHINS children have MH placement plans made at local court hearings “MDT Evaluations”

Historically difficult to arrange mental health evaluations prior to court’s clinical placement Sometimes placed in order to obtain an assessment

often with long lengths of stay Concerns about the appropriateness of many

out of home mental health placements

Challenges per Wyoming DOH

Source: Dr. Jim Bush with DOH

Wyoming has shortage of child/adolescent psychiatrists (now up to 8 total) In-state child psychiatrists reported having

no evaluation capacity for the rapid MDT hearing process

We had a University based consulting team with telemedicine experience, so …

Looking for Access

Source: Dr. Jim Bush with DOH

MDT Psychiatric Consult Process: goal of speed and quality

1) DFS case worker or GAL faxes an appointment request

--Collateral data documents for the consultant2) Coordinator sets up appointment, usually within

1 week3) Case worker and consultant speak for ~30min

prior to meeting patient4) Televideo consult appointment in local DFS office

--With caregiver, when possible5) Final opinion report dictated by the next day

165 done so far…

6-10 page report Gestalt impression, diagnoses, and general

care recommendations We describe child’s care needs, and the local

team decides where that can best happen Judge and the MDT remain the final arbiter of

the placement plan

Our role, and acceptance of it, took a lot of work and time to develop

What the MDT Gets

What we found by doing these televideo consultations Children often had:

Unrecognized problems (i.e. anxiety, ODD, conduct disorders)

High complexity (i.e. mean of 4 diagnoses per child) Frequent desire by teams for inpatient placements

~80% of our initial referrals Less frequently found need for inpatient placements

~25% of our initial referrals Only 2 cases so far where a non-inpatient recommended

child ended up in inpatient placement within the next 6 months

Translates to more care within community & financial savings

Initially: local team wariness about the program Now the DFS case workers praise the service

i.e. Tell us they get as good or better advice within one week than it had been taking them many months and many different providers to obtain before

Encouraging appropriate use of local services Specific psychotherapy treatment recommendations

were made in every case (when a disorder was present) Recommended seeking medication adjustments from

child’s prescribers in ~1/3rd of cases Less specific as we consult to care plan teams, not to

prescribers directly

MDT Psychiatric Consult Feedback

Questions? Contact info:

Robert.hilt@seattlechildrens.org

Note: All programs described were co-developed with WA and WY Medicaid divisions, the support of Dr. Jim Bush and Dr. Jeff Thompson, and administrative support of Jim Myers (Seattle Children’s)