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Primary Care Pediatric Psychology

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Title: Primary Care Pediatric Psychology


1
Primary Care Pediatric Psychology
  • W. Douglas Tynan, Ph.D., ABPP
  • For copies please email
  • Dtynan_at_nemours.org

2
(No Transcript)
3
Overview
  • Why offer mental health services in primary care?
  • What does primary care pediatric psychology look
    like?
  • Establishing a primary care psychology program
  • Training issues
  • Business considerations
  • Coordinated vs. integrated care
  • Training pediatricians to assess and treat child
    mental health problems

4
Unmet Needs for Parent Support Guidance in
Pediatric Care
5
Nemours Pediatric Needs Assessment
6
Texas Childrens Needs Assessment 2006
  • TCPA currently owns 47 practices in Houston
    serving 300,000 children
  • Pilot study to look at Primary Care Psychology
  • Top five mental health concerns at five offices
  • ADHD related problems differential dx
  • School problems and learning difficulties
  • Dx of depression
  • Developmental delay
  • Mental health follow up after referral

7
Why Address Behavior in Primary Care?
  • PCPs are the health professionals most likely to
    come in contact with children adolescents with
    behavioral emotional problems
  • Parents children comfortable with PCP office
  • PCP often knows family well, for long time

8
Why Address Behavior in Primary Care?
  • Non-stigmatizing service delivery
  • Scarcity of community mental health services
  • Promote mental health in children, adolescents,
    families
  • Lack of services for children 0-6
  • Recognize early signs of psychosocial problems

9
When to Address Behavior in Primary Care?
  • Parent seeking information
  • Relatively discrete behavior
  • Mild to moderate severity
  • Recent onset
  • No major psychopathology
  • Family situation reasonably stable
  • Pediatricians routinely do this already. What
    can Psychology meaningfully add to this?

10
How is it different from Healthy Steps?
  • Referred patients Healthy Steps is a universal
    approach for all patients.
  • Healthy Steps excellent program for guidance,
    screening
  • Licensed mental health providers
  • Can bill for services, self supporting
  • Can diagnose disorders in the 15 of children who
    meet diagnostic criteria
  • Shared management of patients, not physician run.
  • Can also assist with screening and other tools
    for all patients, group parent information
    sessions etc.

11
Back to the Future
  • Collaborative practice first introduced by
    Schroeder (1975, 2004)
  • That practice involved
  • Clinical Interventions
  • Teaching of Health Professions
  • Community Advocacy
  • Public Health Issues
  • Not all practices can meet all of these goals
  • Each group needs to determine which of these
    multiple roles Psychologists need to fill

12
What Does Primary Care Pediatric Psychology Look
Like?
  • Understanding pediatric offices
  • Differences between primary tertiary care
  • What does it look like at Nemours?
  • First impressions Missing the bus

13
Understanding Pediatric Offices
  • Majority of visits for infants toddlers
  • Each PCP may see up to 25-30 patients per day
  • Variety of visits well-child, sick, problem
  • Each PCP has own style ways of interacting with
    mental health

14
How is Primary Care Different from Tertiary Care?
  • Philosophy of practice
  • punctuality less important
  • see more patients but spend less time with each
  • sick visits
  • Need broad knowledge base cannot specialize (I
    dont do that)
  • development
  • behavior
  • Immediate access to Rx, some medical tests
  • Flexibility is key!

15
Primary Care Pediatric Psychology What Does it
Look Like For Us?
  • 4 sites
  • 2-6 PCPs at each site
  • Pediatric residency training at 3 sites
  • Low income neighborhoods
  • Racial and ethnic diversity
  • Primarily Medicaid (90-95)
  • Single insurer simplifies insurance issues in the
    carve out era

16
Primary Care Pediatric Psychology First
Impressions
  • Weve been missing the bus!
  • Wider range of symptoms and psychopathology
  • Subclinical/normative behavior
  • Severe psychopathology
  • Missed diagnoses and misdiagnoses
  • GAD referred as sleep problem
  • Several cases of PDD missed at well-child visits

17
Establishing a Primary Care Psychology Program
The Nemours Experience
  • Anecdotal evidence of PCP dissatisfaction with
    psychology services
  • Long wait lists
  • Infrequent communication from psychologists
  • Patients not following through with referrals to
    tertiary care site
  • Pediatric needs assessment
  • Funding sources
  • Setting up services

18
Setting Up Primary Care Psychology Services
  • Nemours Pediatrics 8 sites in underserved areas
  • Grant applications to the Nemours Foundation and
    to HRSA
  • January to May 2002
  • Start services in fall 2002
  • Provide direct services on-site, consultation and
    training
  • Four sites in New Castle County, DE

19
Establishing a Primary Care Psychology Program
Training Considerations
  • Few, if any, psychology residents have worked in
    a primary care setting
  • Consider having resident shadow pediatricians
  • Must be comfortable with babies small children
  • Primary care office is a smaller pond

20
Primary Care Training for Psychology Residents
  • Similar issues to hospital-based training
  • Learn to identify self as medical professional
  • Must be appropriately assertive and directive
    with other medical professionals
  • Develop understanding of pediatricians
    knowledge base and skills in developmental
    behavioral realm
  • Communicate information important to
    pediatricians clearly and with minimal jargon

21
Coordinated Care vs. Integrated Care
  • In Health Psychology discussion of these issues
  • Separate records or a joint record?
  • All providers treated equal
  • E.g. if a child comes to a pediatric appointment
    for a behavior problem do they go directly to
    Psychology (integrated) or see a Pediatrician
    (coordinated) first?
  • Impact of Electronic Medical Record (EMR)
  • Improved, instant communication
  • Confidentiality issues that go both ways
  • Families need to be informed that the record is
    shared
  • This is a continuum, not a dichotomy

22
Training Pediatricians They Provide Most of the
Front Line Mental Health Services.
  • AAP Guidelines
  • Developmental Screening
  • Critical role for pediatricians is to counsel
    parents
  • Child mental health as a top priority in 2005
  • Yet, pediatricians do not necessarily have the
    time or the training to assess and treat child
    mental health problems effectively and efficiently

23
Nemours Primary Care Behavior Program Training
Modules
  • Module I Understanding Parent Child Behavior
  • Module II Assessment
  • Modules III IV Selective Brief Interventions
    in Primary Care
  • W. Douglas Tynan, Ph.D., ABPP, Deborah Miller,
    Ph.D., Jennifer Shroff Pendley, Ph.D.

24
Assessment in Primary Care
  • Use AAP materials
  • You ARE In pediatrics now
  • Intake Interview
  • DSM PC
  • Identify non-normative behavior
  • Assess severity of problems
  • Establish diagnosis
  • Individualized Assessment
  • ABC Analysis
  • Facilitate treatment planning
  • Motivational Interviewing Identify factors that
    mediate or exacerbate problems

25
Overview of Nemours Primary Care Behavior Program
  • Course overview objectives
  • Teaching strategies
  • Didactics
  • Hand-outs
  • modeling
  • Why address behavior in primary care?
  • Use of Bright Futures Mental Health Materials
    from the Academy of Pediatrics
  • Causes of behavior problems
  • Basic behavioral strategies
  • Brief, targeted interventions
  • Motivational interviewing

26
Interventions for Behavioral Problems often Seen
in Primary Care Preschool
  • Tantrums Oppositional Behavior
  • Example
  • Toileting Problems
  • Sleep Problems
  • Fighting / Aggression with Peers
  • Feeding Problems

27
The Nemours Primary Care Psychology Program Some
Initial Outcome Data
  • Provider Satisfaction Survey
  • Nemours Primary Care Psychology Program

28
Nemours Pediatric Provider Satisfaction Jan.
2004 Data to Guide Practice
29
Pediatric Psychology Program Outcome data
  • Calendar Year 2004 829 visits
  • Calendar Year 2005 1072 visits
  • Calendar Year 2006 871 visits
  • Training Primary Care 2004 22 residents
  • Training Primary Care 2005 27 residents and 3
    PNP interns

30
Texas Childrens Provider Satisfaction
  • 6 practices divided into 3 options As usual,
    Fast Track Referral, Psychologists on site
  • Increased satisfaction for both on site and Fast
    Track
  • Physician ratings of improvement much higher for
    on site.
  • Patients seen 28 0-5 year olds, 65 6-12 year
    olds, 7 teens. Boys Girls 2.51 This type of
    program appears to fit the needs of young
    children.

31
Results of Nemours Provider Satisfaction Survey
  • Content with Psychology Service
  • Do not place a high priority on Psychiatry
    services
  • Want more parent education services
  • Lack of confidence in own abilities to treat
    behavioral problems.
  • Indicates need for more help in pediatric training

32
Primary Care Program
  • gt90 Medicaid insured
  • 54 show rate for appointments in 2003
  • 63 show rate for appointments in 2005
  • Typical inner-city rates lt 50
  • 68 show rate for 2006
  • How does this compare with existing programs?

33
Resources
  • Treating childrens psychosocial problems in
    primary care. B.G. Wildman T. Stancin (Eds.),
    Information Age Publishing, 2004
  • Consulting with pediatricians Psychological
    perspectives. Drotar, D. Plenum Press, 1995.

34
Role of Mental Health ProvidersEmpirically
Supported Therapy Example, The Parent Child
Conduct Clinic
  • Provide parenting skills therapy in Behavior
    Modification
  • Provide social skills training for children
  • Emphasis on evidence based practice.
  • Simply increasing service availability does not
    have meaningful impact.

35
Coordinate Pediatric/School/Mental Health Services
  • Obtain informed consent for all parties to
    converse
  • Send copies of reports with your impressions.
  • Request that the school do evaluations for
    problems.
  • Give input to the team meetings
  • Encourage parents to work with the school
  • Engage an advocate if there are problems
    www.picofdel.com

36
Treatment Approach IV18 Great Ideas for
Management
  • Parents are Shepherds, Not Engineers
  • Reduce Delays, Externalize Time
  • Externalize Important Information
  • Externalize Motivation (Think win/win)
  • Externalize Problem-Solving
  • Use Immediate Feedback
  • Increase Frequency of Consequences
  • Increase Accountability to Others
  • Use More Salient Artificial Rewards

37
More of the Great Ideas (2)
  • Change Rewards Periodically
  • Touch More, Talk Less
  • Act, Dont Yak
  • Keep Your Sense of Humor
  • Use Rewards Before Punishment
  • Anticipate Problem Settings - Make A Plan
  • Keep A Sense of Priorities
  • Maintain a Disability Perspective
  • Practice Forgiveness (Child, Self, Others)

38
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