Title: Primary Care Pediatric Psychology
1Primary Care Pediatric Psychology
- W. Douglas Tynan, Ph.D., ABPP
- For copies please email
- Dtynan_at_nemours.org
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3Overview
- 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
4Unmet Needs for Parent Support Guidance in
Pediatric Care
5Nemours Pediatric Needs Assessment
6Texas 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
7Why 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
8Why 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
9When 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?
10How 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.
11Back 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
12What 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
13Understanding 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
14How 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!
15Primary 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
16Primary 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
17Establishing 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
18Setting 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
19Establishing 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
20Primary 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
21Coordinated 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
22Training 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
23Nemours 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.
24Assessment 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
25Overview 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
26Interventions for Behavioral Problems often Seen
in Primary Care Preschool
- Tantrums Oppositional Behavior
- Example
- Toileting Problems
- Sleep Problems
- Fighting / Aggression with Peers
- Feeding Problems
27The Nemours Primary Care Psychology Program Some
Initial Outcome Data
- Provider Satisfaction Survey
- Nemours Primary Care Psychology Program
28Nemours Pediatric Provider Satisfaction Jan.
2004 Data to Guide Practice
29Pediatric 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
30Texas 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.
31Results 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
32Primary 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?
33Resources
- 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.
34Role 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.
35Coordinate 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
36Treatment 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
37More 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)
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