Lakewood Health System · • Substance misuse • Baby safety 10 ... Postpartum MH Burden: Anxiety • PP anxiety and stress: –Ineffective maternal coping –OCD behaviors 11.

Developing a Maternal Mental Health Promotion

Model in a

Rural Health Facility

Nicolle Uban, Ph.D., CNM, RNPaul Davis, Ph.D., LP

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• Quick, guess which number is higher:

– The number of people who sprain an

ankle each year?

– The number of people who have a

stroke?

– The number of women who experience

postpartum depression?

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Outline

1. Review: LHS and mental health burden.

2. Background: Integrated Care Model.

3. Epidemiologic data.

4. LHS: Developing the Model

5. Discuss challenges.

6. Next steps.

7. Questions?

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Purpose• To develop a maternal mental health promotion

model centered on standardized, frequent

screening of pregnant and postpartum women

in order to adequately address maternal mental

health needs.

• To improve treatment outcomes for women

identified with major depression or dysthymia

during their pregnancy and the first postpartum

year through an integrated care model.

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Background:

Lakewood Health System

• City of Staples, Todd County, MN

• Federally certified Rural Health Clinic and Critical Access Hospital

• High Medicare/Medicaid/Medical Assistance– Serving 5 of the poorest counties in MN

– Tri-county area has some of the highest teen pregnancy rates in the state.

• Large population of Army Reserve and National Guard members, their spouses, and families

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Mental Health Burden on the

Healthcare System

• Greater healthcare utilization rates:

highest 20% pts use 88% of healthcare

• Increased medication use (and misuse):

e.g., opioids 3-6x if MH co-morbidity

• Tx noncompliance, drop out, and relapse

• Only 40% of prescriptions taken

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MH Burden: Comorbidities

• Poorer lifestyle management: inactivity,

alcohol/drug use, obesity

• Increased pain complaints, severity, duration

• Greater functional impairment/disability

• Poorer rehab and surgery outcomes

• Delayed return to work

MH Burden during PG: Depression

• Negatively impacts birth outcomes.

Independent risk factor for:

– Low fetal birth weight

– Premature delivery and associated risks

• Medication noncompliance

• Treatment burden

• Maternal comorbidities

8K.J. Gold & S.M. Marcus (2008). Effect of Maternal Mental Illness on Pregnancy Outcomes. Expert Rev of Obstet Gynecol. 3(3), 391-401.

MH Burden during PG: Anxiety

• Negatively impacts birth outcomes:

– Preterm delivery and low fetal birth weight

– Associated with increased risk of miscarriage

– Temperamental problems and fussiness

– Problems with attention regulation and emotional

reactivity

– Lower scores on measures of mental development

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Postpartum MH Burden: Depression

• Poor attachment

• Neonatal depression

• Delayed return to work

• Substance misuse

• Baby safety

10Photo retrieved from: middlesexhospital.org

Postpartum MH Burden: Anxiety

• PP anxiety and stress:

– Ineffective maternal coping

– OCD behaviors

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MH Treatment Data

• De facto BH tx system is Primary Care

– PCP prescribe 60-80% all psychotropic meds

• BH needs routinely not assessed!

• When assessed, pts are lost to follow-up

• PCP don’t have time

• BHC/MHP not available

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Other Factors

• 80% U.S. Population sees PCP yearly

• PC job dissatisfaction due to BH issues in pts

• Medicaid/Medical Assistance population has greater BH needs

• Medication only tx insufficient/less effective

• Rural areas lack access to BH specialists

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Societal Demands• Healthcare Reform

– Increased access expected

– Bundled services

– Prevention focused!

• Outcome focus– NPI data

– Pay for performance

– Cost savings incentives

• Medical/Health Care Home Model

LHS

• Hybrid system: Integrated + Traditional Mental Health (MH) care

• Similarities to DIAMOND

• Improves access, satisfaction, and outcomes

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LHS: Interdisciplinary Team

BH• MD Psychiatrist (2)

• PsyD, LP

• PhD, LP

• APRN, CNS

• MSW, LICSW

• MA, NCC, LPCC, LAMFT (2)

• LPN

• Administrative Assistant/Coordinator

WH• OB/GYN (2)

• CNM

• FNP

• WHNP

• RN case managers (3)

• LPN (5)

• Expectations Nurses

• WH coordinator

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LHS Behavioral Health Team

• Addressing Perinatal Mood and Anxiety Disorders (PMAD), as well as other Maternal Mental Health (MMH) disorders.

• Additional Targeted populations: – Women’s Health

– Palliative Care

– Dementia

– FASD

– Chronic Pain

• Multifaceted Outpatient BH Clinic17

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Integration Model

• Primary Care Behavioral Health Model– Population focused

– Collaborative service with PCPs

– BHC part of PC team

• BHC assesses pt psychosocial needs

• BHC develops tx plan, PCP implements

• Allows easy access to BH care• Not traditional BH care;

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Benefits of Integrated Care

• Improvement in depression remission rates from 42% to 71%

• Improved self management skills for patients with chronic conditions

• Improvement in MH

• Significant improvement in health outcomes for comorbidities

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Benefits of Integration

• Increased Productive Capacity:

– Estimate of revenue ceiling of a health care system is

closely tied to productive capacity of medical

providers

– Current capacity is overwhelmed with frequent

management of behavioral health conditions

– Integrated behavioral health “leverages” BH patients

out of PCP practice schedules

– PCP’s are freed to see medical patients with higher

RVU conditions/top of license

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Benefits of Integrated Care

• Better clinical outcome than by treatment

in either sector alone

• Improved consumer and provider

satisfaction

• High level of patient adherence and

retention in treatment

• Population health benefits

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Benefits of Integrated Care

• Improved process of care:

– Improved recognition of MH and CD

disorders

– Improved PCP skills in medication

prescription practices

– Increased PCP use of behavioral

interventions

– Increased PCP confidence in managing

behavioral health conditions

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Economic Benefits of Integration

– Meta-analysis: 57 controlled studies show

a net 27% cost savings

– 40% savings in Medicaid patients receiving

targeted treatment

– In older populations, up to 70% savings in

in-patient costs

– 20-30% overall cost savings overall

average

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Epidemiologic Data• PMAD most common complication of

pregnancy and childbirth:

• ~20% suffer from prenatal depression

• 45-60% suffer from prenatal anxiety

• 1 in 7 women suffer from PPD

• Fathers are affected too:– Approximately 4% in the 1st PP

year

Diagnosis and Treatment of Women with Depression

25Source: CDC Fact Sheet

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Epidemiologic Data cont…• U.S. Lifetime prevalence for MH Disorders in

general population:

– 46% DSM-IV disorder

– 21% Depressive mood disorder

– 29% Anxiety disorder

– 40-50% medical patients have Depression or

Anxiety

Epidemiologic Data cont…

• Major Depressive Disorder #1 disability in U.S.

• 70% all PCP visits contain psychosocial elements.

• 50% all PCP visits are specifically for a MH disorder.

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LHS: Addressing a Critical gap in

Maternal Mental Health Services

• What we identified:

– A lack of a standardized approach to MMH

screening and MH promotion, in spite of a

growing need among our patient population.

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Our Response:

• Organize a taskforce.

– Key Stakeholders

• Screening tools selected.

• Algorithm developed:

– Intervals for screening

– Pathways for care

– Follow up

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Plan

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8 Critical Screening Points Identified:

• Antenatal x3

• Postnatal x5

• Other maternal visits in

the 1st year PP

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Screening Method

1. PHQ 2: If positive…

2. PHQ9

3. Next Step: Decision made based on

severity of depression, issues of safety,

and MH history.

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Positive Screens

• PHQ9 score: Severity of Depression

– 0-4 Minimal Depression

– 5-9 Mild Depression

– 10-19 Moderate Depression

– 20+ Severe Depression

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Safety and MH History

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Severity of Depression

Minimal to Mild (0-9)

• Consider Safety and MH Hx:

– Suicidal/homicidal; MH hx, on

meds, sig. FH = STAT MH

referral

– Enhanced F/U protocol

• If Safety and MH Hx negative:

– Ongoing screening

• MH hx only:

– Consider med tx

– MH visit within 10 days

– Enhanced F/U

Moderate to Severe (10-20+)

• MH providers triage for level

of referral and acuity of

need.

– STAT MH referral

– Medication

– Enhanced F/U protocol

– Ongoing screening

• Other risk factors

considered.

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Plan

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Referral to BH

• Referral system:

– Collaboration between primary care providers

and BH team

– Collaboration between WH and BH

• 2-4 weeks for non-emergent BH services for

Pregnant/PP women

• Immediate/STAT visits for acute Patients

• ER if BHP unavailable

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LHS: BH Integrated Services• What we offer:

– Therapy: Short term and traditional

– Psych testing

– Medication initiation and management

– OT

– Dietary

– Primary Care

– Close collaboration with: ARMHS/Social

Services/County

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Enhanced Follow Up: • Based on BH recommendations

• EMR Tracking

– Can “flag” at risk patients to providers (OB, peds)

– All calls documented and visible in EMR

– F/U calls flagged to BH and OB provider

• Ongoing screening/therapy/monitoring

– BH provider

– OB Care/PCP

– Pediatrician/Baby doc40

*mom screened at child’s WELCH visit

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Screen # screened

54/69 (468)

Min

0-4

Mild

5-9

Mod

10-19

Severe

20+

1st Trimester 8 (7 TOC)

(4 CPN)

2 2 4 0

2nd Trimester 12 (3 TOC)

(10 CPN)

4 1 0 0

3rd Trimester 24 (0 TOC)

(5 CPN)

0 0 0 0

6 Wk PP Visit 47 (6 no PP) 2 3 3 2

3 mth WELCH* 0 ? ? ? ?

6 mth WELCH* 1 1 ? ? ?

9 mth WELCH* 1 1 ? ? ?

12-15 mth WELCH* ? ? ? ? ?

Midwifery Patients 2013: 54/468

Midwifery Patients 2013: 54/468Number of Pts BH Referral BH Visit Med Start

1 Yes No Yes

1 Yes ? No

1 No No Yes

3 Yes Yes Yes

1 Yes Yes No

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Additional Data: 2013• Other Prenatal Care Providers:

– OB/GYN x2

– Family Practice MD x 8

• Verbal Polling: Are you doing the PHQ9 with

you PP patients?

– 6 wk Screen: YES!

– Additional Maternal Screens in first year PP: NO!

– Screens at WELCH: NO!

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Other OB Care Providers, 2013

44*mom screened at child’s WELCH visit

Screen # screened

54/69 (468)

Min

0-4

Mild

5-9

Mod

10-19

Severe

20+

1st Trimester ? (? TOC)

(? CPN)

2nd Trimester ? (? TOC)

(? CPN)

3rd Trimester ? (? TOC)

(? CPN)

6 Wk PP Visit ? (? no PP)

3 mth WELCH*

6 mth WELCH*

9 mth WELCH*

12-15 mth WELCH*

Barriers to Full Implementation

• MMH not a patient care priority

• Did not get buy in from all providers and

nursing staff on importance of this model

• Time consuming

• Lack of workable EMR

• Limited availability of BH staff for acute

referrals

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What Now?

• Revisit the algorithm

– Is it feasible?

• Market the importance of MMH as a community

health measure and core principle of overall

patient health

• Training: Providers and Nursing staff

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Challenges

• Tradition: not like PC and not like therapy

• Cultural issues: PCP vs. MH providers

• Space!

• Population health vs. Individual health

• Balancing traditional MH care and integrated care innovations

• Cost offset vs. Revenue

• Administrator buy in

• Payor buy in

• Bundled services

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Summary

1. Reviewed mental health burden.

2. Discussed integrated care generally.

3. Shared data demonstrating the need for a maternal mental health promotion model.

4. Outlined Lakewood Health System’s process for developing the model.

5. Discussed challenges.

6. Reviewed next steps.

Questions?

Thank you very much!

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