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:
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)