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Childhood Mental Health:

Strategies for Rural NYS

9/10/07Thomas C. Rosenthal MDDirector: NYS AHEC System

Editor: Journal of Rural HealthProfessor and Chair

UB Dept of Family Medicine

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Rural Challenge

• 1. Making the Diagnosis– Requires team of family, school, primary care

physician and patient.– PCPs diagnose psycho-social problems in 19% of

visits. (Koppelman, 2004)

• Specialty consult obtained for 50% of these cases.

• 2. Urgent Care– Usually the primary care office or the ER.

• 3. Continuity and maintenance care.– Requires integration of family, school, primary care

physician, mental health specialty support.

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Rural Need• Rural Pediatric Mental Health Visits

– 5% of child ER visits are for MH (rural ~ urban).– 10% of psychiatric ER visits are children. (Hartley, 2005)

– Childhood mental health ER visits 102%. (Shah, 2006)

• Only 1 in 5 children receive definitive care. (Rosenkranz, 2006)

• Rural adolescent rates of anxiety, depression, thought problems, attention problems, delinquency, substance abuse and aggressive behavior are equivalent. (Hartley, 1999)

– Suicide is higher in rural America. (Hartley, 1999)

• Only 79% of Rural US Counties have mental health services. (Hartley, 1999)

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Agricultural Worker’s NeedNeeds somewhat unique to farming

Problem: Strategy:

Business PressuresMarkets, regulatory, climatic

business and family management resources.

Poor problem solving, rigidity, change.

Build professional networks

Access to firearms. Crisis services.

Alcohol, prescription drug misuse.

Access to recovery programs.

Lack of knowledge of mental health problems.

Reducing stigma, education.

Source: American Farm Bureau

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Solutions: Integrated Care (PCP)

• Mental Health Care in Primary Care – Mental and physical health are indivisible.– 50% of patients refuse referral. (Olfson, 1991)

• PCPs deal with mental symptoms as part of a larger, more general problem: – Mental symptoms are concentrated in patients who

visit their PCP for other reasons.• Mental health symptoms are imbedded in a matrix of physical

symptoms.

– The Rural PCP remains “stuck” with difficult patients.• Limited opportunity for “passing” the patient onto specialty

care. (Farley, 1998)

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Disease and Illness

DiseasDiseasee The The

Broken Broken PartPart

IllnessIllnessFeelingsFeelingsIdeasIdeasFunctionFunctionExpectationExpectationss

(Stewart, 1995; Rosenthal, 2007)

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Bio-physiological MechanismPrimary Care Model of Disease

Heterogeneous neuroendocrine-immune Heterogeneous neuroendocrine-immune dysfunctiondysfunction

StressStress TraumaTrauma PredispositionPredisposition InfectionInfectionInflammationInflammation

PainPain

Aberrant central Aberrant central pain mechanismpain mechanism

FatigueFatigue Depression/AnxietyDepression/Anxiety Poor sleepPoor sleep FatigueFatigue

Mental Mental stressstress

Physical Physical deconditionindeconditioningg

Sympathetic Sympathetic ActivityActivity TraumaTrauma

EnvironmentEnvironmental stimulial stimuli

Poor Poor postureposture

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Why Primary Care? (PCP)

• “Distress” brings patients into the PCP Office– An emotion that may arise out of physical or mental

trigger.

• 10-20% of people visit a PCP for a mental health problem each year. – 26% have a DSM diagnosis. (deGruy, 1996)

– 50% of high utilizers have significant distress. – 8-15% of PCP Pediatric contacts are for psycho-

social problems. (Costello, 1987)

• Team Care is inherent to Primary Care. (Rosenthal, 2001)

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Why Primary Care? (PCP)

• Mind/Body Integration:– Americans accept the inter-relationship of

mind and body more than clinicians. (Wolsko, 2004)

– 88% of patients accept management of mental illness by their primary care physician. (Smith, 2003)

• Patients expect their PCP to facilitate referrals and consultations. (Rosenthal, 1991)

• Patients expect PCPs to continue participation in their care after referral. (Rosenthal, 1996)

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Solutions: Expand the Team

• Advance Practice Psychiatric Nurses:– Clinical outcomes of high quality.

• Both diagnosis and treatment (Merwin, 1995)

– Licensed with prescription authority in NYS.

• Their holistic framework is essential for rural practice.

– 9.6% of NY’s APPNs practice in rural NY. (Hartley, 2004)

– 8% of NYS is considered rural.

• There are 40 APPNs in rural NYS as of 2004.– Most training programs do not include rural

experiences. (Hartley, 2004)

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Integrate Care: Examples Chevy Version

• Bag Lunch Model: – Letchworth Family Medicine, Perry, NY

• Established in 1978 as a solo (fee-for-service) practice.• Now has 3 Family Physicians and 2 NPs.

– Friday noon lunch in PCP office:• The physicians, NPs and nursing staff.• Clinical psychologists, MHSWs from county mental health

office and private practices in county.

– Agenda: 1) referred cases, 2) problem cases, 3) medically complicated cases, 4) un-referrable cases.

– Enhanced number of referrals, fewer visits per referral, greater patient satisfaction, greater professional comfort. (Rosenthal, 1990)

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Integrate Care: Examples Buick Version

• Tount, Texas (Federally Qualified Health Center est 1993.)

– Step 1: Established grant funded Family violence intervention program.

– Step 2: Hired Clinical Psychologist (CP) initially supported by grant.

– Step 3: Weekly Office PCP, CP and Staff conferences focusing on patient care.

– Step 4: Referrals to CP expanded to other diagnoses. – Step 5: Patient billings evolved to support CP. – Step 6: Grant funding was no longer needed. (Farley,

1998)

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Integrate Care: Examples Cadillac Version

• Inter-professional Partners for Appalachian Children (IPAC)– Assessment and comprehensive treatment of behavioral and

developmental needs of children ages six and under – 19 university and community health care organizations in

Appalachian Ohio participate. – Access is through PCPs and schools.– Provider participants:

• Primary physicians, psychologists, counselors, early child mental health professionals, nurses, educators, and hearing and speech-language pathologists from within the partnership.

• “No matter what door you enter, someone is going to take a look at your child’s broad developmental needs,”

• http://www.oucom.ohiou.edu/ipac.

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Integrate Care: Examples Systems Approach

• ~44 Child visits/yr/fp for psychosocial Issues. – FP sees 102 patient visits/wk 46 weeks a year.(~4,600 visits/year). – 19% (890) of FP visits are patients <19 yoa.– 5% of pediatric visits are psychosocial.

• Swedish Sarcoma Model for non-common conditions.– Regionalize systems approach.

• Connect specialty surgical centers to office based PCP practice.

– In-office “Academic” detailing.– Regular “single message” teaching brochures. – Improved outcomes and lowered recurrance rates by

2/3rds. (Gustafson, 1994)

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Why doesn’t the ideal just happen?

Competing Demands• Competing demands confound PCP visits:

– Most pts have psychosocial and physical co-morbidities.

• They present new problems at every visit• Long problem lists interfere with providing prevention and

treatment of chronic disease. (Jaen, 1994)

• “The attention depression gets during a visit is less associated with the severity of the patient’s emotional symptoms than with the number of other problems the patient has.” (Rost, 2000)

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Strategies:Bringing the PCP Into the Team

• 1. In-Office Training: Treatment of Child Pscyho-social conditions: – 6 hours proved feasible and acceptable to all

FPs in study.• 93% FPs believed that learning were achieved.• 82% felt more confident in care of complex

patients. (Morriss, 2006)

– Specific diagnoses were not essential to management. (Clark, 2006)

– Lowers use of medications. (Salmon, 2006)

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Strategies:Bringing the PCP Into the Team

• 2. Re-imbursement:– Dual Diagnosis Medical management fee:

• ~$5/month per patient per PCP. (Gold Choice)• Saves $1m for every 1,000 enrollees. (Rosenthal, 1996)

• 3. Specialty communication:– Tele-video:

• NY Statewide Tele-psychiatry Task Force (www.hysarh.org)

– Electronic transmission of EMR note.– Visits with urban based specialists as needed.

• Tailored specialty/PCP interaction according to patient needs and PCP participation.

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Strategies:Bringing the PCP Into the Team

• 4. Guided Pharmacologic Care:– 85% of prescriptions for psychotropic meds in children

are written by Pediatricians and Family Physicians. (Koppelman, 2004)

• Use of stimulants (i.e. Ritalin) for ADHD• Use of selective serotonin reuptake inhibitors (SSRIs) for

depression.• Use of clomipramine + fluvoxamine for obsessive-compulsive

disorders. (Greenhill, 1999; Emslie, 1999)

• 5. Support for Psychosocial Interventions.– PCP encourages and facilitates family participation.

(Dore, 2005)

– Combined medical and cognitive care works best. (March, 2004)

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Strategies:Bringing the PCP Into the Team

• 6. Case Management:– Advanced Practice Psychiatric Nurses– Mental Health Social Workers– Special service agencies

• 7. School performance:– Semi-annual case conferences required. – Each member of team may bill the equivalent

of an office visit for each patient conference.

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Solutions: Integrated Care (PCP)

• Key Feature: Case Management at Multi-levels. – Overall Costs are significantly less. (Baldwin, 1993)

• Specialty and social services cost the same.• Emergency and inpatient care costs were much lower.

– Outcomes measures better. (Schulberg, 1995; Katon, 1995)

• Most of the data is from adult care.

– Clinical Care Pathways develop. (Bertram, 1996)

– Specialty consultation is distributed.• Impact is expanded to more patients.• European model of health care. (Rosenthal, 2000)

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New York State AHEC System www.AHEC.buffalo.edu

AHECs:

Brooklyn AHEC, Brooklyn

Bronx AHEC, Bronx

Catskill-Hudson AHEC, New Palz

Central NY AHEC, Cortland

Erie Niagara AHEC, Buffalo

Hudson-Mohawk AHEC, Glens Falls

Manhattan/Staten Island AHEC

Northern AHEC, Potsdam

Western New York Rural-AHEC, Warsaw

Regional Offices:

1998 Statewide Office, UB

1999 Central Region Office, Upstate Med. Univ.

2000 Eastern Region Office, Albany Med. Col.

2000 NY Metropolitan Region Office, The Institute for Urban Family Health

AHEC Districts

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References• Baldwin L, et al. The effect of coordinated multidisciplinary

ambulatory care on service use, charges, quality of care, and patient satisfaction in the elderly. J Community Health. 1993;18:95-108.

• Bertram DA, Rosenthal TC. Implementation of an in-patient case management program in rural hospitals. J Rural Health. 1996 Winter; 12:54-66.

• Clark, M. R. (2006). "Psychogenic disorders: a pragmatic approach for formulation and treatment." Semin Neurol 26(3): 357-65.

• deGruy F. Mental Health Care in the Primary Care Setting. In Primary Care: America’s Health in a new era. Institute of Medicine, Washingotn, DC. 1996

• Dore M. Child and adolescent mental health. In G. Mallon and P. Hess (eds). Child Welfare for the twenty-first century: A handbook of practices, policies and programs. New York: Columbia University Press. P. 488-503.

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References

• Emslie GJ, Walkup JT, Pliszka SR, Ernst M. Non-tricyclic antidepressants: current trends in children and adolescents. J Am Acad Child Adolescent Psychiatry. 1999;38:517-528.

• Farley T. Integrated primary care in rural areas. In Integrated Primary Care, Ed: Blount A. WW Norton, New York, NY. 1998.

• Greenhill LL, Halperin JM, Abikoff H. Stimulant medications. J Am Acad Child Adolescent Psychiatry. 1999;38:503-512.

• Gustafson P, Dreinhofer KE, Rydholm A. Soft tissue sarcoma should be treated at a tumor center: a comparison of quality of surgery in 375 patients. Acata Orthop Scand 1994;65:47-50.

• Gustafson P. Soft tissue sarcoma. Epidemiology and prognosis in 508 patients. Acta Orthopaedical Scandinavica. 1994;259(Supplementum):1-31.

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References• Hartley D, Bird DC, Dempsey P. Rural Mental Health and

Substance Abuse. In: Ricketts TC (ed.). Rural Health in the United States. Oxford University Press. New York, NY. 1999.

• Hartley, D, et al. Are advanced practice psychiatric nurses a solution to rural mental health workforce shortages? Working paper #31. (muskie.usm.maine.edu/publications/rural/wp31.pdf. Accessed 8/27/07) April 2004.

• Hartley, D, et al. Mental health encounters in critical access hospitals emergency rooms: a national survey. Portland ME. Muskie School of Public Services. 2005.

• Hartley, D., Ziller, E., Loux, S., Gale, J., Lambert, D., & Yousefian, A. E. (2007). Use of Critical Access Hospital emergency rooms by patients with mental health symptoms. Journal of Rural Health, 2007;23(2):108-115.

• Koppelman J. The provider system for children’s mental health: Workforce capacity and effective treatment. NHPF Issue Brief No. 801. October 26, 2004.

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References• March J, et al. Fluoxetine, cognitive-behavioral therapy, and their

combination for adolescents with depression. JAMA 2004;292:807-820.• Mechanic D. Integrating mental health into a general health care

system. Hosp Community Psychiatry. 1994;45:893-897.• Merwin E, Mauch A. Psychiatric nursing outcome research: The state

of the science. Archives of Psychiatric Nursing. 1995;9(6):311-331.• Morriss, R., C. Dowrick, et al. (2006). "Turning theory into practice:

rationale, feasibility and external validity of an exploratory randomized controlled trial of training family practitioners in reattribution to manage patients with medically unexplained symptoms (the MUST)." Gen Hosp Psychiatry 28(4): 343-51.

• Olfson M. Primary care patients who refuse specialized mental health services. Arch Intern Med. 1991;151:129-132.

• Owens PL, Hoawood K, Horwitz SJ, Leaf PJ, Poduska JM, et al. Barriers to children’s mental health services. J Am Acad Child Adolescent Psychiatry. 2002;41:731-738.

• Rosenkranz, B. Mental Health Care Issuesfor Children and Youth, Childre’s Bureau/ACF/DHHS. NY, NY. www.nrcfcppp.org, 2006

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References• Rosenthal TC, Shiffner J, Panebianco S. Physician and psychologists'

beliefs about factors influencing successful psychology referrals. Fam Med 1990;22:38-41.

• Rosenthal TC, Shiffner J, DiMaggio M. Factors involved in successful psychotherapy referral in rural primary care. Fam Med 1991;23:527-530.

• Rosenthal TC, Riemenschneider T, Feather J. A generalist-patient-specialist alliance for the nineties. Amer J Med. 1996 March; 100:338-343.

• Rosenthal TC, Horwitz ME, Snyder G, O’Connor J. Medicaid Primary Care Services in New York State: Partial Capitation vs Full Capitation. J Fam Pract. 1996;42(4):362-368.

• Rosenthal TC, Fox C. Access to health care for the rural elderly. JAMA 2000;284:2034-6.

• Rosenthal TC, Campbell-Heider N. Ther rural health care team. In Textbook of Rural Medicine, eds. Geyman JP, Norris TE, Hart LG. McGraw-Hill. NY, NY. 2001.

• Rosenthal TC, Griswold KS, Danzo A. Puzzling Physical Conditions. FP Essentials. Edition #334 AAFP Home Study. Leawood, Kan: American Academy of Family Physicians. March 2007.

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References• Salmon, P., G. M. Humphris, et al. (2006). "Why do primary care

physicians propose medical care to patients with medically unexplained symptoms? A new method of sequence analysis to test theories of patient pressure." Psychosom Med 68(4): 570-7.

• Shah, MV, et al. Emergency department trends for pediatric and pediatric psychiatric visits. Pediatric Emergency Care. 2006;22(9):685-686.

• Smith, R.C., et al., Treating patients with medically unexplained symptoms in primary care. J Gen Intern Med, 2003. 18(6): p. 478-89.

• Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Sage Publications. Thousand Oaks, California. 1995. (p26)

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Suicide Rates in Rural America

• NY Times article:– Social Isolation, Guns and a Culture of

Suicide. February 13, 2005.• Byline: Fox Butterfield.

– “Americans in small towns and rural areas are just as likely to die from gunfire as Americans in Major cities. The difference is in who does the shooting.”