Integrating Behavioral Health into Wellness Visits in Pediatric Primary Care

Integrating Behavioral Health into Wellness Visits in Pediatric Primary Care

Jean Cobb, Ph.D. J. David Bull, Psy.D.

Behavioral Health Consultants, Cherokee Health Systems

Collaborative Family Healthcare Association 15th Annual ConferenceOctober 10-12, 2013 Broomfield, Colorado U.S.A.

Session #H3b Friday, October 11, 2013

© 2013 Cherokee Health SystemsAll Rights Reserved

Faculty DisclosureFaculty Disclosure

We We have nothave not had any relevant financial relationships had any relevant financial relationships during the past 12 months. during the past 12 months.


ObjectivesObjectives• Describe an effective clinical model that implements Describe an effective clinical model that implements

behavioral health as a routine part of pediatric primary behavioral health as a routine part of pediatric primary carecare

• Identify screening instruments that are clinically useful Identify screening instruments that are clinically useful and easily implemented and easily implemented

• Demonstrate working relationships between BHC, Demonstrate working relationships between BHC, patient/family, PCP, and medical staffpatient/family, PCP, and medical staff

• Illustrate a team approach to address prevention, Illustrate a team approach to address prevention, identification, and treatment of behavioral health identification, and treatment of behavioral health problems within pediatric primary careproblems within pediatric primary care


Overview and RationaleOverview and Rationale

• Well Child ChecksWell Child Checks• A routine part of pediatric wellnessA routine part of pediatric wellness• Longevity of careLongevity of care• Many areas covered (medical, developmental, social, Many areas covered (medical, developmental, social,

behavioral)behavioral)• ChallengesChallenges• Busy schedules/ pace in pediatric primary careBusy schedules/ pace in pediatric primary care• How to efficiently and effectively address prevention, How to efficiently and effectively address prevention,

identification, and treatment of behavioral health identification, and treatment of behavioral health problems in pediatric primary careproblems in pediatric primary care


Role of BHCRole of BHC

• Member of primary care teamMember of primary care team• Screening, updating social history, anticipatory Screening, updating social history, anticipatory

guidanceguidance• BHC as behavioral “expert”BHC as behavioral “expert”• Addressing holistic needs of patients , while working to Addressing holistic needs of patients , while working to

increase efficiency/flowincrease efficiency/flow


Screening InstrumentsScreening Instruments• Infant Development Inventory (IDI)Infant Development Inventory (IDI)• Child Development Review (CDR)Child Development Review (CDR)• Pediatric Symptom Checklist (PSC)Pediatric Symptom Checklist (PSC)• Edinburgh Postnatal Depression Scale (EPDS)Edinburgh Postnatal Depression Scale (EPDS)• Modified Checklist for Autism in Toddlers (MCHAT)Modified Checklist for Autism in Toddlers (MCHAT)• Adolescent Drug & Alcohol Use: CRAFFTAdolescent Drug & Alcohol Use: CRAFFT


Clinical FlowClinical Flow• Nurse retrieves family from waiting room (vitals, Nurse retrieves family from waiting room (vitals,

place in exam room)place in exam room)• BHC reviews screening measures, reviews social BHC reviews screening measures, reviews social

history, and anticipatory guidancehistory, and anticipatory guidance• BHC documentation is part of PCP’s WCC encounter BHC documentation is part of PCP’s WCC encounter

and noteand note



Clinical FlowClinical Flow• Any concerns identified by screening measures, Any concerns identified by screening measures,

social history, or through clinical contact are social history, or through clinical contact are addressed either through brief intervention or addressed either through brief intervention or follow-up with BHCfollow-up with BHC

• BHC provides immediate feedback and synopsis of BHC provides immediate feedback and synopsis of any interventions offered to PCP before entering any interventions offered to PCP before entering roomroom


OutcomesOutcomes• Enhanced quality of careEnhanced quality of care• Implementation of consistent prevention componentImplementation of consistent prevention component• Improved identification and increased intervention Improved identification and increased intervention

for children at-riskfor children at-risk• Increased primary care productivityIncreased primary care productivity• Enabling PCP to have more patient visitsEnabling PCP to have more patient visits• BHC service for WCC is billed as extension of BHC service for WCC is billed as extension of

PCP’s encounterPCP’s encounter


Case ExamplesCase Examples• 2 month-old, White male, mother has elevated score 2 month-old, White male, mother has elevated score

(11) on Edinburgh Postnatal Depression Scale(11) on Edinburgh Postnatal Depression Scale• 11 year-old, Hispanic male with BMI in the 8311 year-old, Hispanic male with BMI in the 83rdrd

percentile, was on 70percentile, was on 70thth percentile growth curve since percentile growth curve since age 6, gained 8 lbs in past yearage 6, gained 8 lbs in past year

• 30 month-old, African American male, mother says “I 30 month-old, African American male, mother says “I am worried because he is not talking as much as his am worried because he is not talking as much as his brother did at this age”brother did at this age”

• 15 year-old, White female with elevated score (22) of 15 year-old, White female with elevated score (22) of PSC, father reports they have been “arguing a lot PSC, father reports they have been “arguing a lot more than usual”more than usual”


ImplementationImplementation• Before implementing, anticipate that pediatric Before implementing, anticipate that pediatric

providers may express concerns:providers may express concerns:– Disruption of clinical flowDisruption of clinical flow– Need for BHC expertise on topics typically covered Need for BHC expertise on topics typically covered

by pediatriciansby pediatricians• Emphasize to team that goal is to improve clinic’s Emphasize to team that goal is to improve clinic’s

efficiency, while also enhancing patient visitefficiency, while also enhancing patient visit


ImplementationImplementation• SchedulingScheduling– Make a 15 min block on BHC schedule for WCC Make a 15 min block on BHC schedule for WCC – On provider’s schedule template schedule sick On provider’s schedule template schedule sick

visits before and after WCC to maximize PCP work visits before and after WCC to maximize PCP work flowflow

– If multiple providers try to stagger WCC by 15min, If multiple providers try to stagger WCC by 15min, so BHC can be involved without disrupting clinical so BHC can be involved without disrupting clinical flowflow


ImplementationImplementation• BHC must be aware of clinic flow – be an asset, not BHC must be aware of clinic flow – be an asset, not

burdenburden• Obtain helpful patient handouts that cover common Obtain helpful patient handouts that cover common

concerns (tantrums, baby blues, sleep problems, concerns (tantrums, baby blues, sleep problems, weight management etc.)weight management etc.)

• Make plan for when BHC is not available (train nurses Make plan for when BHC is not available (train nurses on reviewing screening measures, completing social on reviewing screening measures, completing social history, knowing when to refer to BHC)history, knowing when to refer to BHC)


Discussion & Discussion & Learning Assessment Learning Assessment

[email protected]@cherokeehealth.com

[email protected]@cherokeehealth.com

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!

Documents

Integrating Behavioral Health into Wellness Visits in Pediatric Primary Care