MENTAL HEALTH SCREENINGSIN PRIMARY CARE

A LEGAL OVERVIEW Stamford Hospital Department of Pediatrics

Grand Rounds - May 16, 2013

Jay Sicklick, Deputy DirectorCenter for Children’s Advocacy

Medical Legal Partnership Project (MLPP)

Overview & Goals

What does the law have to do with mental health screenings?

Medicaid as a foundation for screenings Best practice vs. overburdening requirement A Massachusetts case study

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Case Study: Billy M.

4 year old boy in primary care office for his well-care exam

Presents with no speech or language delays Academically solid in pre-school setting

Psycho-educ eval tests at above normal range

But - conduct poor due to “behavioral issues” (mom called frequently to pick son up early)

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Case Study: Billy M.

Mom shares that Billy has recently been described as using aggressive behavior and inappropriate language

Unbeknownst to you, Mom has history of bipolar disorder

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Case Study: Billy M.

What is the PCP’s next step?

1. Tell the mom to wait and see what happens and call back?

2. Make a referral? To whom? 3. Conduct a brief validated screen

for mental health red flags?

Why or Why Not?cca mlpp

Screening Tools

What behavioral/mental health screening tools do you utilize on a regular basis (if any) to screen patients (0-3 or above) in a well-care visit?

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What If We Do Not Screen? In any given year, more than 1 in 5 Connecticut

children struggle with mental health or substance abuse

More than 50% do not receive treatment 51% had - or were at risk of - court involvement,

juvenile justice intervention, court referral for families with service needs

Source: Andrea M. Spencer, PhD, Center for Children’s AdvocacyBlind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012)

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Mental Heath Screening = Primary Care orMental Heath Screening ≠ Primary Care?

Federal Medicaid Law Early and Periodic Screening, Diagnosis

and Treatment (EPSDT)* (Medicaid’s child health component)

EPSDT mandatory set of services and benefits for children under 21 enrolled in Medicaid

1 in 3 U.S. children under 6 are eligible for Medicaid

*Source: 42 U.S.C. § 1396d(r)(1) et seq.

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EPSDT and Screening

EPSDT vital to ensure that young children receive appropriate health, mental health, and developmental services

Screening to detect physical and mental conditions must be covered at established, periodic intervals

(periodic screens) and whenever a problem is suspected

(inter-periodic screens).

42 U.S.C. § 1396d(r)(1) et seq. (emphasis added).cca mlpp

EPSDT Non-Compliance?

Bring on the Lawsuits Rosie D. v. Romney

Mass district court screening delivery system in primary care was woefully inadequate for state’s Medicaid children and lack of community-based mental health systems violated EPSDT

Ordered MASS Health (Medicaid Agency) to design comprehensive screening and referral system for children at risk insured through MASS

Compliance ensured through data collection (EPSDT numbers)

Rosie D. v. Romney, 410 F. Supp. 2d 18 (2006).

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Rosie D. Outcomes

2008 Q1 2009 Q4 2011 Q30.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

14%

58%

67%

Reported Mental Health Screenings at Well-Child Visits

Reported Mental Health Screenings at Well-Child Visits

Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010); MassHealth Quarterly Screening Data: April-June 2011.cca mlpp

Positive Screen = Referrals

Rosie D. Outcomes

2008 Q1 2009 Q30

10,000

20,000

30,000

40,000

50,000

60,000

1,533

50,535

Number of Children Screened Positive for Mental Health Disorders

Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010).cca mlpp

Referrals = Intervention

Rosie D. Outcomes

FY 2010 FY 2011 0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

5.00%

3.50%

4.70%

Number of Youth Receiving Any Remedy Service

Def.’s Report on Implementation(Jan. 1 2012).

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Positive Screens = Referrals

Oregon Study utilized ASQ ASQ compared to Pediatric Developmental

Impression (PDI) PDI on scale from

typical–questionable–delayed 224% increase in referral rate in a year

PDIs alone = 42% of referrals

Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 PEDIATRICS 381 (2007).

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Importance of Screening Instruments

PDIs missed children at risk 67.5% of delayed cases only identified by ASQ 45.1% of early intervention eligible children

missed by PDI Generally

38% of 12 month cases missed by PDI 23% of 24 month cases missed by PDI Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 PEDIATRICS 381 (2007).

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Where Has It Lead?

CCA Proposed Legislation2011 Session of Connecticut GA

DSS to develop reimbursement strategies to provide support for PCPs to conduct screenings in primary care setting

DSS requested the convening of a task force rather than pursue legislative initiative

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Where Has It Lead? Behavioral Health Screening Task Force

Examination of delivery systems to ensure that screenings are promoted, supported and reimbursed in primary care.

Players DSS DCF CT Chapter - AAP CT Council of C&A Psychiatrists (CCCAP) ACAP DDS – Birth to Three CHDI CT Behavioral Health Partnership (CT-BHP) School based health centers (SBHC) Early Childcare Systems – Head Start OPM CHN – CT

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Where Has It Lead?

BH Task Force met monthly Aug.2012 - Mar.2013

Experts in-state and out-of-state (Mass e.g.) Information obtained, recommendations provided

Mass Experience – PCC feedback Not exceptionally burdensome,

infrastructure working MCPAP as a workable idea and resource

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Where Has It Lead?

Massachusetts Feedback PCPs balked at screenings Curriculum developed Validated screens – in public domain PCP’s found …

50% already receiving BH treatment 40% handled with practical advice –

clinician training 10% referred to “system” for BH treatment

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Where Does It Lead?

Task Force Recommendations (3/2013) R/Q PCPs in MASS/HUSKY Program to perform

annual behavioral health screens using validated instrument from ages 1 - 17

Instruments used must be validated and recommended by AAP (and approved by DSS)

Providers will receive $18 per screen through DSS DSS must maintain claims data and report quarterly DSS to work with AAP to develop curriculum and

trainings for PCPs

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Where Does It Lead?

Recommendations (continued) DSS work with Behavioral Health experts (CT Council

on Child & Adol. Psychiatrists and CHDI, etc.) to assist PCP’s on the “What to do Next” questions …

DSS shall participate in formation of child psychiatry access project in CT – if enacted by GA

Task force meets semi-annually to review data and revise recommendations etc.

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Where Does It Lead?

General Themes Develop support to encourage PCPs to meet the

challenge of conducting MH screens Education to PCPs that reimbursement is available for

those practices not already seeking or to those practices where reimbursement is not included (in bundled rate)

Support DSS’s Person Centered Medical Home (PCMH) initiative (resources)

Know that the threat of a lawsuit lurks in the background (a la Rosie D.)

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Thoughts?

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Questions?

Center for Children’s AdvocacyMedical Legal Partnership Project

Attorney Jay Sicklick860-714-1412jsicklick@kidscounsel.org

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