Primary Behavioral Health Care for Children and Families: A Systemic

Longitudinal ApproachPatricia Gerrity, PhD, RN, FAAN

Associate Dean for Community ProgramsDrexel University, College of Nursing & Health Professions

Jessica Covitz, MSWPrimary Behavioral Health Consultant

11th Street Family Health Services of Drexel UniversityCollaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session # C5October _29_, 20111:30 PM

Faculty Disclosure

Please add the commercial interest disclosures that you reported on your signed Disclosure form:

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

Need/Practice Gap & Supporting Resources

What is the scientific basis for this talk?

Research has shown that infant mental health is crucial to the prevention of mental, emotional, and behavioral disorders throughout the lifespan.

Brain development occurs most rapidly in the first 1,000 days of life, when social and emotional building blocks begin to form. During this time children are particularly receptive to positive experiences, and very vulnerable to negative ones.

Objectives1.Describe the expanded role of the pediatric primary care consultant as part of the primary care team.

2.Identify opportunities for implementing prevention programs to promote infant well-being and mental health.

3. Recognize the role of the mental health consultant in a Life Course Perspective model of care.

4. List potential outcomes measures used to evaluate integrated behavioral care for children and families

Expected Outcome

What do you plan for this talk to change in the participant’s practice?

• Increase awareness of the potential for expanding the role of thePBHC for children.

• Build in prevention programs with specific emphasis on sensitive periods using a Life Course Perspective.

• Consider use of routine surveys and evaluations for individual and aggregate planning & evaluation

In partnership with the Family & Practice & Counseling Network

11th Street Family Health Services of Drexel University

Integrative Health Care

To create a seamless engagement by patients and caregivers of the full range of physical, psychological, social, preventive, and therapeutic factors known to be effective and necessary for the achievement of optimal health throughout the lifespan.

Integrated Team

• Family nurse practitioner• Primary behavioral health consultant

– Child & Adult

• Generalist social worker• Health educator/nutritionist• Complementary & integrated therapist• Physical therapist• Creative Arts Therpaist

Transdisciplinary Model of Care

• Helps break down the barriers between professions

• Holistic approach to assessment and treatment plans

• Continuing cross disciplinary education

• Flexibility of roles among providers

• Improves both efficiency & quality of care

• Adults and children need a single point of access for care that addresses both the physiological and psycho-social aspects of the person and family.

Trauma & Adversity

• Integral experience in the lives of many patients

• Both research & practice revealed the close correlation among trauma, increased depression, and exacerbated chronic conditions

Original Study vs 11th St Results

Number of Adverse Childhood

Experiences (ACE Score) Women Men Total

11th Street Patients

Original Study

11th Street Patients Original

Study

11th Street Patients Original

Study

0 6.8% 34.5% 3.9% 38.0% 6.3% 36.1%

1 12.5% 24.5% 9.9% 27.9% 12.0% 26.0%

2 18.5% 15.5% 14.5% 16.4% 17.8% 15.9%

3 14.6% 10.3% 16.4% 8.6% 14.9% 9.5%

4 or more 47.5% 15.2% 55.3% 9.2% 49.0% 12.5%

Trauma Informed care

• A culture, gender and age –sensitive service system that recognizes and addresses the presence and long term effects of violence, neglect, victimization, abuse and other traumatic experiences in the lives of their patients.

Target Population

• Young families living in the area around the health center

• The majority are headed by female who live in public housing

• Predominately African American• Subject to a range of material hardships such

as overcrowding, frequent moves, poor schools, stressful environments and lack of adequate nutrition

Life Course Perspective

• The life course approach to conceptualizing health care needs and services evolved from research documenting the important role early life events play in shaping an individual’s health trajectory. The interplay of risk and protective factors, such as socioeconomic status, toxic environmental exposures, health behaviors, stress, and nutrition, influence health throughout one’s lifetime.

Early Programming

• Early experience can program an individual's future health and development

• Prenatal- exposure in utero• Intergenerational-health of mother prior to

conception• Adverse programing can directly result in a

condition or make one vulnerable or more susceptible

Why needs not adequately being addressed

•The concept of mental health intervention has traditionally been associated with treatment efforts to reduce the effects of an individual’s mental health problem.

Primary Behavioral Health Consultant

• Formalized, routine, longitudinal contact with an interdisciplinary team

• Building a foundation of healthy family behaviors and mental health

• The cornerstone of BHC’s interventions is therapeutic and educational.

PBHC’s Goals

• Therapeutic strategies:Quickly engage and build a relationship with the patient and family while providing psychoeducation to empower families with life skills Establish long-term relationships with people and families

Referred by Nurse Practitioners or Self:• In the moment consultations• Scheduled brief therapy• Sexual health for teens• Options counseling

• Links with early head start, schools,

Referral Process

Well Child Visits

• PBHC works mostly with families and children • Go into visit before Nurse Practitioner to gather

history and do developmental and behavioral screenings.

• In the moment anticipatory guidance• Assist families in referrals to developmental and

behavioral services.• Evaluate for behavioral/emotional causes of

symptoms such as: bedwetting, headaches, sleep disturbances, school difficulties.

Screenings used to focus visits and collect data.

Patient Wellness Tracker

Data & Evaluation Challenge

• EMR – gather data during more routine primary care visits

• Limited use in capturing information that reflects integrated and holistic nature of the center’s services as well as survey data

• Data stored in fragmented places hindering patient tracking and outcome evaluation

• Providers needed effective ways to exchange information

Patient Wellness Tracker

• Institute for Health Informatics• Develop a comprehensive health information

system that can draw from the EMR• Used to collect all survey data from patients• Captures information about participation in

chronic illness management, yoga, fitness, cooking classes and smoking cessation

• Allows the use of tags – concise qualitative information

Transition to Centering Model

• Patient centered care• Group setting providing support from their

peers• More time with practitioners

Centering Model

• Incorporation of – Assessment – Education– Support

• provided by an interdisciplinary team in a group setting

Centering Pregnancy• Eight to twelve women with similar

gestational ages meet together, learning care skills, participating in a facilitated discussion, and developing a support network with other group members.

• Each Pregnancy group meets for a total of 10 sessions

• The practitioner completes standard physical health assessments within the group space.

• Co-facilitated discussions by mid-wife and either PBHC or Public Health Nurse.

• Assessment, support, and education:dental, nutrition, yoga, self-care, newborn care, birth preparation, family relationships, contraception.

• Very positive feedback from moms.

Group Prenatal Care

Centering Parenting

• Continuing the model of family focused care from pregnancy to well child care

• Utilizing the group model of education and support to shift focus to parent-baby dyad

• Providing formalized, routine and longitudinal care with interdisciplinary team

Visit for Mother and Baby

Centering Parenting

• Babies grouped by age• Care for mom and baby

in same visit• 6-8 parent-baby dyads

per group • 2 hours with

practitioners• Focus on development,

safety, nutrition, family

Centering Parenting

•Fosters stronger relationships between providers and parents•These relationships allow greater knowledge and understanding of family circumstances, challenges, hopes, and strengths for themselves and their babies

Through relationship based practice, providers promote positive parent-child interactions, while encouraging continued supportive relationships with the practitioners.

Centering Parenting

Mom’s Visit:• Contraception, Weight

management, Depression, Nutrition, Stress, Parenting Issues

• Parents talking together forming a supportive network

• Encouragement of father involvement

Helps establish a foundation for supporting healthy family behaviors and promoting mental health

Build Relationships with Providers

Relationship Based Practice

Results in early identification of developmental, behavioral and health problems – can receive early intervention

Learn Normal Development

Provide Support

Use of Aggregate Data for Program Planning

Screenings are used to focus individual visits and document progress.

Survey results are also used for overall program evaluation and revising services

  Often Sometimes Often Sometimes Often SometimesPediatric Symptom Checklist All All male Male female FemaleDoes not show feelings 29.6 43.7 22.2 51.9 34.1 38.6

Distracted easily 25.4 40.8 40.7 33.3 15.9 45.5Has trouble concentrating 25.4 36.6 48.1 25.9 11.4 43.2Has trouble with a teacher 25.4 31 51.9 33.3 9.1 29.5

Feels sad, unhappy 22.5 59.2 7.4 70.4 31.8 52.3

Is irritable, angry 21.1 54.9 18.5 66.7 22.7 47.7Spends more time alone 21.1 57.7 14.8 59.3 25 56.8Acts as if driven by a motor 18.5 14.1 37 14.8 6.8 13.6Less interested in school 18.3 43.7 29.6 48.1 11.4 40.9Fidgety, unable to sit still 18.3 19.7 33.3 18.5 9.1 20.5Does not listen to rules 16.9 42.3 29.6 44.4 9.1 40.9

Fights with others 16.9 38 22.2 44.4 13.6 34.1

Worries a lot 15.5 46.5 14.8 29.6 15.9 56.8Daydreams too much 15.5 39.4 29.6 22.2 6.8 50Wants to be with you more than before 14.1 42.3 18.5 44.4 11.4 40.9Is down on him or herself 14.1 40.8 3.7 37 20.5 43.2

Feels hopeless 14.1 26.8 7.4 22.2 18.2 29.5Takes unnecessary risks 14.1 23.9 25.9 29.6 6.8 20.5

Does not understand other people's feelings 11.3 47.9 11.1 48.1 11.4 47.7School grades dropping 11.3 35.2 18.5 37 6.8 34.1

The Future of Health Care

Acknowledgments

• Pew Charitable Trusts• First Hospital Foundation• March of Dimes

• Emily Duffy, MSW, LCSW Founding Pediatric PBHC at 11th Street

Review Questions

• Do you currently use PBHC for children? If so how can you expand prevention efforts?

• How could a Life Course Perspective help to coordinate efforts of all providers caring for families over the lifespan?

• What screening & evaluation methods could be most useful for your practice?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!