Massachusetts Child Psychiatry Access Project

1. Massachusetts Child Psychiatry Access Project John H. Straus, MD Massachusetts Behavioral Health Partnership

2. Players • Massachusetts Behavioral Health Partnership (MBHP) is the behavioral health vendor for the Massachusetts Medicaid program, MassHealth. • John Straus is a pediatrician, medical director of Special Projects at MBHP, and the MCPAP developer and executive director. • The Massachusetts Department of Mental Health is the state agency responsible for MCPAP.

3. An idea that has caught on…. • Alaska • Arkansas • California • Colorado • Connecticut • Delaware • Florida • Illinois • Iowa • Louisiana • Maine • Maryland • Massachusetts • Michigan • Minnesota • Missouri • Texas • Vermont • Virginia • Washington • Washington DC • Wyoming • Wisconsin • Nebraska • New Hampshire • New Jersey • New York • North Carolina • Ohio • Oregon • Pennsylvania NNCPAP.org

4. Concept 1 BH problems require either or both: • BH clinician • Prescriber/higher level diagnostician/screener (PCP, PNP, CAP, APRN)

5. Concept 2: Continuum of Collaborative Care LessComplex More Complex ChΨ ChΨ PCP PCP Primary Care Taking Lead Child Psychiatrist Taking Lead ChΨ PCP

6. What is MCPAP? • MCPAP is a system of regional children's mental health consultation teams designed to help primary care providers meet the needs of children with psychiatric problems.

7. MCPAP Goals • Improve access to treatment for children with psychiatric illness • Promote the inclusion of child psychiatry within the scope of primary care practice • Create functional primary care/specialist relationship between pcp’s and child and adolescent psychiatrists • Promote the rational utilization of scarce specialty resources for the most complex and high-risk children

8. Politics! • Health Plans • Providers • AAP • AACAP • Stakeholders • Advocates • Legislators • Health Services Administration • Health Agencies • Payment Reform • Health Home • Legislation

9. How many Children in the District?110,000About 1/14th the size of Massachusetts!

10. Program Design • Dedicated teams deployed regionally across state • A state governmental program, through the Massachusetts Department of Mental Health, administered by the Medicaid managed care organization. • Serves all children and families in Massachusetts regardless of insurance status. • Serves all types of PCPs (MDs, PNPs, PAs) • Teams hosted by prominent children’s healthcare institutions with existing relationships with pediatricians and family physicians. • Operating budgets of teams are fully funded, subject to reconciliation of third party reimbursement .

11. 6 MCPAP “HUBS” Mass General Hospital Lauren Hart, MPH Leah Grant, MSW LICSW Jeff Bostic, MD EdD Betty Wang, MD Elizabeth Pinsky, MD Paul Hammerness, MD UMass Memorial Med Ctr Kelly Chabot Deanna Pedro, LICSW Danette Mucaria, LICSW Mary Jeffers-Terry, CNS Matthieu Bermingham, MD William O’Brien, MSW Northshore Children’s Hospital Brianna Roy Tracey Terrazzano, LICSW Jennifer McAdoo, LMHC Jefferson Prince, MD Lisa D’Silva, MD Michele Reardon, MD Joseph DiPietro, PsyD * * * Tufts Med Ctr Children’s Hospital Boston Rachael Roy Gorton Alexis Hinchey Davis, LICSW Sigalit Hoffman, MD Neha Sharma, DO Eric Goepfert MD Mimi Thein, MD Lauren Mckenna * Baystate Med Ctr Arlyn Perez Jodi Devine, LICSW Barry Sarvet, MD Bruce Waslick, MD Shadi Zaghloul, MD Sara Brewer, MD John Fanton, MD Marjorie Williams-Kohl, CNS * * * * * * * McLean Hospital/Brockton Amanda Carveiro Carla Fink, MSSA LICSW Charles Moore, MD Tracy Mullare MD Mark Picciotto, PhD *

12. MCPAP Services • Telephonic child psychiatry consultation to PCPs within 30 minutes, Monday thru Friday. Last quarter response time met target for 89% of consultations. • Face to face consultations (18% of youth served) • Care Coordination • Transitional support when youth waiting for behavioral health services • PCP education - newsletter, practice meetings, CME

13. Overview • 438 practices with 1,559 FTEs of primary care providers (2,991 individuals) • 92% of pediatric practices with panel size of 2000 or more in MA used MCPAP at least once in FY2012 • 45% of all PCPs used MCPAP in FY2012 • 20,641 encounters, 10,553 youth in FY 2013 • Over 1,460,000 children now covered • Over 98% of Commonwealth • Cost = $2.20 per child per year

14. Utilization – Encounters by Month 60% Commercially Insured – 40% Publicly Insured

15. MCPAP Encounter Types

16. Types of Consultation Questions Screening Support Medication Questions: -Selection -Side Effects -Interim management Help! Diagnostic question Treatment planning Unable to access MH resources Need second opinion Therapy Questions: -Selection -Monitoring -Linkages

17. Reason for contact(% of total calls)

18. Diagnoses (% of total calls)

19. Medications (% of total calls)

20. Outcome 65% Medical Follow Up with PCPs

21. Adapting to Practice Transformation • Integration: Integrated BH clinician usually Masters level so puts more pressure on PCP to provide diagnostic and medication expertise. MCPAP is there supporting both clinician and PCP. • Patient Centered Medical Homes: MCPAP care coordinators now working with practice based care coordinators.

22. MCPAP as Statewide Vehicle for Quality Improvement • Use of Standardized BH screening tools • Screening of children of military families • Use of national guidelines (GLAD-PC) • Promotion of court ordered services (Rosie D.) • Improving management of teen substance use as part of recently received state CMS SIM grant • Implementation of Triple P for youth < 6 • Research

23. www.mcpap.org

24. See newsletter archives at: http://www.mcpap. com/news_archieves.asp

25. Encourage parents to use PCP for Behavioral Health Issues

27. Politics! • It never stops! • Legislature just increased MCPAP budget to full funding with requirement that all insurers pay their share. Pushed over the top with support of mothers’ groups by agreeing that MCPAP would facilitate obstetric and pediatric prenatal and postpartum depression screening with provider education and consultation for obstetric and pediatric practices. • Keep various agencies up to date and supportive.

28. References • Sarvet B, Wegner L. Developing Effective Child Psychiatry Collaboration with Primary Care: Leadership and Management Strategies. Child Adolesc Psychiatr Clin N Am. 2010 Jan;19(1):139-48 • Sarvet B, Gold J, Straus J. Bridging the Divide between Child Psychiatry and Primary Care: The Use of Telephone Consultation within a Population-Based Collaborative System. Child Adolesc Psychiatr Clin N Am. 2011 Jan;20(1):41-53. • Sarvet B, Gold J, Bostic JQ et al. Improving Access to Mental Health Care for Children: the Massachusetts Child Psychiatry Access Project. Pediatrics. 2010 Dec; 126: 1191-1200. • Rosie D. and Mental Health Screening: A Case Study in Providing Mental Health Screening at the Medicaid EPSDT Visit, TeenScreen National Center for Mental Health Checkups at Columbia University, Fall 2010 • The Massachusetts Child Psychiatry Access Project: Supporting Mental Health Treatment In Primary Care, Wendy Holt, Commonwealth Fund, Publication 1378, Volume 41, March 2010