Well-Child Visits: A Platform for Prevention and Early Intervention

1. Session # D2b • October 17, 2014 Well-Child Visits: A Platform for Prevention and Early Intervention Alicia L. Smith, Psy.D., Behavioral Health Consultant, Cabin Creek Health Systems Jennifer J. Hancock, Psy.D., Behavioral Health Consultant, Cabin Creek Health Systems • Collaborative Family Healthcare Association 16th Annual Conference • October 16-18, 2014 Washington, DC U.S.A.

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

3. Learning ObjectivesAt the conclusion of this session, participants will be able to: • Learn how to implement behavioral health screenings during well-child visits • Identify common behavioral and health promotion diagnoses seen in a rural primary care clinic • Learn more about evidence-based interventions for common health related and mental health conditions

4. References 1. American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP). (2009). Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration. Pediatrics, 123, 1248–1251. 2. Behrens, D., Lear, J. G., & Price, O. A. (2013). Improving access to children’s mental health care: Lessons from a study of eleven states. George Washington University: The Center for Health and Healthcare in Schools. 3. Bitar, G. W., Springer, P., Gee, R., Graff, C., & Schydlower, M. (2009). Barriers and facilitators of adolescent behavioral health in primary care: Perceptions of primary care providers. Families, Systems, and Health, 27, 346-61.

5. References 4. Calonge, N., Petitti, D. B., DeWitt, T. G., et al. (2009). Screening and treatment for major depressive disorder in children and adolescents: US Preventitive Services Task Force Recommendation Statement. Pediatrics, 123, 1223-1228. 5. Centers for Disease Control (CDC). (2013). Youth Risk Behavior Surveillance System (YRBSS). Retrieved from http://www.cdc.gov/HealthyYouth/yrbs/index.htm 6. Chapman, C., Laird, J., Ifill, N., & KewalRamani, A. (2011). Trends in high school dropout and completion rates in the United States: 1972–2009. Education Statistics Services Institute American Institutes for Research: Compendium Report: U.S. Department of Education.

6. References 7. Keeton, V., Soleimanpour, S., & Brindis, C, D. (2012). School-based health centers in an era of health care reform: building on history. Current Problems in Pedicatric and Adolescent Health Care, 42, 132-156. 8. Lofink, H., Kuebler, J., Juszczak, L., Schlitt, J., Even, M., Rosenberg, J., & White, I. (2013). 2010-2011 School-Based Health Alliance Census Report. Washington, D.C.: School-Based Health Alliance. 9. Massachusetts Department of Public Health Bureau of Substance Abuse Services. (2009). Provider guide: Adolescent screening, brief intervention, and referral to treatment using the CRAFFT screening tool. Boston, MA: Massachusetts Department of Public Health.

7. References 10. Moyer, V. A. (2013). Primary care interventions to prevent tobacco use in children and adolescents: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 159, 552-558. 11. Ozer, E. M., Adams, S. H., Orrell-Valente, J. K., Wibbelsman, C. J., Lustig, J. L., Millstein, S. G., Garber, A. K., & Irwin, C. E. (2011). Does delivering preventive services in primary care reduce adolescent risky behavior? Journal of Adolescent Health, 49, 476–482. 12. Patnode, C. D., O’Connor, E., Whitlock, E. P., Perdue, L. A., Soh, C., & Hollis, J. (2013). Primary care-relevant interventions for tobacco use prevention and cessation in children and adolescents: A systematic evidence review for the U.S. preventive services task force. Annals of Internal Medicine, 158, 253-260.

8. References 13. Richardson, L. P., Rockhill, C., Russo, J. E., Grossman, D. C., Richards, J, McCauley, E., Katon, W. (2010). Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics, 125, 1097-1103. 14. U.S. Preventive Services Task Force (USPSTF). (2010). Screening for obesity in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics, 125, 2009-2037.

9. Learning Assessment • How many people here would be comfortable screening for behavioral health issues during well-child visits? • What do you anticipate are common behavioral and health promotion diagnoses in rural primary care clinics? What are some potential risks of screening at WCVs? • What EBTs do you believe are most frequently utilized for behavior health concerns in primary care? *A question and answer period will be conducted at the end of this presentation.

10. Addressing Adolescent Behavioral Health in Primary Care Some interesting facts… • 1/5 adolescents experience emotional distress (20%). • 1/10 adolescents are emotionally impaired and unable to function in daily activities (10%).

11. Addressing Adolescent Behavioral Health in Primary Care • Behavioral Health services may be less stigmatizing and more coordinated when addressed in primary care. • Addressing behavioral health problems may decrease the overutilization of health services that is common among children and adolescents with behavioral health issues. • Primary care providers already provide behavioral health treatment, including psychotropic medication for children and adults.

12. The Well-Child Visit Using an integrated approach to care, the WCV is an optimal time for behavior health prevention and early intervention. But HOW??? But WHO??? “I’m Scared!”

13. Addressing Pediatric Mental Health “It’s not that bad!”

14. Cabin Creek Health Systems • FQHC located in Rural, WV • 5 Community Health Centers • 4 School-Based Health Centers • Services offered: Adult Care Women’s Health Children’s Health Prenatal Care and Obstetrics Behavioral Health Pharmacy Dental Care Pulmonary Rehab

15. School-Based Health Well-Child Visit Protocol • Students complete the Student Health Questionnaire at Well-Child Visits • From Aug. 2012 to May 2014, we administered 377 SHQs at 2 of our SBHCs

16. Percentage of Adolescents Who Report Risky Health Behaviors • Do not eat 5 fruits & veg/day day • More than 2 hours of screen time/day • Less than 1 hour of physical activity/day • Less than 3 servings of dairy/day • Did not visit the dentist during the past year • Use tanning beds

17. Percentage of Adolescents Who Report Risky Health Behaviors • Have ever used tobacco • Have not seen a dentist during the past year • Use tanning beds

18. Percentage of Adolescents Who Report Risky Substance Use Behaviors: CRAFFT • Ridden in a Car with someone who was drunk or high • Used drugs/alcohol to relax • Used drugs/alcohol when alone • Forget things while using drugs/alcohol • Family & Friends tell you to cut down • Gotten into Trouble Using Drugs/Alcohol

19. Percentage of Adolescents Who Report Emotional Concerns • Felt sad or down as though you have nothing to look forward to? • During the last month, have you had trouble sleeping, poor appetite, or low energy? • Have you ever seriously thought about hurting or killing yourself? • When you get angry, do you do violent things? • Do you have at least one friend or family member you can talk to?

20. Percentage of Adolescents Who Report Safety Concerns • Do not feel safe at home • Do not feel safe at school • Do not always wear a helmet • Do not always wear a seatbelt • Been in a gang • Been in jail • Stayed in a homeless shelter • Abuse history

21. Percentage of Adolescents Who Report Sexual Concerns • Engaged in sexual practices including oral, vaginal, and anal • Do you think you might be gay, Lesbian or Bi-sexual? • Of those who have had sex, do you use a condom? • Of those who have had sex, do you use other forms of birth control? • Have ever been or gotten someone else pregnant • Felt pressured to have sex • Have had an HIV Test

22. Percentage of Adolescents Who Report School and Academic Performance Concerns • Have been suspended from school • Do not want to do well in school and life • Report problems with concentration and focus • Do not have plans after graduation

23. Common Diagnoses Seen at the Clinics Resulting from the Well-Child Protocol • Anxiety/Depression • Adjustment Disorders • (Probable) ADHD • Learning Disorders • Tobacco Use Disorder • Substance Abuse (Marijuana, Alcohol, Heroin) • Health Concerns: Insomnia, Obesity

24. Risks, Challenges & Limitations • No parent measure at SBHCs • Pathologizing normal reactions to stressors • Can be hard to manage the number of BHC referrals • Important to use problem-focused EBT • Refer out when necessary • For intensive treatment • Full-Battery Assessment • Billing Issues: Varying success with reimbursement (99420 CPT code)

25. Well-Child Protocol • Patients presenting for Well-Child Visits receive: • Student Health Questionnaire (adolescents complete) • Pediatric Symptom Checklist Parent Report (parents complete) • Concerns can warrant either a: • Warm Hand-off • BHC Referral

26. Primary Care EBT: Anxiety/Depression • Relaxation Strategies (Can use YouTube for practice at home) • Behavioral Activation • Activity Scheduling • Exercise • Cognitive Behavior Therapy (CBT) • Interpersonal Therapy (IPT) • Mindfulness • Psychoeducation

27. Primary Care EBT: ADHD • Screen (Vanderbilt Forms given to teachers and parents) • If positive, refer for psychological testing • ADHD Battery • D-Kefs • EBTs include • Stimulant medication • Behavioral Therapy

28. Primary Care EBT: Tobacco Use Disorder • Motivational Interviewing • STAR • Set a quit date • Tell family & friends about quit plan and request support. • Anticipate challenges (withdrawal/triggers) • Remove tobacco products from environment

29. Primary Care EBT: Insomnia • Sleep hygiene • Cognitive Behavior Therapy for Insomnia (CBT-I)

30. Why All the Work? • To promote an integrative approach to care • Early intervention leads to better outcomes • Addressing mental health concerns reduces PCP visits • Allows parents the opportunity to discuss behavioral and emotional concerns that may have otherwise gone unnoticed

31. Additional Perks! • Address Meaningful Use Measures • Depression Screening • Physical Activity Counseling • Nutrition counseling • Tobacco Use

32. Question, Comments, Points of Clarification?

33. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!