Meeting Psychotropic Medication Prescribing Needs

9/19/2018

Meeting Psychotropic Medication Prescribing Needs in Primary Care:

Interprofessional Collaboration Involving Pediatricians, Psychiatrists, and Psychologists

Concurrent Session 1

2018 Annual Meeting Anaheim, CA September 15, 2018

Presenters Cody Hostutler, PhD, Pediatric Psychologist Nationwide Children's Hospital and Ohio State University, Columbus, OH Jeffrey Shahidullah, PhD, Pediatric Psychologist Rutgers University and Robert Wood Johnson Medical School, New Brunswick, NJ Raman Marwaha, MD, Child and Adolescent Psychiatrist MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH Rebecca Baum, MD, Developmental and Behavioral Pediatrician Nationwide Children's Hospital and Ohio State University, Columbus, OH Terry Stancin, PhD, Pediatric Psychologist MetroHealth Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH 2018 Annual Meeting Anaheim, CA September 15, 2018

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Disclosures The presenters of this session have no conflict of interest or disclosures


Learning Objectives 1. Improve knowledge/awareness of current state of training and practice for psychotropic medication prescribing to children in primary care 2. Learn about innovative collaborative care models using psychiatrists and psychologists to improve the standard of PCP prescribing of psychotropic medications 3. Explore how models could incorporate DBP expertise as consultants or embedded providers


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Interprofessional Primary Care Practices to Support Psychotropic Medication Management in Primary Care Cody A. Hostutler, PhD Nationwide Children’s Hospital The Ohio State University Columbus, OH 2018 Annual Meeting Anaheim, CA September 15, 2018

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Rationale: Increasing Rates of Psychotropic Use

Rationale: Types of Psychotropics

Sultan et al., (2018). National patterns of commonly prescribed psychotropic medications to young people. Journal of child and Adolescent Psychopharmacology. 28(3). 158-165.

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Rationale: Shortage of Psychiatrists

Rationale: Shortage of DBPs

Leslie LK et al. Revisiting the Viability of the Developmental-Behavioral Health Care Workforce. Pediatrics. 2018.

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Rationale: PCPs Prescribe as Much or More

Rationale: But PCPs Face many Barriers • PCPs often report lack of: • • • •

Confidence Knowledge Skills Time

• More time, lower reimbursement for Mental Health visits 2018 Annual Meeting Anaheim, CA September 15, 2018

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Existing Attempts to Remedy • Clinical Practice guidelines and toolkits • E.g., GLAD-PC (Cheung et al., 2018)

• Coordinated Psychiatric Service • MA Child Psychiatry Access Project (Straus & Sarvet, 2014)

• Collaborative care models • ROAD (Richardson et al., 2014)


Model Comparison Integrated Care • Work alongside PCPs • Broad range of conditions • Diagnostic, intervention, and care managment • Psychiatric consultation when necessary • Allows psychologists to work at top of license

Collaborative Care • Work Under PCPs • Narrow focus of conditions • Care management • Built in psychiatric support • Top of master’s license, not psychologists

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Integrated Psychology Roles in Medication Management • Supporting Diagnostic Clarity • Providing Psychotropic Information to Families • Joint planning and Care Coordination • Addressing Barriers to Adherence • Pill swallowing • Stigma • Misinformation

• Evaluation and monitoring of medication effects 2018 Annual Meeting Anaheim, CA September 15, 2018

Levels of Practice • Level 1 • Psychotropic information providing (graduate training)

• Level 2 • Collaborative Practice (graduate training + supervised experience)

• Level 3 • Prescriptive Authority • Master’s degree or certificate in psychopharmacology • Alliant International University • Nova southeastern University • Fairleigh Dickinson University

• Passage of Psychopharmacology Examination for Psychologists (PEP)

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Nationwide Children’s Hospital Collaboration PCP

MLP

Clinical Pharmacy

• Joint Visits in Primary Care Trainees

Primary Care Team Social Work

*** Psychiatry ***

• Psychosocial Rounds • Training • Case Discussion • Care Management • Phone and Electronic Consultation • Brief Intervention with Psychology • Curbside consultations with DBP

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Embedding Psychologists within a Rural Primary Care Clinic to Enhance Pediatrician Management of BH Conditions & Pharmacological Regimens Jeffrey D. Shahidullah, PhD Rutgers University, Robert Wood Johnson Medical School New Brunswick, NJ 2018 Annual Meeting Anaheim, CA September 15, 2018

Setting – Geisinger Health System • Rural catchment area (central/northeastern PA) • Pediatric Residency Program (Danville, PA)

• Integrated healthcare system • Payer/provider in same fiduciary structure (Geisinger Health Plan)

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Psychotropic Medication Prescribing for Mental Health Concerns: An Unmet Need • Lack of access to child/adolescent psychiatrists • Very few in Geisinger System and community • Families drive hours away for appointment/long wait time

• PCP attendings/residents tasked with managing pharmacological regimens “in-house” • Clear and consistent reporting that residents (and many attendings) do not feel comfortable, lack the time/capacity within busy primary care practice • PCPs requesting increased access to medication consults for years – very few viable/workable solutions

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Integrated Behavioral Health in Primary Care Initiative • 2010 – 2018: embedded 7 full-time psychologists & 4 full-time postdocs in primary care sites • “Fully Integrated Model” • • • •

Shared space/staff/EMR Warm handoffs (immediate evaluations/recommendations/treatment) Curbside consultations Joint appointments

• Medication-related roles that psychologists frequently undertake • • • • •

Supporting diagnostic clarity Providing psychotropic information to families Joint planning and care coordination with PCPs Addressing barriers to adherence Medication monitoring – data to assist PCP

IBH in Primary Care: Resident Training Initiative

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Data Collection • July 2015 - Survey and focus groups conducted before psychologist integration in resident continuity clinic • 4 focus groups run by trained facilitators (PGY 1,2,3’s) • 2 focus groups run at Geisinger (1 w/ PGY1’s; 1 w/ PGY2/3’s) • 2 focus groups run at a similar residency program 1-hr away • Most behavioral health training came from 1-mo DBP rotation; no IBH care

• June 2016 – End of year survey and focus groups conducted

Focus Group Themes 1. Time management difficulties (high patient volume/short appt. times) 2. Difficulties with rapport building/working with families 3. Lack of knowledge/awareness of resources and referrals for behavioral health 4. Lack of knowledge/confidence in prescribing psychotropic medications 5. Less confidence in treating than in diagnosing 6. Acknowledgement of the importance of behavioral health 7. Fears of missing something (child abuse, suicidality) 8. Inadequacy of training in behavioral health

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Subthemes within “medications” theme • Lack of referral options to psychiatric specialists

• Poor patient follow-through to those options • Convincing families to try behavioral options as 1st-line

• Suboptimal training

• Highly variable experiences • Working with adult populations > pediatrics population

• Difficulties in managing Rx regimens • • • • •

Dosing issues/2nd line options Co-occurring/comorbid behavioral health conditions Managing Rx regimen that another prescriber initiated Safety issues Lack of time/continuity with patients for follow-up

Lack of Referral Options  …its hard finding psychiatrists…we have kids admitted [in

hospital] and we want to hook them up and get them in the system, but we don’t have time and they have to go back to someone there and that’s a system limitation which there isn’t a great fix for. I wish we felt more integrated into the system or even just knew where to send kids because, I usually have to call [psychology] and say I don’t know where this kid should go and I don’t even know where to look up a local psychiatrist who can help me…  I had a mom say, “my son is depressed, he needs medication” and I was like, “ok, lets talk a little more first” and she was like, “no, I want you to give him a prescription. My daughter has it, like that’s it”. I’m not comfortable doing that and she was in a 10-m visit slot. Its hard because I couldn’t go grab someone who was familiar with these issues to run questions or medications by.

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Suboptimal Training Things you worry you haven’t addressed well during residency? I feel like getting more exposure to when we actually should start the medication and what dose to start at. At least I haven’t had that experience of actually prescribing it myself because they’re already on it or someone else is controlling it since we refer [to psychiatry]. What conditions could benefit from more knowledge regarding prescribing?  The stimulants or any of the SSRI’s, anxiety meds, depression meds in general. I don’t feel that comfortable to just start someone on it.  I feel like it’s a factor of who you work under too. We have attendings who are more comfortable than others with starting these medications, but a lot of the clinic attendings, I’ve noticed, don’t like starting patients on these meds- they’ll refer out.

Suboptimal Training/Difficulties in Managing Rx Regimens Gaps in training in managing pediatric behavioral health issues?  I’m fine asking questions about depression, suicidality. I don’t feel comfortable knowing how to manage those patients. I don’t know what the right protocol is after I find out they’re not suicidal, but really depressed…I know from working with the different providers there that they recommend therapy and counseling for everybody, so I know that’s a good place to start. But when it comes to starting a medication, what kind do you put them on? That I don’t feel comfortable with yet.  I agree. You get comfortable asking the questions and starting to get the diagnosis part and you’re always scared you’re going to miss somebody, but I feel more comfortable in that area than the treatment. I’m starting to learn where to send people and the best resources, but what do I do in the meantime? I get really confused on the right medication or is there medication? Do they need it? I don’t feel comfortable with that part.  …and sometimes you know the right medications, but when do you start them?  I’d feel more comfortable with an 80 year old female than an 18 year old female…

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Suboptimal Training/Difficulties in Managing Rx Regimens  Yea, in the situation [where people aren’t willing to follow up with psychology], I would be remotely comfortable prescribing an SSRI. I wouldn’t be comfortable prescribing anything else. There would be one medication that I would maybe be ok with, and just hope that would work.  My psych training was mainly with adults. In med school that’s what you see. Level of comfort with prescribing medications to children with behavioral health issues?  Zero (laughing)  I’m okay initiating an SSRI but if its not working...if we start getting side effects and complications then I’m tapped out.

Difficulties in Managing Rx Regimens Some of you are saying initiating was not as difficult as managing regimens that were initiated by someone else…  I think starting a patient on a medication is always scary if you don’t have much experience with it.  It’s also tough when it’s not your patient…that comes from being in a resident clinic with multiple providers, but also from the nature of the population here that they’re in and out and the providers in the area change a lot. I have no idea where they started…have no baseline for this patient, you have no idea how bad they were or how bad they were not, you don’t know….you’ve missed all the initial stuff. It’s hard to get a patient who’s coming in for a refill of whatever and you want to go back to day 1 and say “tell me how this all started again” and they’re like, “no, I just want you to refill my medications because I ran out.” And they always run out like 2 weeks ago and now the kid is having a meltdown. I feel like it’s always the worst situation…I usually end up refilling them, but that makes me uncomfortable because I didn’t start these medications and I can’t go back because if it’s not in our charts you’re limited to how much you can figure out.

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End of Year – Focus Group After one year of psychologist integration into continuity clinic

Experiences having psychologists embedded and sharing patients with them? We’re spoiled (laughter) It’s great, especially when you’re already behind and you don’t have much time to speak with a family, having them come in and giving them other strategies to help kind of helps us out. When you have a kid in need and you only have 15 minutes it’s nice to say, “hey, can you come talk to this family while I go see my other patient that’s waiting?” It’s a luxury that I don’t think a lot of offices have. We’re lucky to have it. The families like it too. Like every time I ask “hey we have this person here to come talk to you. Would you mind?” and they’re usually very willing to talk to them so I think they also like it. Yea, I think when you offer it and tell them someone will contact you, it kind of just gets lost, but if they are willing at that point in time, it’s easier for them to actually talk to somebody right then and there.

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I had a family that the kid had more oppositional behavior problems and they kept requesting increases in ADHD medications that I wasn’t comfortable with and his Vanderbilt scores and things didn’t match with ADHD and to convince them that that wasn’t the solution when that’s what they wanted was difficult. To have someone else explain other options and support what I presented and providing resources for that and encouragement was helpful. I don’t think that family had the best follow through with it, but it helped in that occasion to say “here are the reasons why we can’t increase your medication and why it’s not the best for your child”. That support from [psychologist] was helpful. …you have those patients who can’t be seen by someone else so you’re stuck with having to manage their medications, which again we don’t get much experience so….I’ll increase your dose but probably not as much as you want me to because I’m too scared.

How do you know when its time to refer to the psychologist? When I have a behavioral child and they’re there (laughter from room). That’s the honest answer. And sometimes they’re listening in when we’re talking about a patient with an attending and will offer to come in which is nice too. When you get to that point where you’re uncomfortable and not sure if what you’re doing is right. Or it might be right but we just know one way to do it because that’s what we did with our last patient, but there’s multiple ways to go about it. Things you would like to learn more about in order to provide behavioral health care to children in your practice?

I think sometimes the observation…I think hearing what they have to say and how they coach a family through it is just as beneficial as seeing a patient.

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Survey Data Comfort with prescribing psychotropic medications for Anxiety in children and adolescents Very Comfortable, Comfortable, Somewhat Comfortable, Not at all Comfortable

Comfort with prescribing psychotropic medications for Depression in children and adolescents Very Comfortable, Comfortable, Somewhat Comfortable, Not at all Comfortable

Comfort with prescribing stimulant medications for ADHD in children and adolescents Very Comfortable, Comfortable, Somewhat Comfortable, Not at all Comfortable

Survey Data – following PGY1’s for 3 years… Geisinger (n = 10) Pre

Comparison site (N = 5)

Post

Pre

2.2

3

ANX Meds 3.3 DPR Meds 2.9

Post ANX Meds 3.4

t = 3.54 p = 0.005*

3

t = 1.29 p = 0.221

2.6

t = 2.46 p = 0.020*

DPR Meds 2.2

3

ADHD Meds 2.9

Test

ADHD Meds 1.4

3

1 = Very Comfortable 2 = Comfortable 3 = Somewhat Comfortable 4 = Not at all Comfortable

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Psychopharmacology Consultation Facilitated by Integrated Psychology Residents in a Pediatric Continuity Care Clinic: A Feasibility Study Raman Marwaha, MD Child and Adolescent Psychiatrist Psychiatry Residency Program Director MetroHealth Medical Center Assistant Professor Case Western Reserve University Cleveland, Ohio

MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Co-Authors

• Julie Pajek, PhD • Lisa Ramirez Shah, PhD, ABPP • Terry Stancin, PhD, ABPP


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Disclosures • Supported by Ohio Dept. of Medicaid, Medicaid Technical Assistance and Policy Program (MEDTAPP) Healthcare Access Initiative, CaseCAN: Case Children's Access Now • We have no relevant financial relationships with any commercial interests to the content of this activity


Rationale of Problem • Behavioral health (BH) conditions are most common presenting problem in pediatric primary care and are most costly condition in youth • Integrated care has become a widely accepted strategy for addressing unmet BH needs

Coordinated Care

Co-located Care

• Screening • Consultation • Navigation

• Colocation • Health Homes

Integrated Care • Collaborative • System-Level Integration

Adapted from Kaiser Family Foundation, Integrating Physical and Behavioral Health Care: Promising Medicaid Models, Issue Brief, Executive Summary. Feb 2014:3 MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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Training Issues • •

Pediatrician BH training needs are well-known Workforce shortages – Developmental/Behavioral Pediatricians – Child psychiatrists – Child psychologists • Few training opportunities in integrated primary care • Lack of training of interprofessional team members & in team functioning MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

MetroHealth System •

58% Cleveland children live in poverty (2014 U.S. Census)

• • • •

County safety net hospital 25+ locations Academic medical system/ Case Western Reserve University Pediatric clinic – 100,000 ambulatory visits/year – 90% insured by Medicaid – Racially, ethnically diverse

•

Child/Adol Psychiatry & Psychology – 7 PhD, 1 MD, 3 LISWs – Psychology trainees (7) – 10,000+ visits/year


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MetroHealth Integrated Care Model: Ambulatory Services (Stancin, 2018) Integrated Primary & Specialty Care Specialty Clinics*

• • • •

Warm handoffs Same-day consults Brief, problem-focused tx Risk/suicide assessments

Primary Care Resident/Staff Continuity Clinics

Urgent Care

Integrated Peds Psychology:

Child Psychiatrist

Residents + Fellow, Onsite Faculty Supervision


Psychology Psychopharm Competency (APA Integrated Health Care Alliance)

• Level 1: Psychotropic Information Provider – Tx collaboration/decision-making w/families & PCPs on uses, contraindications, side effects – Basic graduate training in psychopharm

• Level 2: Collaborative Practice – Conduct evaluations for meds, monitoring responses, advising titration, side effects – Advanced training + supervised practice

• Level 3: Prescriptive Authority – Prescribe, administer, d/c, distribute meds for BH – Post-doctoral “RxP” specialized training, certification


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Objective (1) Determine feasibility of adapting BH integrated care model to include child and adolescent psychiatry (CAP) consultation

(2) Enhance comfort and knowledge of pediatric (PED) residents in psychopharmacology (3) Advance psychology (PSY) residents to Level 2 Psychopharm competence


Educational Sessions • 4 CAP-led educational didactics with PED and PSY residents – Diagnostic criteria for ADHD, anxiety disorders, mood disorders – Evidence-based indications/assessment/uses for psychotropic medications – Case-based examples

• Monthly group supervision/case discussion sessions with PSY residents


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CAP Consultation  PSY & PED residents collaborate to identify patients  PSY resident conducts augmented billable BH diagnostic assessment of patient  PSY resident reviews case with CAP  CAP sends recommendations to PED resident & attending via EHR  PED resident/attending consider recs and prescribes/manages psychotropic medications  PSY & PED residents collaborate on follow-up care  CAP consulted as needed MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

Project Design


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Outcomes • Patient diagnosis • Medications prescribed • Average CAP time per consultation • Pre- and post- subjective measure of PED psychopharm comfort & knowledge • Pre- and post- objective measure of PED psychopharm knowledge


Results • 19 cases consulted in 4 months – 17 started on psychotropic medications – 1 case was lost to follow up – 1 provider uncomfortable in prescribing

• Patient Characteristics – Age range: 6 to 17 years – Sex: 11 males, 8 females

• Average CAP time per consultation – Mean = 20 minutes – Decreased over time MetroHealth and Case Western Reserve University, affiliated since 1914, partners in advancing patient care through research and teaching.

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Results


PED Resident Knowledge •Total PED objective knowledge score (range 0-10) •Improved from pre- (M = 5.1, SD = 1.55) to post-intervention (M = 8.1, SD = 1.04, t=-8.70, p