Transcript Update on PAL Implementation

Child Mental Health Consults for
Quality Improvement
August 27, 2012
Robert Hilt, MD
Director Partnership Access Line, MDT Consult, and
2nd Opinion Consult Services in WA and WY
Associate Professor of Psychiatry,
University of Washington
Practicalities of QI programming

Will describe three types of state Medicaid consult
programs which address:
 rising
medication use
 increasing costs
 questionable or dangerous prescribing
 inappropriate foster care treatment planning
 poor child psychiatrist access
 community need for more assistance
#1
Mandatory Medication Reviews
To address outlier prescribing
Medication Review Triggers

Medicaid’s review “flags”
Created by WA and WY workgroups of experts
 Prescription arriving at pharmacy triggers reviews
 Examples:

stimulants under age 5 (WA and WY)
 methylphenidate (Ritalin) at >120mg/day (WA) or
>135mg/day (WY)
 risperidone (Risperdal) at >2mg/day for 3-5 year old (WA) or
>5mg/day in any age child (WY)

(all flags in “DUR” section of care guide at wyomingpal.org
and in “DSHS” section of care guide at palforkids.org)
Medication Review History

Washington
 ADHD
medication reviews started 2006
 Antipsychotic medication reviews started 2009
 reviews for >5 meds starting this month

Wyoming
 ADHD

and antipsychotic med reviews started 2011
~1900 reviews completed since 2006
Running a Medication Review Program

Lesson 1: Prescriber’s written rationale is usually
insufficient to support an authorization
 doc-to-doc
reviews for better communication
 more able to teach best practices

Lesson 2: If do a “stop” at the pharmacy, rapid
processing time is vital
 Delays
undermine collaboration, can interfere with best
patient care
Running a Medication Review Program

Lesson 3: Delivering a consistent message is a
major challenge
 Initial
multi-center design had to be abandoned
 Audits
kept finding diverging approaches
 Collaborative/educational
approach more valued than
just “approve vs. deny”
 Teaching
 Found
best practices
a review leader needs to be regularly present
 Quarterly audits ensure consistency
Running a Medication Review Program

Lesson 4: Even high risk regimens can be fiercely
defended
 i.e.

methylphenidate 450mg, or using 9 medications
Lesson 5: Even if well run, many will resent
having required reviews
 Second
Opinion program feedback surveys:
 Review
was “useful” 53% of the time
 Review was “not useful” 27% of the time

(other s reported a “neutral” opinion)
#2
Elective Consultation Services
To assist the primary care medical home
To efficiently leverage use of child psychiatrists in rural
areas
PAL Consult Process
PCP calls
PAL consult
team with a
mental health
question on
any patient
(8AM-5PM)
PAL CAP
provides a
rapid access
phone
consult
PAL CAP
EMR entered
advice is
faxed to PCP
(by next day)
PAL SW offers resource
assistance or a phone consult
(by PCP or CAP request)
PCP=primary care provider
PAL=Partnership Access Line
PAL rapid
televideo consult
scheduled if both
A) desired by PCP
B) Medicaid child
Same day PCP
feedback, then a
dictated note
CAP=child & adolescent psychiatrist
SW=social work
EMR=electronic medical record
Telemedicine Equipment
Other Aspects of PAL Services

Free psychiatric care
education conferences
4 times a year in WA
 3 times a year in WY


Free, expert reviewed care
guide


At palforkids.org and
wyomingpal.org
Quarterly fidelity audits and
team consult approach to
ensure advice is consistent
PAL Program Lessons Learned

Lesson 1: PCPs manage very complex issues in
rural areas
 Usually
call PAL at a point of crisis in care
 Complex problems
 ~2/3rd
with “Serious Emotional Disturbance” (CGAS < 50)
~3 MH diagnoses per patient
 Major mental illnesses like true bipolar, schizophrenia


Rural PCPs often don’t feel they need/want that full consult
appointment but DO want to know it is available
Note: more specific/detailed PAL information is coming soon in an
Archives of Pediatrics & Adolescent Medicine article
PAL Program Lessons Learned

Lesson 2: Despite high complexity, care often can
remain in the medical home


~2/3 of the time, we recommended care to remain with the
PCP (± a therapist)
Lesson 3: Care coordination is necessary component

~½ of all callers receive PAL Social Work assistance


Connect to therapists and other resources
Lesson 4: PAL program impacts different part of care
system than Second Opinion Reviews

minimal patient overlap
PAL Program Lessons Learned

Lesson 5: Actually recruiting providers to use the
service is a challenge in rural, very underserved
states
i.e. impractical to set up lunchtime meetings to meet all PCPs
 CME meetings and word of mouth among colleagues recruit
participants


Lesson 6: A small “virtual” team can work
2 PAL offices, 300 miles apart, televideo connected
 Using 2 child psychiatrist FTEs to serve a 1.7 million child
region

PAL Program Lessons Learned

Lesson 7: PCPs that use the service love it (though
not everyone will use it)
 Very
positive PAL feedback survey data after the calls
 Increased
the PCP’s mental health care skills
 Helped the PCP to manage their patient’s care
 More PAL contacts → higher feedback survey scores

Lesson 8: Consults steer kids into more
psychosocial services (EBP therapies)
 ~9/10
calls recommend new psychosocial treatments
 Significant increase in foster children utilizing psychotherapy
appointments after the PAL call (WA FFS Medicaid data)
PAL Program Lessons Learned

Lesson 9: If open the door to accepting all calls,
Medicaid issues still predominate
 ~2/3

of calls about Medicaid kids
Lesson 10: PCPs usually call because they seek
medication advice
 ~½
PAL recommended to start a medication
 ~¼ PAL recommended to stop a medication
 Example: PAL gave PCPs advice to change
antipsychotic prescriptions >200 times (2008-2010)
Do Consults Change Antipsychotic
Prescribing?
PAL & 2nd Opinion Medication Reviews
Did Influence AP Prescribing

Fewer kids now on antipsychotics in WA
 decrease
of 8.6% in all Medicaid children receiving
antipsychotic medications (2007-2010)
 decrease
of 34.7% in the subset of foster care children
 decrease
in expenditure of ~$300,000 per month on
antipsychotics in first 2 years of PAL (2008-2009) and
first year of antipsychotic med reviews
 During
that same 2 years, antipsychotic expenditures
increased unaltered for adults in WA
Data provided Dr. Jeff Thompson
Antipsychotic Use Changes in Washington Medicaid
1800
5200
4979
1600
1400
5000
1456
4800
4551
1200
1000
800
895
4400
952
4200
669
600
4600
4000
400
3800
200
3600
187
0
2007
122
3400
Foster Care children receiving
antipsychotics
(35% decrease)
Multiple Antipsychotic Use for
>60 days
(25% decrease)
Medicaid Age under 5 years
receiving antipsychotics
(35% decrease)
Medicaid Children (All Categories)
receiving antipsychotics
(8.6% decrease)
2010
(from 2004-2007, use had been increasing annually)
#3
Wyoming MDT Consultations
To improve dependent child care planning through
telemedicine
Challenges per Wyoming DOH

Foster care and CHINS children have MH placement
plans made at local court hearings
 “MDT

Evaluations”
Historically difficult to arrange mental health
evaluations prior to court’s clinical placement
 Sometimes
 often

placed in order to obtain an assessment
with long lengths of stay
Concerns about the appropriateness of many out of
home mental health placements
Source: Dr. Jim Bush with DOH
Looking for Access

Wyoming has shortage of child/adolescent
psychiatrists (now up to 8 total)
 In-state
child psychiatrists reported having no
evaluation capacity for the rapid MDT hearing process
 We
had a University based consulting team with
telemedicine experience, so …
Source: Dr. Jim Bush with DOH
MDT Psychiatric Consult Process:
goal of speed and quality
1)
DFS case worker or GAL faxes an appointment
request
--Collateral data documents for the consultant
2)
3)
4)
Coordinator sets up appointment, usually within 1
week
Case worker and consultant speak for ~30min
prior to meeting patient
Televideo consult appointment in local DFS office
--With caregiver, when possible
5)
Final opinion report dictated by the next day
165 done so far…
What the MDT Gets


6-10 page report
Gestalt impression, diagnoses, and general care
recommendations
 We
describe child’s care needs, and the local team
decides where that can best happen
 Judge and the MDT remain the final arbiter of the
placement plan

Our role, and acceptance of it, took a lot of work
and time to develop
What we found by doing these
televideo consultations

Children often had:
Unrecognized problems (i.e. anxiety, ODD, conduct
disorders)
 High complexity (i.e. mean of 4 diagnoses per child)
 Frequent desire by teams for inpatient placements



~80% of our initial referrals
Less frequently found need for inpatient placements
~25% of our initial referrals
 Only 2 cases so far where a non-inpatient recommended child
ended up in inpatient placement within the next 6 months
 Translates to more care within community & financial savings

MDT Psychiatric Consult Feedback


Initially: local team wariness about the program
Now the DFS case workers praise the service


i.e. Tell us they get as good or better advice within one
week than it had been taking them many months and many
different providers to obtain before
Encouraging appropriate use of local services
Specific psychotherapy treatment recommendations were
made in every case (when a disorder was present)
 Recommended seeking medication adjustments from child’s
prescribers in ~1/3rd of cases


Less specific as we consult to care plan teams, not to prescribers
directly
Questions?

Contact info:
 [email protected]
Note: All programs described were co-developed with
WA and WY Medicaid divisions, the support of Dr. Jim
Bush and Dr. Jeff Thompson, and administrative
support of Jim Myers (Seattle Children’s)