Caring for Youth: Building Partnerships with Primary Care

to Improve Health and Functioning

Joan R. Asarnow, Ph.D.

Professor of Psychiatry & Biobehavioral Sciences

UCLA School of Medicine

Presentation Goals

• Review rationale for building partnership with primary care

• To illustrate this approach, we present preliminary data from our current study aimed at improving care for adolescent depression through primary care

• Offer some conclusions and recommendations regarding directions for further clinical and research initiatives

Why Primary Care?

• Most children and adolescents have some contact with a primary care provider each year– 70% of youth, ages 10-18, visit a primary care

provider a year, with an average of 3 visits

• Psychiatric and behavioral complaints more common among high utilizers of primary care– True for children and adolescents

Detection of Need in Primary Care

• Not currently a major source of mental health care• Need identified in only a small subset of youth

– Sensitivity Low: Primary care providers detect mental health problems in a small proportion of youth with need (Kramer & Garralda,1998)

– Specificity high: When primary care providers detect mental health need it is likely to be present (Kramer & Garralda,1998)

Youth Partners in Care:Youth Partners in Care:A Research Project to Improve Treatment of A Research Project to Improve Treatment of

Adolescent Depression in Primary CareAdolescent Depression in Primary Care

Joan Asarnow, Ph.D., Lisa Jaycox, Ph.D., Ken Wells, M.D., Joan Asarnow, Ph.D., Lisa Jaycox, Ph.D., Ken Wells, M.D., M.P.H., Margaret Rea Ph.D., Emily McGrath, Ph.D., Janeen M.P.H., Margaret Rea Ph.D., Emily McGrath, Ph.D., Janeen

Armm, Ph.D., Anne LaBorde, Ph.D., Psy.D., Martin Armm, Ph.D., Anne LaBorde, Ph.D., Psy.D., Martin Anderson, M.D., Pamela Murray, M.D., Chris Landon, M.D., Anderson, M.D., Pamela Murray, M.D., Chris Landon, M.D.,

James McKowen and colleagues James McKowen and colleagues • Sponsored by the Agency for Healthcare Research and Quality (AHRQ)• 5-year study to identify ways to improve quality of care for adolescent depression in primary care

Youth Partners in Care

YYYCCCPPPIII

Academic Medical Centers – UCLA Mattell Children’s Hospital & Satellite Clinics– University of Pittsburgh Children’s Hospital

Managed Care Clinics– Kaiser Permanente Los Angeles Medical Center– Family Practice & Pediatric Departments– Sunset & East LA Sites

Public Sector Clinics– Ventura County Medical Center-Family Practice &

Pediatrics– Venice Family Clinic

YPIC: Participating Sites

Study Flow Chart

U C QI

6-, 12-, 18-M onth Assessments

Random ized to Treatm ent

Baseline Assessm ent and Diagnostic Interview

Determine E ligibility

Screening in Prim ary Care

58%

6%

36% Current Depression

Depression Past Year

No Depression

Need: Rates of Depression

Need:Trauma Exposure and PTSD Symptoms

No TraumaTrauma, No PTSDTrauma, PTSD

23%

17%60%

Barriers to Detection in Primary Care

• Brief visits– About 10 minutes with children– About 16 minutes with adolescents

• Emphasis on physical health– Multiple health issues need to be addressed– Youth may not disclose difficulties

Barriers to Detection in Primary Care

• If detected, additional time required to address problem

• Lack of resources for addressing mental health needs in primary care

• Referral to specialty care often associated with lack of follow-up due to barriers to initiating care (e.g. perceived stigma, lack of insurance, transportation)

When is detection best?

• Continuity of care: best predictor of whether provider detects need is whether provider saw their own patient (Kelleher et al., 1997)

• Well child vs acute care visits (Horwitz et al., 1992)

• Severe impairment (Kramer & Iliffe, 1997)

Models for Treating Depression Within Primary Care

• Provider training and increased management by primary care providers– Little evidence of improvements in objective

provider behavior or child outcomes– Some data suggest brief provider training may

lead to changes in subjective outcomes, such as provider confidence and knowledge

Models for Treating Depression Within Primary Care

• Use of specialty mental health providers within primary care– Absence of adequately controlled evaluations of this

approach

– Likely that interventions that are effective in mental health settings will show comparable effects in primary care when delivered by comparable providers with similar patients

– Patient characteristics may differ in primary care

Depression in Primary Care Populations: Comorbidity With

Chronic Physical Health Problems

0

10

20

30

40

50

60

Depression Negative Depression Positive

Per

cent

age

wit

h 1

or m

ore

chro

nic

hea

lth

prob

lem

s

Models for Treating Depression Within Primary Care

• Consultation liason– Specialty mental health providers support

primary care management– Mimimal data

• Some data suggests reduced rate of specialty referrals and more “appropriate” referrals

• Only small percentage of providers felt knowledge and skills had improved

Models for Treating Depression Within Primary Care

• Team based disease management program– Non-physicians play a major role in patient assessment,

education, treatment, and monitoring

– Mechanisms developed for improving partnerships between primary care and specialty mental health care

– Addresses major barriers such as: inadequate practice resources, insufficient time in primary care visit, limited access to specialty services and evidence based treatments

YPIC Goals

To test an innovative model of care for depression among youth in primary care

To evaluate intervention effects compared to “care as usual” on:

Quality of care Clinical outcomes Social outcomes Costs

YPIC Intervention Goals

To improve initiation of and adherence to known effective treatment regiments

– Psychotherapy (CBT)– Antidepressant medication

Taking into account patient, parent and provider preferences: can choose any treatment or no treatment

Enhancing the doctor-patient relationship and maintaining provider autonomy

Real-world practice conditions

Provider education Care managers to track cases and support

primary care providers Patient & family education Study trained cognitive-behavioral therapists

within primary care Emphasis on patient, parent and provider

choice Local expert teams Tailoring the depression management model to

each system

Intervention ComponentsIntervention Components

Study Flow Chart

U C QI

6-, 12-, 18-M onth Assessments

Random ized to Treatm ent

Baseline Assessm ent and Diagnostic Interview

Determine E ligibility

Screening in Prim ary Care

Figure 1. YPIC INTERVENTION FLOW CHART

Initial Patient Visit with CM (45 min.)

Structured EvaluationBasic Patient and Family Education

Initial Patient Visit with CM (45 min.)

Structured EvaluationBasic Patient and Family Education

Patient Visit withPrimary Care Provider

(15 min.)Develop Primary Care MD management planConsider specialty mental health consultation

Patient Visit withPrimary Care Provider

(15 min.)Develop Primary Care MD management planConsider specialty mental health consultation

Patient contacted and visit with CM and Primary

Care Provider scheduled

Patient contacted and visit with CM and Primary

Care Provider scheduled

Primary Care Provider contacted

and briefed

Primary Care Provider contacted

and briefed

Referred to Care Manager (CM)Referred to Care Manager (CM)

Patient Identified:Screener indicates high levels of

depressive symptoms

Patient Identified:Screener indicates high levels of

depressive symptoms

Follow-up visits/phone calls by CM and primary care

clinicians

Medication or medication plus psychotherapy is prescribed

Psychotherapy is prescribed

POST-VISIT EDUCATION WITH

CM

Patients not started on treatment

CM re-contacts

In 4 weeks for follow-up

CM refers to therapist

and arranges primary care follow-

up

Intervention Implementation Site 1: Preliminary Data

Site 1N =32

Number (%)Initial Care Manager Evaluation 25 (78%)

In-person Visit 19 (76%)

Telephone Evaluation 6 (24%)

Total Receiving Treatment 25 (78%)

Total Psychosocial Treatment Only 17 ( 53%)

Cognitive-Behavior Therapy (CBT) Only

7 (41%)

Care Manager (CM) Only 10 (59%)

Medication 8 (25%)

Medication + CM 0 (0%)

Medication +CBT 8 (100%)

Total Receiving CBT 15 (47%)

Barriers to Intervention Implementation Care Manager unable to reach patient

– “Unable to schedule” was modal reason for no initial evaluation (75%)

– “Unable to schedule” was modal reason for not following treatment plan (90%)

No perceived need for additional services, low motivation (Youth, Parent)

Access problems (no time, transportation, conflicting demands)

Barriers to Intervention Implementation

Stigma associated with care (e.g. “It’s against my religion to see social workers”)

Health care organization can’t implement and sustain treatment model (Motivation, flexibility, perceived value)

Discrepancy between Care Manager role and traditional psychotherapist role

Strategies for Addressing Barriers

• Telephone contacts

• Flexible hours

• Treatment provided through primary care setting

W atch fu lw a it in g

S p ec ia ltyR efe rra l

Trea tm en t inP rim ary care

C are M an ag er

E d u ca tion an dtrea tm en t p lan n in g

M otiva tion :Y ou th an d fam ily

a re m otiva ted an drecep tive to ca re

D etec tion :Y ou th w ith d ep ress ion id en tifiedth rou g h p rim ary ca re sc reen in g

Y ou th a tten d s p rim ary ca re vis it

Pathways to care for depression through primary care

Conclusions: Access

– Need to ensure access to primary care– Universal access not guaranteed in United

States– Some youth, particularly uninsured and/or

disadvantaged, never reach primary care– Outreach needed to emergency services, urgent

care, and OB-GYN

Conclusions: Detection

• Need to develop and test strategies for improving detection – Will need to be brief and require minimal time from

primary care provider

– Use of practice assistants, nursing staff, or associated mental health workers

– Brief self-report instruments likely to lead to over-identification and will need to be supplemented with additional evaluation and triage of youth to appropriate services

Conclusions: Issues

• Detection likely to yield a somewhat different population than the population of youth identified in specialty mental health clinic and schools (e.g. health problems

• Need for efforts to better understand barriers to care within primary care settings and develop intervention strategies to reduce barriers and improve access to high quality care

Conclusions: Motivation for Treatment

• Motivation for treatment may be low, particularly when youth have not identified themselves as needing or wanting mental health care

• Adolescents tend to seek care for sensitive issues (e.g. pregnancy) and parents may be unaware of youth problems and/or visits to primary care

• Need for effective strategies to work with families and help families to mobilize and support treatment

Conclusions: Treatment

• Collaborative care models have shown promise for improving patient care and outcomes

• This approach builds on the strengths of primary care settings, but supports primary care practices with resources needed to evaluate and treat depression and other mental health problems

• Future research is needed to clarify the effectiveness, costs, and benefits of this approach in real-world practice settings