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Integrating Routine Mental and Behavioral Health Screenings in Pediatric Specialty Clinics
Steven Hardy, PhDLinda Herbert, PhD
Children’s National Health System
Objectives
Learning Objective 1
Describe at least four potential advantages of integrating routine mental and behavioral health screenings in a medical setting.
Learning Objective 2
Discuss challenges inherent to implementing mental and behavioral health screenings in a medical setting
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Why Implement a Mental Health Screening Tool?
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High volume of patients in our outpatient specialty clinics
• 12,000+ annual patient appointments, representing 1,600+patients in Allergy/Immunology
• 1,350+ patients with sickle cell disease
There are challenges to identifying patients’ mental health concerns
• Training
• Time
• Competing priorities
Psychosocial support services are limited
• 1 psychologist/1 trainee for Allergy/Immunology
• 2 psychologists/4-6 trainees for Hematology/Oncology
Methods
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ParticipantsParents of children ages 5-17 yrsChildren ages 8-17 yrsPhysicians who provide medical care to parent/child participants
MeasuresPROMIS Pediatric Profile 25 and Parent-Proxy forms• Assesses fatigue, anxiety, depression, pain interference, mobility, and peer relationships
Parent Post-Interview• Yes/No and open-ended questions about mental health discussion during the appointment• Press Ganey patient satisfaction questions
Physician Post-Interview• Yes/No and open-ended questions about mental health discussion during patients’ appointments
Procedures
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Baseline Assessment Phase Mental Health Screening Phase
Volunteers approach
parents before medical
appointment
Medical appointment
Parents and children
complete PROMIS
Pediatric Profile on iPads
Volunteers generate
PROMIS Physician Report
Physician references
PROMIS Physician Report
during appointment
Parents complete
Post-Interview
Physicians complete
Post-Interview
Volunteers approach
parents before medical
appointment
Parents complete
Post-Interview
Physicians complete
Post-Interview
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Child Demographic Information
DomainBaseline Assessment
(n = 65) MH Screening
(n = 71)
Child sex (% female) 45% 45%
Child race African-AmericanAsian/African/OtherCaucasianNot provided
60%6%
12%22%
58%17%24%1%
Child ethnicity HispanicNon-HispanicNot provided
9%69%22%
6%92%2%
ClinicAllergyImmunologySickle Cell
52%8%
40%
54%16%30%
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Parent Perceptions of Mental Health Discussions Occurring in Clinic
Post-Interview ItemBaseline
Parent n = 65Physician n = 63
MH ScreeningParent n = 71
Physician n = 62
A mental health-related discussion occurred
Parent report 58% 59%
Physician report 68% 82%
A mental health-related referral was made
Parent report 6% 10%
Physician report 11% 13%
I liked that my child’s physician discussed MH (parent) 97% (n = 37) 100% (n = 41)
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Physicians’ Ratings of the Frequency of Mental Health Concerns
Mental Health ConcernBaseline(n = 63)
MH Screening(n = 62)
Did you discuss any of these issues e up?
Whether pain disrupted Activities of Daily Living 37% 44%
Physical mobility or ability to engage in desired activities 33% 37%
Fatigue 24% 31%
Peer/Social Relationships 25% 29%
Anxiety 13% 31%
Depression 8% 16%
Impact of asthma on daily living/QoL (if applicable) 27% 34%
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Frequency of Parents’ “Agree” or “Strongly Agree” Ratings
Mental Health Screener Feedback ItemMH Screening
(n = 71)
It was a good idea to ask these (MH) questions before my child’s visit 97%
It was easy to fill out the survey on the iPad 96%
I enjoyed using the iPad to complete the survey 96%
The length of the screener was appropriate 94%
The survey asked questions that seemed important for the care of my child 90%
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Frequency of Physicians’ “Very” or “Yes” Responses
Post-Interview ItemMH Screening
(n = 62)
How helpful was it to discuss those (MH) issues? 69%
How engaged was the patient during the discussion? 56%
How engaged was the caregiver during the discussion? 88%
Did you refer to the mental health screening summary to guide any part of your visit with this patient?
77%
How useful was the mental health screening summary? 78%
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Parents’ Frequency of “Very Good” Ratings on Press Ganey
Press Ganey ItemBaseline
(n = 65)MH Screening
(n = 71)
Physician’s efforts to include you in decisions about your child’s treatment 80% 89%
Degree to which physician talked with you using words you could understand 89% 96%
Amount of time the physician spent with you 74% 80%
Confidence in the physician 86% 91%
Likelihood of your recommending the physician to others 86% 90%
Positive Outcomes
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Low-cost, low-burden mental health screenings can be integrated into pediatric specialty clinics
• Parents rated the program as acceptable and easy to complete
• Medical providers reported high levels of adoption and utility
Preliminary evidence of enhanced clinic-based discussions about mental health
• More frequent discussion of mental health issues according to providers
• Greater odds of providers referring for mental health services according to parents
• Clinically meaningful improvements in certain domains of patient/family satisfaction
• Feeling included in decisions about child’s treatment
• Satisfaction with amount of time the physician spent with you
• Confidence in the physician
Challenges/Future Directions
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Lessons Learned• Screening is labor intensive for staff• Use of iPads and printers requires specific IT approval
Remaining Questions• Long-term feasibility of implementing mental health screening• Clarifying potential benefits of the mental health screening program• Clarifying discrepancies between parent and provider reports• Assessing whether or not families follow-through with mental health referrals
Future Directions• Spanish forms of the interviews and PROMIS forms• ABAB design, larger sample• Repeat PROMIS administration for ongoing mental health monitoring• EHR integration
Thank you!
VolunteersTebianne AbubakerSarah BillsSarah BreenDolores EspinozaElizabeth FloryKate Frelinger
Children’s National Health System’s Center for Translational Science – Psychology Research Voucher Award
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