Northeast Florida Medicine - Winter 2017 - Mental Health

C M E : P r o m o t i n g W e l l n e s s i n Re s i d e n c y T r a i n i n g

Northea st Florida

MedicinE

Published by the DCMS Foundation Marking 164 Years of Local Organized Medicine

Vo lu m e 68, N O 4

164

In partnership with the Medical Societies of Duval, Clay and Nassau Counties

WINTER 2017

MENTAL HEALTH

VOLUME 68, NUMBER 4 Mental Health Winter 2017

Winter 2017

EDITOR IN CHIEF Ruple Galani, MD

Contents

MANAGING EDITOR Kristy Williford ASSOCIATE EDITORS Megan Deacon-Casey, MD Steve Dorman, MD Mark Fleisher, MD Sunil Joshi, MD Ali Kasraeian, MD Gazanfar Rahmathulla, MD Manish Relan, MD James St. George, MD

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John Stauffer, MD

Winter CME Promoting Wellness in Residency Training

By Mary S. Hedges, MD, Monia E. Werlang, MD, Chrysanthe M. Yates, BA, Michele D. Lewis, MD

CHIEF EXECUTIVE OFFICER Bryan Campbell DCMS FOUNDATION BOARD OF DIRECTORS President: Sunil Joshi, MD Vice President: Ashley Norse, MD Immediate Past President: Todd Sack, MD Douglas Baer Richard Brock Solomon G. Brotman, DDS Mia Jones Todd Sack, MD Kelli Wells, MD

2017 Mission First FOUNDATION DONORS 904THIN Molly and James Altomare, MD Raed Assar, MD Douglas Baer Richard and Janice Brock Sol Brotman, DDS Peter J. Clagnaz, MD The Community Foundation of Northeast Florida Thomas Connolly, MD Lisa and Patrick DeMarco, MD Elizabeth DeVos, MD Susan K. Dorsch, MD Robert E. Duncan, MD Mark Fleisher, MD Patricia and Malcolm Foster, Jr., MD Gina and Ruple Galani, MD Robert Harmon, MD Walter Alan Harmon, MD John Jeans Manisha and Sunil Joshi, MD Steven Kailes, MD Stephen Mandia, MD Orangetheory Fitness Beaumont and William Palmer, MD John & Mary Ellen Panaccione, MD Todd Sack, MD James St. George, MD Guy T. Selander, MD Titan Consulting and Speaking, LLC N. H. Tucker, III, MD

Physician burnout levels have become alarmingly high is recent years. At the same time, physician depression and suicide completion rates are increasing, with recent data showing that the risk of suicide among physicians is significantly higher than their non-physician age matched controls. The tendency towards depressive symptoms and suicidal ideation appears to start early in medical training, and accelerate through medical school and residency.

To address burnout, depression, and suicide risk during residency, Mayo Clinic Florida has initiated a multifaceted wellness approach. Identifying wellness champions with leadership interest is important to implement specific wellness initiatives. Wellness initiatives include: resident wellness education, duty hour and fatigue mitigation, arts and humanities, pet therapy, nutrition, counseling services, social gatherings, resilience training, access to medical care, nutritious food, and ongoing monitoring for burnout among residency programs. To lower the rates of physician burnout, depression, and suicide, it is imperative that the medical community be proactive.

Features Integrated Care of Adult Behavioral Health and Medical Specialties: Three Models of Success

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By George Royal, PhD, Nicole Winter, PsyD, Ellen Williams, PhD, and Peter Clagnaz, MD

The Role of Pediatric Psychology in Inpatient 19 Medical Settings: An Overview into Clinical Practice

By Nicole A. Kahhan, PhD, Shana L. Boyle, PhD, Lisa M. Schilling, PhD, ABPP, and Lisa M. Buckloh, PhD

The Collaborative Core Initiative: 37 A Response to the Child Mental Health Crisis

By Elise M. Fallucco, MD

The Medical-Behavioral Health Home: A Case Study

42

By Jeffrey L. Goldhagen, MD, MPH and Jennifer Peace, RN

Departments 6

5

4

From the Editor’s Desk From the President’s Desk

From the Chief Executive Officer’s Desk

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7

Guest Editorial

Residents’ Corner

Please note: Editorial and contents of this magazine reflect the records of the Duval County Medical Society (DCMS). The DCMS has done their best to provide useful and accurate information, but please take into account that some information does change. E&M Consulting, Inc., publishers and the DCMS take no responsibility for the accuracy of the information printed, inadvertent omissions, printing errors, nor do they endorse products and services. We take no responsibility regarding representations or warranties concerning the content of advertisements of products/services for a particular use, including all information, graphics, copyrighted materials, and assertions included in the advertisements. The reader is advised to independently check all information before basing decisions on such information.

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Northeast Florida Medicine Vol. 68, No. 4 2017 3

From the Editor’s Desk

Shared Responsibility in Healthcare Every day physicians are faced with the challenge of providing high quality care, personal care, and cost-effective care to our patients. The evolution of our healthcare system has placed this burden mostly on the physicians and partially on hospital systems. There is the belief that physicians have always been driven by fee-forservice, and that quality care is not a high priority. In the last 10 years, government (i.e. Medicare) has deemed healthcare inefficient and the premise is that physicians Ruple Galani, MD Editor-in-Chief are the driving factor in the Northeast Florida Medicine inefficiency. The response has been to mandate EMR, meaningful use, bundled payments, length of stay reductions, and 30-day readmission penalties to make healthcare more “efficient,” “higher quality,” and “cost effective.” However, in the ongoing healthcare debate, there has been little effort to also share this burden with the patients themselves. What responsibility do patients have in their own health? What is their “shared” cost if they don’t follow medication orders, advice to stop smoking, or advice to lose weight? If patients do take responsibility, what is their “reward”?

In the world of cardiology, we are constantly burdened with the ever consuming 30-day readmission rates for acute myocardial infarction and acute heart failure. We spend countless hours in hospital meetings with nurses, care managers, administrators, and even the housekeeping staff to help reduce 30-day readmission rates. This is driven by the fear of a bad Medicare rating and payment penalty. We can definitely set up heart failure clinics, use ACC/AHA guideline based therapy, and preach about diet, exercise and smoking cessation.

However, we have many patients who willingly choose to eat and drink what they want. Even after a bypass surgery, there are patients that will continue to smoke, sporadically take

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their medications, and cancel follow-up appointments. The non-adherent patients are the very ones that get readmitted, increase costs, and waste more physician time and effort in trying to bring down readmission numbers. Yet, there is no penalty for these patients. They don’t pay more, they don’t get kicked out of the practice, and they don’t have any sense of personal health responsibility. In the end, the physicians are the ones who are chastised, have pay withheld, and are judged as “quality” or “not-quality” providers.

On the other hand, the healthcare system does very little to reward patients that comply with their medications, make lifestyle changes, and seek regular outpatient follow-up care. Medicare patients don’t get a bonus for good health.

Outside of personal concern and responsibility for their own health, there is little recognition or reward for good behavior. For physicians, there is no metric or clear way to capture complaint patients. A physician could have 99 heart failure patients stay out of the hospital for one year, but the one patient that has recurrent 30-day readmissions has the ability to negate the good patient care.

I always stress to my patients that the physician doctor relationship is of respect and, most importantly, responsibility.

I am very frank with post-myocardial infarction and heart failure patients that they need to take their medications, watch their diet, and do as I say to stay as healthy as possible. More importantly, I make it very clear that not being responsible is harmful to them, to other patients, and to our healthcare system. I also tell them that the system is set to penalize physicians, practices, and hospitals for readmissions and quality metrics. I have found this blunt honesty actually improves my patient relationships and even their care.

In the end, physicians have to take control of what is considered appropriate and high-quality care. We need to shift the paradigm and reward patients and physicians for responsibility. The bullying of physicians into unilateral responsibility for patient outcomes and care needs to end. v

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From the President’s Desk

Reflecting on 2017 As I reflect upon the year that I have been granted to serve as your president, I find myself feeling that my cup remains half full. There is still so much work to be done. I am satiated by the notion that although my term is ending, my dedication and commitment to organized medicine remains. Therefore, the work will be done. This has been a robust year for our grand profession and our esteemed society.

There have been attempts to make changes to our healthcare system that many agreed would not have been in the best interest of patients or clinicians. The medical community spoke out in a loud and resounding voice Tra’Chella Johnson Foy 2017 DCMS President and helped to defeat what ultimately was counter to the common good of our society. This has created an opportunity for us to re-examine how we can truly create a system that is in the best interest of our country by providing insurance for as many people as possible and ensuring that it is as affordable as possible. I consider this an overall victory, but I know that the real challenge is ahead of us as we continue to search for more permanent solutions.

In addition, there has been both a local and national directive to address the opioid epidemic. At DCMS, we have developed a taskforce made up of individuals from every health system and other major stakeholders. The task force will help determine how physicians can make the greatest impact on this crisis. WE have been charged with determining how to clarify and promote best practice measures when it comes to opioid prescribing. We are also looking to adopt or support the development of creative ways to minimize the use of opiates. Many of our members accompanied our DCMS Chief Executive Officer to Tallahassee to sit face to face with our legislators and lay out what doctors in Duval and North Florida would like to see happen with regards to any legislation related to this matter.

This is just one of the many legislative issues that we at DCMS have done our best to make sure we are out front on when it comes to advocating on behalf of our members. Unfortunately, we don’t always win the battles. This year, those who are in opposition to medicine were able to successfully have caps and max limits removed on malpractice lawsuits. Although we are disappointed with the result, the war is not over. We will work diligently alongside the FMA and AMA to ensure this fight continues. Many of you are also trying to understand how to best

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navigate MACRA and MIPS. We are in tune to your concerns about how this is going to affect you- especially if you have small private practices. Through the work of your society and organized medicine in general, we were able to ensure that if you completed the reporting requirements on just one patient this calendar year then you would satisfy requirements.

Several other DCMS members and I are delegates to the FMA, as well as alternate delegates and delegates to the AMA, you can be reassured that the voice of the physicians in Duval County and North Florida will always be heard. I am your voice and we speak to your needs and desires and that things that are critical to the practice of medicine specifically in Duval County. We are always working for you. As members of this great society, it is you that helps guide and shape the future of medicine. We encourage your engagement. Let us know how we can best be of service.

When Hurricane Irma hit, we readied a plan that would help facilitate and coordinate our doctors’ ability to continue the practice of medicine through this devastation. In addition, due to the destruction of Hurricane Maria to our brothers and sisters of Puerto Rico and the close vicinity to our county, we made sure to discuss how this may affect our physicians. We are prepared to work with the community stakeholders if the need arises to accommodate both patients and physicians who are rightful citizens of the United States that may need our assistance.

We know that the practice of medicine has changed tremendously and that this has led to a high prevalence of physician burnout.

In collaboration with the DCMS Foundation, our response to this growing major health issue was to successfully launch the Physician Wellness Program which is meant to assist you and many others during your career. Whether it is the stressors of home, the job or the challenges with balancing it all, we are here for you 24 hours a day by calling our Physician Wellness line.

The goal is to guarantee that you are best equipped to ideally experience the life you desired when you decided you would commit yourself to this honorable profession. We want you to feel good about encouraging your sons and daughters to pursue a career in the medical field. In addition, we are working diligently with the Duval County Public School system to nurture and develop the passion in our youth to start early on the path to choosing vocations in medicine, but very specifically to be doctors. It is with clear vision and understanding that to move medicine forward we must honor and learn from our past while we enthusiastically embrace the future. So as my presidency draws to a close, I pledge to continue on as a soldier who will fight beside you as I always have, because there is still work to be done! v

Northeast Florida Medicine Vol. 68, No. 4 2017 5

From the CEO’s Desk

Have You Ever Experienced Burnout?

It was a simple question, and one that I didn’t have to answer.

In early October, I was presenting information on physician burnout and physician wellness programs to medical society executives from around the country. The question was posed by one of the other presenters at the conference, and I was probably focusing more on my next presentation, or keeping an eye on the clock to make sure that the meeting was running on time.

Bryan Campbell DCMS Chief Executive Officer

I’m not sure what made this moment different than so many others talking about burnout, but it was.

Many people are surprised to learn that before I worked in Organized Medicine, I was an award-winning television journalist, working 14 years in the industry before leaving to start my new career direction.

“Do you miss it?” or “What made you leave?” are questions I inevitably hear when someone learns about my past profession.

My answers are all honest and varied: I wanted to spend more time with my family while the kids were still in school. I was not interested in moving to another television market to “move up” the corporate ladder. It’s hard to deal with the negativity of the industry for which a “good” news day is inevitably someone’s tragedy. Those things are all true.

Yet, at this moment I realized, I had been burned out. I couldn’t do it anymore. My animosity towards the news industry and the job made it impossible to work at the highest level, and made it impossible to be happy. When I left it behind, I felt reborn and happier than I had in years.

Ultimately, I had suffered from, and was defeated by, burnout.

For the past two years, the Duval County Medical Society has been hard at work trying to assist with the growing epidemic of burnout in the physician community. Earlier this year, Medscape released its Annual Lifestyle Report, which included a closer look at burnout among various specialties.

As you can see, a large number of specialties report more than half of the physicians in practice are suffering from burnout.

It’s the number one reason physicians are leaving practice or

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Which Physicians Are Most Burned Out? 59% 56% 55% 55% 55% 54% 53% 53% 53% 52% 52% 51% 51% 51% 50% 50% 49% 49% 49% 49% 47% 46% 46% 43% 43% 43% 42%

Emergency Medicine Ob/Gyn Family Medicine Internal Medicine Infectious Disease Rheumetology Plastic Surgery Otolaryngology Critical Care Cardiology Urology Neurology Pediatrics Anesthesiology Gastroenterology Nephrology Orthopedics Surgery Pulmonary Medicine Radiology Oncology Dermatology Diabetes & Endiocrinology Pathology Ophthalmology Allergy & Immunology Psychiatry & Mental Health

0%

20%

40%

60%

Image reprinted with permission from Medscape (www.medscape.com), Medscape Lifestyle Report 2017, available at: www.medscape.com/features/slideshow/lifestyle/2017/overview

retiring early. This is why it was imperative that the Duval County Medical Society and DCMS Foundation work together to create the Physician Wellness Program.

This free program provides access to counseling for DCMS members who need to talk to someone. The issue could be stress related to work conditions, or something more personal in nature.

Physicians often fail to seek care that they need because they are concerned about the visit becoming a part of their medical record and impacting their relicensing. The DCMS Physician Wellness Program does not create a medical record and has been supported by the Florida Board of Medicine as a valuable resource for physicians.

Burnout can manifest itself in so many different ways. Perhaps you are concerned about the changes in the Affordable Care Act, or feel unprepared for MACRA. Perhaps you are concerned about consolidation in healthcare or the ever-changing Health IT requirements.

Those are the hallmarks of physician burnout. I implore you, if you are feeling any of these symptoms, please consider calling our Physician Wellness Hotline at (904) 631-1446 to arrange your free sessions. You are an important part of the Northeast Florida medical community, and we are here to help you. v

DCMS online . org

Guest Editorial

Mental Health Care Today: The Upside of Improving Access to Care This is a pivotal moment in the history of mental health

is due to a better understanding of its beneficial effects, some

care, and that is why this edition of Northeast Florida Med-

of this shift in attitude is undoubtedly financially driven. As

icine is so important. For psychiatrists and psychologists,

healthcare moves toward value-based care and away from fee-

nurse practitioners and therapists,

for-service models of practice, it’s a fact that without mental

treating the mentally ill and

health care, outcome-driven models of care will lose some of

advocating for their rights have

their effectiveness, and the value of care will diminish.

always been two sides of the same coin. Until recently, mental illness was something that happened to other people, was seen as an embarrassment, or even, in the case of substance abuse in particular, a Peter Clagnaz, MD Guest Editor

character flaw. What has changed in the last several years is that mental illness has come out of the shadows. Advocating for the right to mental health care has moved beyond mental health professionals. Family members are speaking up about the need for increased access to care for their loved ones, celebrities and

Ellen Williams, PhD Guest Editor

athletes are speaking out about the impact of mental illness on

their lives, and legislators are passing laws to make insurance companies pay for mental health problems on par with other chronic health conditions. The result is that we have seen a significant chipping away of the stigmas that surround mental illness, and more people than ever are accessing care.

This is substantial progress. Not only are individuals and families acknowledging the importance of mental wellbeing, more healthcare institutions, more primary care physicians, and more specialty care physicians are recognizing the importance of good mental health in the overall well-being of every patient they treat. In best-case scenarios, mental health providers are an integral part of the care team. They are as important in the recovery process as any other specialty care provider. Although we’d like to think this shift in acceptance of mental health care

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Unfortunately, despite the reduction of stigma around mental illness, the suicide rate in America is at an apex, especially for veterans, white middle-aged males, and young people.

According to the American Psychiatric Association, anxiety is at an all-time high in our society, especially in adolescents and young adults. There is an epidemic of mass murders, and more and more Americans are personally and psychically impacted by these horrific incidents. Yet, pockets of resistance and ignorance persist with regard to the need for readily available mental health care. In Florida, payors still find ways around parity laws that reduce access to care (and costs to them), and as a result, reimbursement for mental health services in our state is the lowest in the nation. This makes it difficult to recruit and retain mental health professionals locally. The deficit in psychiatrists, especially child psychiatrists, makes it impossible to meet the demand. Psychologists and therapists in every institution we know in Northeast Florida – jails, courts, college counseling centers, community mental health centers, hospitals, physician groups - are overloaded with mentally ill defendants, patients, referrals, and pleas to pull strings to get an appointment sooner than the 2-3 month wait that is typical for a new patient.

Mental illness is a treatable condition that affects more than 20 percent of the population at some time during their life. Mental illness, just like any other illness, can be acute, chronic, treatable with drugs, drug resistant, text-book or idiosyncratic. Just like cancer or heart disease, it can show up in any socio-economic strata, in any family line. It’s an equal opportunity condition.

Treatment should be as easy to access as primary care. When it is, we can help people to live with less suffering and distress, counsel people about how to cope, how to be resilient, how to recover, and how to care for themselves and each other.

Northeast Florida Medicine Vol. 68, No. 4 2017 7

Guest Editorial

In this issue of Northeast Florida Medicine, experts at four major healthcare institutions in Jacksonville share with you their latest efforts to improve access to mental health care, and strengthen the value of mental wellness in our society.

will help instill the same wellness standards for themselves that they hope to see in their patients.

Elise M. Fallucco, MD at UF Health - Jacksonville has been researching and implementing a collaborative approach

We worked with George Royal, PhD, and Nicole Winter,

to child mental health for more than five years. The approach

PsyD from Baptist Health to demonstrate how to successfully

entails training pediatricians and child psychiatrists to share in

integrate behavioral health practitioners into three medical

the care of a patient who might need psychotropic medication

specialty areas. Our team provides case examples of how patients

from a psychiatrist, but once stabilized, can safely return to

with a broad range of cancer diagnoses benefit from embedded

the pediatrician for long-term medication management. Her

behavioral health treatment services, how a comprehensive care

research is in response to a crisis in care brought on by a dearth

clinic for seniors addresses dual diagnoses in the elderly, and

of child psychiatrists in Northeast Florida, and brings together

how a team of psychiatrists and nurse practitioners collaborates

physicians who might otherwise not be available to benefit from

with a busy emergency department.

each other’s expertise.

Nicole A. Kahhan, PhD, Shana L. Boyle, PhD, Lisa M.

Jeffrey Goldhagen, MD, MPH and Jennifer Peace, RN of

Schilling, PhD, ABPP, and Lisa M. Buckloh, PhD from

UF Health - Jacksonville present an innovative model of mental

Nemours Children’s Hospital share their expertise in providing

health care called a medical-behavioral health home, and provides

consultation liaison services to physicians and nurses in an

compelling clinical examples that demonstrate the complexity

inpatient medical setting. The specialized skills and services

of cases that a medical home can effectively treat. Practitioners

they add to the treatment of children who are hospitalized can

without regular exposure to patients with moderate to severe

help prepare a child for medical interventions and coach them

mental illnesses can get a sense of the difficulties these patients

toward full recovery.

may face in a non-integrated health delivery system.

In this issue’s CME article, Mary S. Hedges, MD, Monia

These authors have contributed innovative solutions to the

E. Werlang, MD, Chrysanthe M. Yates, BA, and Michele D.

mental health challenges of our time. Their dedication to the

Lewis, MD from The Mayo Clinic discuss the development of

field and to this special edition of Northeast Florida Medicine

a robust wellness program in their residency training experience.

is most appreciated. We hope their work provides readers with

They remind us of the alarming rates of depression and suicide

an enriched understanding of the critical need for better access

in physicians, and the high rates of physician burnout at all

to mental health care for patients and colleagues. More broadly,

levels of physician seniority. Their wellness program draws on

our sincere hope is that this issue leads us all to improved mental

a wide range of pro-social and supportive activities aimed at

wellness for our patients, ourselves, and each other. v

reducing stress and burnout. The hope is that this experience

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REGISTRATION NOW OPEN Join us in shaping the future of healthcare in Northeast Florida!

F u t u r e of H e a lt hc a r e C o n f e r e n c e May 21-22, 2018 at the Prime Osborn Convention Center • Opioid Epidemic in Florida • Mental Health • Violent Crimes with Guns

Early bird pricing available until Feb. 16 Just $149 for this two-day conference!

Call (904) 355-6561 to get registered or visit: dcmsonline.org/FutureofHealthcare

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Northeast Florida Medicine Vol. 68, No. 4 2017 9

Residents’ Corner: Mayo Clinic Simulation Center

Full Spectrum Care: A look at St. Vincent’s Family Medicine Residency

By John W. Diefenderfer, DO About St. Vincent’s Family Medicine Residency Program was accredited by the Accreditation Council for Graduate Medical Education (ACGME) in 1972, and is dually accredited by the American Osteopathic Association since 2005. The program has graduated over 325 physicians. The clinical practice at St. Vincent’s Family Medicine Center is the cornerstone of resident education with 37,159 office encounters, 390 obstetrical deliveries, and over 2,200 hospital medical admissions in the last academic year. With the transition to a single graduate medical education accreditation system, St. Vincent’s applied for, and was one of the first to achieve, the Osteopathic Recognition from the ACGME. Every year St. Vincent’s accepts 10 residents into the three-year program with an average of four being Osteopathic physicians.

The residency program focuses on continuity and full spectrum care with a diverse faculty that includes physicians boarded in Obstetrics and Gynecology, Dermatology and Pathology, and Pediatrics, as well as physicians with extra certifications in Geriatrics, Maternal Child Health, and Osteopathic Manipulation. In addition, the program has a full-time PhD Clinical Psychologist and two Psychology fellows that lead the Behavioral Health team.

Research and Physician Wellness PGY-2 Lauren Woodard, DO, under the guidance of faculty advisor Helena Karnani, MD applied for and won a $10,000 grant from the American Academy of Family Physicians to improve the immunization rates in the adolescent population of the Jacksonville community. This is a tremendous achievement that will help decrease the rates of communicable diseases and promote the health and wellness of the community as a whole.

PGY-3 Tanielle Brew, MD and PGY-2 Jennifer Shonk, DO have created a Wellness Committee that seeks to combat physician burnout by organizing resident events and providing a positive and supportive environment for residents. Activities thus far have included flag football, pumpkin carving, happy hour events, Resident of the Month awards, and birthday celebrations with

10 Vol. 68, No. 4 2017 Northeast Florida Medicine

baked goods and recognition for those celebrating their birthday each month. Future events hope to include alumni networking get-togethers, Friends-giving (where residents who have to work during the Thanksgiving holiday can get together and socialize/ celebrate), hiking and kayaking trips, and mindfulness classes.

Fellowship Opportunities Family medicine is unique because of the breadth and depth of care that is provided to patients of all ages – truly as they say, from womb to tomb. If graduates wish to complete an additional year of training, they can select from numerous fellowship programs including academic or leadership, advanced obstetrics and women’s health, primary care sports medicine, geriatrics, addiction medicine, hospice and palliative medicine, integrative medicine, or neuromuscular medicine, just to name a few. This year St. Vincent’s has three PGY-3 residents who are applying for fellowships. John Diefenderfer, DO is pursuing a Primary Care Sports Medicine fellowship, and Sara Sholar, DO and Shaunna Escobar, MD are pursuing Advanced Obstetrics and Women’s Health fellowships.

Curriculum Development Over the last year St. Vincent’s has begun exciting new curriculum development for Point-of-care and Musculoskeletal Ultrasound under the direction of Robin Potts, MD, with support from PGY-3 John Diefenderfer, DO. Dr. Potts was able to acquire a portable ultrasound device for use in the outpatient clinic and Stephan Esser, MD provides lectures once per block for additional training of residents on-site. Dr. Esser is a parttime faculty member who is board certified in Physical Medicine and Rehabilitation from Harvard University with additional fellowship training in Primary Care Sports Medicine from the Mayo Clinic. He works with Southeast Orthopedics both in Ponte Vedra and Riverside.

St. Vincent’s is also expanding its Geriatrics curriculum by joining with Ravish Narvel, MD, who is the medical director of St. Catherine’s Laboure Manor. St. Catherine’s is a skilled nursing facility affiliated with St. Vincent’s that provides short-

DCMS online . org

Residents’ Corner: Mayo Clinic Simulation Center

The Wellness Committee sponsored a pumpkin carving for residents, one of many social events to help combat physician burnout.

The class of 2020.

The Wellness Committee seeks to combat physician burnout by organizing resident events and providing a positive and supportive environment for residents.

Fernando Moreno, MD is one of several new St. Vincent’s Family Medicine Residency OBGYN faculty members.

term rehabilitation, as well as long-term care. St. Vincent’s residents will work with Dr. Narvel during PGY-2 and PGY-3 years for a longitudinal curriculum designed to have continuity of care with exposure to all aspects of geriatrics.

Training in Action Danielle Carter, MD served as the medical director for Ironman Florida which was held in Panama City Beach, Florida on November 4th, 2017. This Ironman offered 40 qualifying spots for the World Championships in Hawaii next year. PGY-3 John Diefenderfer, DO volunteered alongside Dr. Carter during the all-day event which included thousands of athletes.

DCMS online . org

Looking Ahead Lastly, St. Vincent’s would like to introduce three new faculty members. Qudratullah Mojadidi, MD and Fernando Moreno, Jr., MD are both Obstetrics and Gynecology board-certified, and Jason Largen, MD is Family Medicine board-certified. Dr. Largen, one of our 2016 Chief Residents, chose to stay with St. Vincent’s for a junior faculty position while completing his fellowship in Healthcare Quality and Leadership. St. Vincent’s is very excited to have them on board and looking forward to having them as part of the Residency Program family for years to come! v

Northeast Florida Medicine Vol. 68, No. 4 2017 11

Mental Health

Integrated Care of Adult Behavioral Health and Medical Specialties: Three Models of Success

By George Royal, PhD1, Nicole Winter, PsyD1, Ellen Williams, PhD2, and Peter Clagnaz, MD1 1 Baptist Health St. Vincent’s HealthCare

2

Abstract: Integrating behavioral health services into medical practices supports the triple aim of improving health outcomes and patient satisfaction while reducing healthcare costs. This article discusses three case examples of integrated care in a geriatric primary care setting, an oncology setting, and an emergency care setting. In each instance, because mental health professionals were embedded into the daily operations of medical and hospital settings, patients received more comprehensive treatment.

Introduction The Institute for Healthcare Improvement has challenged organizations and communities to achieve the “Triple Aim.”1 The goal of the “Triple Aim” is to simultaneously improve the health outcomes of patients while increasing patient satisfaction and reducing the cost of care. Population health initiatives across the country place a heavy emphasis on improved coordination of care to address the shortcomings of the current fragmented systems of care, and setting forth expectations for better outcomes and reduced costs for those with co-morbid conditions. The Affordable Care Act (ACA) specifically included mental health and substance use disorder services as one of the ten categories of required “essential health benefits,” and the law required parity between the mental and physical health benefits covered by health plans.

There is now a revolution occurring in the delivery systems of care to match the advancement of medical science that has dramatically improved the longevity and quality of human life.

Five overarching strategies are currently underway in population health initiatives: universal screening, navigators, co-location, health homes, and system-level integration.2 Mental disorders

Address correspondence to: Ellen A. Williams, PhD St. Vincent’s HealthCare 4205 Belfort Road, Suite #4015 Jacksonville FL, 32216 Phone: (904) 450-6068 DCMS online . org

are common throughout the United States, affecting tens of millions of people each year.3 It is a major concern that 60 percent of patients with a psychiatric diagnosis do not receive any form of treatment.3 Over half of those who do receive treatment will get their care in primary care settings. Unfortunately, in primary care settings, only 13 percent of mental health care is considered to be “minimally adequate.”2 It is generally recognized that the lack of mental health practitioners has reached crisis levels especially in rural areas, hospitals, and emergency settings. Several factors working in concert have led to this crisis. Until passage of the ACA, the future of which is uncertain, there were structural differences that generally disfavored the delivery of mental health care.

This included lack of coverage or coverage with lower limits and higher co-pays than for all other types of medical care.4 Lack of funding for internships and fellowships in training for mental healthcare has contributed to shortages in the workforce.

Collaborative Care in Mental Health Integrating primary care and behavioral health is an innovative model of care delivery which improves access and treatment of mental health conditions in general medical settings. The Agency for Healthcare Research and Quality defines integrated behavioral healthcare as “the care a patient experiences as a result of a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.”5 There are several ways to implement this collaborative care model, but most embrace a behavioral health provider (social worker, psychologist, therapist) located in a primary care clinic with a primary care provider, utilizing screening tools and patient concerns to identify those in need of mental health Northeast Florida Medicine Vol. 68, No. 4 2017 13

Mental Health

interventions. They consult with the primary care physician with regard to diagnosis and treatment, and provide psychotherapeutic interventions. A psychiatric consultant (psychiatrist, nurse practitioner, physician’s assistant) may also be available to provide advice to the team on diagnoses, treatment options, and medication selection.6 Outcome studies of the integrated care model first published in the early 2000’s and replicated over 70 times have consistently demonstrated improved outcomes over a range of psychiatric disorders, age groups, ethnic populations, and payer sources in comparison to usual care.7 Additionally, there is significant patient and primary care satisfaction.7 Overall healthcare costs have shown significant reductions as well.7 Thus, the collaborative care model which integrates primary care and behavioral health meets the “Triple Aim” of improved outcomes, reduced costs, and enhanced patient experience.

There are several examples of the successful implementation of integrated care in Jacksonville. This article reviews three examples involving cancer treatment, geriatric care, and emergency care.

Co-Location of Mental and Physical Health for the Geriatric Population Mr. R is an 83-year-old, widowed Caucasian male who has resided alone since the sudden passing of his wife of 60 years, two years ago. Mr. R has a history of diabetes mellitus and hypertension. He suffered a heart attack at age 54 and had a pacemaker implanted seven years ago. Mr. R lives one city over from his two adult children and grandchildren, who are his primary sources of support. Since his wife’s death, Mr. R’s children have noticed a gradual decline in his physical and mental health; his mood has been low and irritable, he’s been less engaged and alert, and he’s lost interest in golf and his usual outings with his grandchildren. He’s also had one hospitalization and two emergency room visits due to dehydration and altered mental status. Mr. R’s adult children have assumed significant caretaking responsibility, including taking him to all doctor’s appointments and managing his medications. At a follow-up appointment with his primary care physician (a geriatrician) for his most recent emergency room visit, Mr. R described symptoms of increased fatigue and tiredness, weight loss, and generalized body aches and pains. Mr. R’s children also expressed their concerns related to their father’s deterioration in health; Mr. R was quick to explain he was “just getting older.” For

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example, he shared that his desire to remain at home all day was due to leaving being “too much effort,” saying he was in too much pain to enjoy anything at his “old age.” Additional questions about Mr. R’s change in mood and behavior revealed possible risk for and suspicion of depression.

The case of Mr. R illustrates a common example of how older adults face comorbid physical illness and mental disorders.8 Unlike younger adults, older adults are less likely to self-identify as having difficulty coping with stressors and tend to not seek out mental health services, especially services available in traditional mental health settings.9 Instead, a majority of geriatric patients present to traditional healthcare professionals with physical symptoms when they are actually experiencing an emotional disorder, often due to high rates of mental health stigma among this population.10 As many as 85 percent of physician visits in the geriatric population (age 65+) are for problems that have a significant psychological and/or behavioral component, such as chronic illnesses.11 As a result, a significant proportion of latelife mental health problems can go undetected and untreated in these settings without the integration of mental health services.10 According to Davidson and Meltzer-Brody, older adult patients actually prefer to receive treatment for depression in primary care settings, despite the fact that many seen by primary care physicians are neither diagnosed or treated for the condition.12 This exemplifies the utility of integrating mental healthcare into the medical setting. A psychologist or other mental health professional integrated within a medical setting such as in the case with Mr. R, would be able to meet with the patient and adult children to conduct a more thorough evaluation of mood and mental state, including the nature and extent of his depressive symptoms and a brief cognitive evaluation. In this instance, psychoeducation about depression and the relationship between cardiac illness and depression as well as options for treatment could be provided. The integrated nature of such a team would allow the psychologist, primary care physician and/ or geriatrician, and other involved disciplines to meet and share the results of the psychological meeting with patient and family, and then formulate a preliminary treatment plan.

Behavioral (mental) health is essential to the overall health and well-being of older adults. Although the vast majority cope with the challenges of aging and distressing life events successfully, mental health problems and disorders are not a part of normal aging.10 There is wide-ranging impact of various physiological, social, and psychological dynamics of the aging process, such

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as adaption to transitions and stressors like retirement, acute and chronic illness, increased dependency, declining social support network, grief and loss, and functional impairments.

These require considerable adaptation in order to achieve and sustain optimum mental and physical health and wellbeing.8 Such factors impose significant difficulties both on the individual and family members that the integration of mental health services can assist. According to the World Health Organization (WHO), approximately 15-20 percent of adults aged 60 and over suffer from a mental disorder, and 6.6 percent of all disability among this age range is attributed to mental and/or neurological disorders.13 In addition to those listed above, mental health conditions in late life are associated with significant disease progression and burden including issues of medical adherence, functional status and increases in mortality risk.14 Empirical evidence for the integration of mental health services directly into the medical setting for older adults is quickly accumulating since major contributions on integrated care teams that help treat this population have been documented.10 Foremost, studies have found that older adult primary care patients actually prefer receiving mental health services through an integrated care model, where such services are received at the same location as their primary care setting rather than at an off-premise location.14,15 Additionally, behavioral and social factors cause or contribute to nearly every cause of death, illness, and disability,16 and mental and behavioral healthcare plays a significant role in the prevention, diagnosis and/or treatment of the 15 leading causes of death in the United States (e.g. heart disease, cancer, stroke, diabetes, Alzheimer’s disease).17 Research

by Samuels and colleagues reveals that the co-location of mental health treatment in medical settings has been shown to reduce stigma, enhance access to services, and increase coordination of care between mental health and medical care teams.8 Agerelated integration of care has also been shown to enhance quality of care, lower overall healthcare expenditures,8 reduce rates and severity of patients’ emotional distress and functional impairment, improve quality of life,18 and in some settings may even enhance primary care physicians’ satisfaction.19 Finally, data from a number of studies since 2009 shows that suicidal ideation, a serious mental health concern with completion rates highest for older adults (particularly for older Caucasian males), may also be decreased in primary care populations served by a collaborative mental health component.20

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At the AgeWell Center for Senior Health at Baptist Health Medical Center, the co-location of a mental health and geriatric medical practice focuses on promoting healthy aging for older adults facing challenging medical and mental health issues. In the process, a richer, more complete understanding of the patient emerges, and holistic treatment plans can be made to address the interrelated problems each patient presents. The Center’s integrative treatment model helps to assist the nation’s aging population with living more independently and productively by providing an enriched level care in one central location. This proves especially important, as an exceedingly large percentage of older U.S. adults are living longer—79.3 years for both sexes in year 2015 as reported by the WHO.13 Additionally, between 2015 and 2050, the proportion of the world’s older adults is estimated to almost double from about 12 percent to 22 percent.13 Collaborative mental health services at the AgeWell Center focus on treating the older adult holistically while reducing the impact of multiple environmental influences and assisting in differentiating normal versus pathological changes associated with aging. Geropsychological insight is used to clarify clinical problems that may be reversible, such as those caused by medications. Integrating mental health may assist those coping with declining memory or physical illness, managing emotions related to grief and/or loss, as well as adjustment difficulties with life role transitions. It may also provide useful input concerning preventive care as well as treatment of conditions with significant behavioral components including pain, incontinence, medication non-adherence, sleep disorders, and emotional and behavioral problems related to cognitive impairment. AgeWell’s comprehensive mental health treatment approach aids in assisting an interdisciplinary team of medical providers with assessment and treatment of cognition, capacity, personality traits, mood, suicide, and psychotic symptoms, among many others. As integral members of the patient’s collaborative care team, the psychiatrist and psychologist at Age Well offer consultation to family members, caregivers, and other professionals.

Unlike primary geriatric medical clinics/settings without integrated mental health services, integrated medical and mental health teams offer collaborative care to address and help improve the health and quality of life of older patients.

Despite the inevitable circumstances involved in aging, integrated health teams are “poised to capitalize on more positive conceptualizations of the aging experience.”10

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Co-location of Mental and Physical Health in an Oncology Setting Telling a patient that they have cancer often elicits feelings of fear, panic, uncertainty and sadness. Once past the initial shock of the diagnosis, the patient can begin working with their medical team to develop a treatment plan to appropriately address the disease.21,22,23 Health psychologists function as critical members of the multidisciplinary treatment team in the medical oncology clinic and hospital setting.24 Numerous studies have identified the psychological impact of cancer on patients.25,26,27 Psychological issues can and do affect critical quality of life issues, treatment compliance and even treatment outcomes. Common emotional reactions include anxiety, depression, anger, helplessness, hopelessness, frustration, shock/disbelief, denial, uncertainty, guilt, and fear.

Fear can center around a variety of life issues such as alienation from family, friends and co-workers, fear of disfigurement28,29 (e.g., hair loss, weight gain, mastectomy), fear of losing control30 (e.g., physically, emotionally, financially), fear of pain31 and suffering, fear of the dying process and death,32 and fear of cancer recurrence.33,34 In addition to the physical and emotional challenges of cancer, patients and their family members must also cope with psychosocial issues including ability to work/attend school, financial expenses (e.g., medical bills/co-payments, mortgage payments, prescriptions, insurance premiums, etc.), ability to drive, and the ability to engage in social, spiritual and leisure activities.

The primary goal of the health psychologist is to improve the quality of life of the medically ill patient and his/her family.

Treating the patient, rather than the disease, means addressing all areas of the patient’s life – physical, emotional, spiritual, social, etc. Mental health professionals do this by treating and preventing emotional, behavioral and psychological problems, and promoting treatment compliance and healthy behaviors to reduce the risk of cancer recurrence. They also assist the medical team in providing comprehensive services to patients and help the patient and their family understand and cope with the emotional/psychological effects of a chronic medical illness.

In the medical oncology setting, clinical psychologists may also be called upon to evaluate candidates for bone marrow transplantation. Neuropsychologists specialize in evaluating the relationship between brain function and human behavior, memory, cognitive abilities, and changes in personality.

Considerable research has been done by neuropsychologists on the impact of chemotherapy and radiation therapy on patients’ post-treatment functioning.

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At Baptist MD Anderson, psychological services are available to patients and family members at the time of diagnosis, during treatment, if cancer recurs and when end-of-life support is needed. Services include cognitive behavioral therapy, stress management, relaxation training, skills training, crisis intervention, psychoeducation and supportive therapy for individuals, couples, and families. Psychological services may include consultation-liaison services in both inpatient and outpatient procedural settings. The staff psychologist attends regular multidisciplinary tumor boards. In this capacity, they provide input and recommendations regarding patient issues and plans of care.

Emergency Care and Telepsychiatry Telepsychiatry is part of the growing telemedicine movement to provide remote healthcare through technology, most often using videoconferencing. Videoconferencing was first used in 1959 at the Nebraska Psychiatric Institute in Norfolk, Nebraska to provide diagnosis, treatment, consultation, and medical student training. Almost 60 years later, due to explosive growth of the technology, most states have either adopted laws or are deliberating over legislation to cover telepsychiatry as part of regular, accepted healthcare procedures.

Hospital emergency departments are a major hub of access into the healthcare system. The Agency for Healthcare Research and Quality estimates that at least 12 percent of patients seeking care in hospital emergency departments have a substance abuse or psychiatric disorder.35 Most hospital emergency departments do not have the staff and are not equipped to handle serious mental health problems. Upwards of 80 percent of hospitals do not have a psychiatrist on call and available for emergencies.35 Telepsychiatry has been a successful solution to bridging access gaps by bringing the psychiatrist to the patient.

At Baptist Medical Center in Jacksonville, a psychiatrist or ARNP rounds each morning to assist with treatment and disposition of patients with mental health issues. The emergency room physicians and the psychiatry team have agreed upon criteria for determining medical clearance before patients can be admitted to the psychiatric inpatient unit. If patients don’t meet criteria for medical clearance, and they are admitted to a medical bed, a psychiatrist is consulted as needed to assess, treat, and discharge/transition the patient to the appropriate outpatient or inpatient setting. For other Baptist Emergency facilities that are not in downtown Jacksonville, telepsychiatry may be used if a consulting psychiatrist is not available. The experience at Baptist DCMS online . org

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using telepsychiatry has been one of efficient and timely access of mental health evaluations to patients who might otherwise be hospitalized unnecessarily or released without proper evaluation and care. Based on the experience of author Dr. Peter Clagnaz in using both psychiatrists and ARNPs as evaluators, approximately 75 percent of patients can be safely discharged home. Those able to return home are given referrals to appropriate providers and agencies that best match their clinical needs.

Conclusion Providing psychiatric and psychological support services in medical practices and hospitals is an important part of comprehensive patient care. To ignore the mental health aspects of acute and chronic medical illnesses is to fail to acknowledge the “Triple Aim” of containing costs, improving outcomes, and increasing patient satisfaction. With the current emphasis on population health and integrated care, the medical team must understand patient needs, evaluate the whole patient (physically and emotionally) and offer mental health assessment and treatment to all patients. v

8. Samuels SR, Abrams R, Shengelia M, et al. Integration of geriatric mental health screening into a primary care practice: A patient satisfaction survey. Int J Geriatr Psychiatry. 2015 May;30(5):539-46. Retrieved from www.ncbi.nlm.nih.gov/pmc/ articles/PMC4363083/.

9. Demmler J. Utilization of specialty mental health organizations by older adults: U.S. national profile. Psychiatr Serv. 1998 Aug;49(8):1079-81.

10. American Psychological Association Presidential Task Force on Integrative Health Care for an Aging Population. Blueprint for change: Achieving integrated health care for an aging populating. Washington (DC); 2008. 73 p.

11. Vedantam D. Stress found to weaken resistance to illness [Internet]. Washington Post. 2003 Dec 22. Retrieved from http://www.washingtonpost.com/archive/politics/2003/12/22/ stressfound-to-weaken-resistance-to-illness/8a2d6819-33dc4dda-a3bb-b30fd83a4bce/.

12. Davidson JR, Meltzer-Brody SE. The underrecognition and undertreatment of depression: What is the depth and breadth of the problem? J Clin Psychiatry. 1999;60 Suppl 7:4-11.

13. World Health Organization. Mental health and older adults fact sheet [Internet]. 2016 Apr [cited 2017 May]. Available from: http://www.who.int/mediacentre/factsheets/fs381/en/.

References

14. Shadmi E, Boyd CM, Hsiao CJ, et al. Morbidity and older persons’ perceptions of the quality of their primary care. J Am Geriatr Soc. 2006 Feb;54(2):330-4.

1. Institute for Healthcare Improvement. Triple aim for populations [Internet]. 2017 [cited 2017 May]. Available from: http://www.ihi.org/Topics/TripleAim/Pages/default.aspx.

15. Chen H, Coakley EH, Cheal K, et al. Satisfaction with mental health services in older primary care patients. Am J Geriatr Psychiatry. 2006 Apr;14(4):371-9.

2. Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Arch Gen Psychiatry.

2005 Jun;62(6):629-40.

16. Williamson GM. Aging well: Outlook for the 2century. In Snyder CR, Lopez SJ, editors. Handbook of Positive Psychology.

New York: Oxford University Press; 2002. p. 676-86.

3. National Institute of Mental Health. Statistics [Internet].

National Institutes of Health; 2017 [cited 2017 May]. Available from: https://www.nimh.nih.gov/health/statistics/index.shtml.

4. Frank RG, Beronio K, Giled SA. Behavioral health parity and the Affordable Care Act. J Soc Work Disabil Rehabil. 2014;13(12):31-43.

5. Agency for Healthcare Research and Quality: The Academy.

What is integrated behavioral health care (IBHC)? [Internet].

U.S. Department of Health and Human Services; 2013 [cited 2017 May]. Available from: https://integrationacademy.ahrq. gov/resources/ibhc-measures-atlas/what-integrated-behavioralhealth-care-ibhc.

6. Rancy LE. Integrating primary care and behavioral health: The role of the psychiatrist in the collaborative care model. AM J Psychiatry. 2016 Aug 1;172(8):721-8.

7. American Psychiatric Association Academy of Psychosomatic Medicine. Dissemination of integrated care within adult primary care settings: the collaborative care model. 2016. 85 p.

Report 2016.

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17. Johnson NB, Hayes LD, Brown K, et al. CDC National Health Report: Leading causes of morbidity and mortality and associated behavioral risk and protective factors—United States, 2005–2013. MMWR Suppl. 2014 Oct 31;63(4):3-27.

18. Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836-45.

19. Gallo JJ, Ryan SD, Ford DE. Attitudes, knowledge, and behavior of family physicians regarding depression in late life.

Arch Fam Med. 1999 May-Jun;8(3):249-56.

20. Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary care: Identification and management in older adults. Curr Psychiatry Rep. 2014 Sep;16(9):466.

21. Woznick LA, Goodheart CD. Living with childhood cancer: A practical guide to help families cope. Washington (DC): American Psychological Association; 2001.

22. Suinn RM, VandenBos GR. Cancer patients and their families: Readings on disease course, coping, and psychological interventions.

Washington (DC): American Psychological Association; 1999.

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23. Park CL, Lechner SC, Antoni MH, et al. Medical illness and positive life change: Can crisis lead to personal transformation?

Washington (DC): American Psychological Association; 2009.

30. Norberg AL, Boman KK. Mothers and fathers of children with cancer: loss of control during treatment and posttraumatic stress at later follow-up. Psychooncology. 2013 Feb;22(2):324-9.

24. Kazak AE, Noll RB. The integration of psychology in pediatric oncology research and practice: Collaboration to improve care and outcomes for children and families. Am Psychol. 2015 FebMar;70(2):146-58.

31. te Boveldt N, Vernooij-Dassen M, Leppinik I, et al. Patient empowerment in cancer pain management: An integrative literature review. Psychooncology. 2014 Nov;23(11):1203-11.

25. Krebber AMH, Buffart LM, Kleijn G, et al. Prevalence of depression in cancer patients: A meta-analysis of diagnostic interviews and self-report instruments. Psychooncology. 2014 Feb;23(2):121-30.

26. Stanton AL, Rowland JH, Ganz PA. Life after diagnosis and treatment of cancer in adulthood: Contributions from psychosocial oncology research. Am Psychol. 2015 FebMar;70(2):159-74.

27. Swartzman S, Booth JN, Munro A, et al. Posttraumatic stress disorder after cancer diagnosis in adults: A meta-analysis.

Depress Anxiety. 2017 Apr;34(4):327-39.

28. Die-Trill M, Straker N. Psychological adaptation to facial disfigurement in a female head and neck cancer patient.

Psychooncology. 1992 Dec;1(4):247-51.

32. Little M, Sayers E. The skull beneath the skin: cancer survival and awareness of death. Psychooncology. 2004 Mar;13(3):190-8.

33. Lee-Jones C, Humphris G, Dixon R, et al. Fear of cancer recurrence– a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears.

Psychooncology. 1997 Jun;6(2):95-105.

34. Thewes B, Bell ML, Butow P. Fear of cancer recurrence in young early-stage breast cancer survivors: The role of metacognitive style and disease-related factors. Psychooncology. 2013 Sep;22(9):2059-63.

35. Agency for Healthcare Research and Quality. Trends in Emergency Department Visits Involving Mental and Substance Use Disorders 2006-2013. 2016 Dec;216. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb216-MentalSubstance-Use-Disorder-ED-Visit-Trends.pdf.

29. Sun L, Ang E, Ang WHD, et al. Losing the breast: a metasynthesis of the impact in women breast cancer survivors.

Psychooncology. 2017 May 20.

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The Role of Pediatric Psychology in Inpatient Medical Settings: An Overview into Clinical Practice

By Nicole A. Kahhan, PhD, Shana L. Boyle, PhD, Lisa M. Schilling, PhD, ABPP, and Lisa M. Buckloh, PhD Nemours Children’s Specialty Care, Jacksonville, FL

Abstract: Pediatric psychologists are valuable members of medical teams and have specialized education and training that allow them to deliver consultation-liaison services in medical settings. This article provides a brief overview of pediatric psychology as a discipline, including specific training and competencies. Also described are the specific roles of a pediatric psychologist, as well as a model for consultation-liaison services. Using a case example, these competencies and roles of a pediatric psychologist are highlighted. Challenges and limitations of psychological consultation are reviewed. Pediatric psychologists can best provide consultation services when they work closely with referring physicians and other medical staff. The benefits of psychological consultation to the medical team and key points to allow for successful consultation are outlined.

Introduction Background Accounts of the relationships and collaborations between psychologists and pediatricians date back to the 1890s; however, it was not until the late 1960s that the “marriage” between these fields were formally named and described as thier own model, that of pediatric psychology.1-3 Pediatric psychologists have specialized knowledge and training that crosscut the core domains of clinical child psychology, child health and illness, systemic and contextual factors affecting health and health disparities, and knowledge and appreciation of multidisciplinary teams and services in pediatric care, among others.4 Pediatric psychologists serve in a variety of clinical, teaching, advocacy and research roles and may work in hospital-based, critical care, rehabilitation, university, school, outpatient, medical clinic, and primary care settings.5

The role of a pediatric psychologist in providing consultationliaison (CL) services in pediatric inpatient medical settings is vital to delivering integrated, efficient, and effective healthcare.5,6 It is important to understand the core competencies of a pediatric psychologist, as well as the consultation-liaison role of a pediatric psychologist in an inpatient medical setting.

Pediatric psychologists have specialized education and training across ten knowledge competencies, specifically: 1) Valuing and understanding the scientific foundation for the practice of pediatric psychology 2) Having a strong foundation in clinical child psychology (normative, adaptive, and maladaptive development across emotional, cognitive, social, and behavioral domains) 3) Understanding children’s health and illness from a multifaceted and context-driven perspective 4) Utilizing medical literature and understanding medical management of pediatric illnesses 5) Recognizing the role of the family on child health and illness 6) Understanding socioeconomic and cultural factors and their effect on health and health disparities 7) Having knowledge of relevant systems and contexts impacting health (schools, state/federal policies, healthcare) 8) Understanding and respecting the roles of other disciplines in health service delivery 9) Appreciating the function of health information technology 10) Understanding the process of transition from pediatric to adult-oriented health services.4,7

Training and Specialization Address correspondence to: Nicole A. Kahhan, PhD Division of Psychology 807 Children’s Way Jacksonville, FL 32207 904-697-3698 Nicole.Kahhan@nemours.org

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To achieve competence in the ten knowledge areas, pediatric psychologists typically complete a doctoral program, which includes a one-year clinical internship, and are licensed in the state in which they practice. They may also pursue an additional one to two years of post-doctoral training in clinical practice, research, or a combination of the two. Board certification in Northeast Florida Medicine Vol. 68, No. 4 2017 19

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Clinical Child and Adolescent Psychology or Health Psychology also may be pursued through the American Board of Professional Psychology.5 While pediatric psychologists often practice in medical settings, they are not able to prescribe medication in most states.

Consultation Liaison Model of Practice Specific to the role of a pediatric psychologist in an inpatient consultation-liaison setting, a “six C’s of CL” model has been proposed. This model reviews the role of a pediatric psychologist in managing crises, assisting with coping, addressing and improving compliance/adherence, facilitating communication, enhancing collaboration, and changing systems.8 This model is consistent with other models of care, and can be integrated directly with the Pediatric Psychosocial Preventative Health Model7 and the Bioecological Systems Theory (BST).9,10 A similar consultation model is used by health psychologists in adult medical care settings. In a pediatric inpatient setting, a patient might be referred to a pediatric psychologist within the context of one or more of these domains. Examples are a patient presenting with a needle phobia impacting coping and compliance to the medical regimen following a new diagnosis of diabetes, a service looking to establish a behavior management plan in the PICU, a request for teaching behavioral pain management skills in a pediatric oncology patient, or a team consultation regarding potential somatization or conversion symptoms in a patient with a complex neurological presentation.

Consultations vary greatly by referral question, acuity of need, length of inpatient stay, service or medical specialty requesting referral, and other factors.8 As such, the following case example is presented to describe the role of the pediatric psychologist on a multidisciplinary inpatient care team, evaluation and treatment of the patient, and the results and recommendations in the context of both core pediatric psychology competencies and the “six C’s of CL.”

Case Example: Patient information: An 11-year-old female patient presented to the hospital with cardiac complaints and ongoing hematochezia. She had a recent diagnosis of pancolitis and H. pylori at time of admission.

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Notably, the patient was diagnosed with Ulcerative Colitis following a CT scan on day of admission. Cardiac complaints were thought to be from anxiety and severe acute anemia due to blood loss.

Referral question: Pediatric Psychology was consulted on day of admission by the patient’s hospitalist due to significant anxiety surrounding her hospitalization.

Ideally, a referral to inpatient pediatric psychology in inpatient medical settings would include the following information: 1) brief, relevant medical and family history, 2) known psychosocial or family stressors, and 3) a specific referral question. To best address the physician and patient needs, the specificity of the referral question assists the consulting psychologist in appropriately evaluating and triaging the patient. If additional pertinent information is required by the consulting psychologist (e.g., the patient is unaware of the diagnosis), it is best for this information to also be placed within the referral. Similarly, if the feedback of the consulting pediatric psychologist is required for medical care planning, discharge, or other immediate needs, this information should be clearly detailed as part of the referral.

The referring physician should always make the child and family aware that a psychology consult has been placed and why it is being requested.

Intake information: During the initial visit in the patient’s hospital room, the parents reported that their daughter had developed a significant fear of needles and injections following a previous traumatic medical procedure. They described administration of oral medications as a daily struggle, with multiple family members intervening. The patient reported to the psychologist that she feared sleeping, as she worried that medical procedures would be performed while she was asleep. The family denied any previous history of mental health issues, including anxiety. The patient’s parents endorsed a high level of stress surrounding the patient’s new IBD diagnosis.

The patient was highly anxious due to a scheduled medical procedure that day. She cried throughout the visit and avoided speaking to the psychologist. She alternated between yelling at, and seeking reassurance from, her parents. The patient repeatedly asked questions about medical procedures. Her

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heart rate increased to the 150s. Due to the high level of patient and parent distress, the initial visit focused on acute symptom management, specifically, teaching the patient a relaxation exercise (diaphragmatic breathing) and providing support to the parents.

In an inpatient CL intake, the following information is typically gathered by the consulting pediatric psychologist: 1) history of present illness, 2) presenting concerns, 3) developmental history, 4) medical history, 5) psychiatric history, 6) social functioning, 7) school functioning, 8) evaluation of mental status, and 9) behavioral observations. This information is then used to determine an appropriate diagnosis and develop a treatment plan. The case example, however, demonstrates the level of flexibility required to complete an intake in the context of patient distress, and how acute symptom management may be needed prior to the assessment of other domains.

Diagnosis and treatment plan: Based on history gathered from the patient and family, as well as behavioral observations, diagnoses of Adjustment Disorder with Anxiety and Specific Phobia (needles) were assigned.

Recommendations to medical staff and parents in the inpatient setting included not sharing the patient’s diagnosis (this was deemed in the best interest of the patient due to high level of anxiety and chronicity of diagnosis), providing advance notice about any upcoming procedures, avoiding discussion of future procedures too far in advance, avoiding the use of coaxing and excessive reassurance (to take medications and complete procedures), providing the patient with choices, and encouraging the use of distraction and relaxation exercises to reduce anxiety.

The parents were also advised to take “breaks” from the patient’s bedside to help manage their own emotional distress.

The initial evaluation and intervention described above addressed several of the “six C’s of CL”, including coping with a new diagnosis, collaboration between the provider and other staff members (i.e., face-to-face delivery of recommendations to nursing staff and discussions with the medical team to help increase understanding of the patient’s behavioral and emotional functioning), and addressing concerns about compliance to the medical regimen.

Treatment goals and outcomes: Following the initial visit, the pediatric psychologist collaborated with the Child Life Specialist on the medical floor to develop DCMS online . org

a child-friendly visual medication schedule (to be displayed in the patient’s hospital room) to help motivate the patient to take medications and reduce anxiety about her medication regimen. The patient was able to earn stickers and small prizes to play with during her hospital admission. The reward chart was successful in helping the patient to take all medications in a timely manner with reduced anxiety. The patient was very pleased to earn rewards and was excited to share her progress with the psychologist.

The patient and her family were seen two more times during the hospital admission by the psychologist. Sessions focused on reviewing strategies for reducing anxiety and supporting the patient’s transition back to school. The family took turns caring for the patient and made efforts to reduce coaxing to take medication. The patient was also encouraged to use diaphragmatic breathing and distraction when anxious, which appeared to be effective in reducing anxiety. The family was referred to outpatient therapy with the psychologist after discharge to continue to address anxiety and adjustment-related concerns.

In the time between hospital admission and the first outpatient therapy visit, the patient learned of her Ulcerative Colitis diagnosis. Her parents reported improvements in taking medication, but still required significant encouragement. The parents also reported that she was having difficulty accepting her IBD diagnosis.

Over the course of therapy, differences in parenting style and management of the patient’s anxiety and other illness-related adjustments (e.g., dietary restrictions, taking medications) became apparent. Establishing consistency in management of the patient’s behavior in the context of adjusting to a chronic medical illness was a primary goal of treatment. For example, the psychologist discussed ways that the family could help support their child surrounding dietary restrictions and poor appetite (e.g., allowing occasional treats, not punishing for not finishing meals to avoid struggles over control, and giving the child opportunity to suggest “favorite meals” and select snack foods at the grocery store). Therapy also focused on helping the patient to feel more comfortable communicating with her school and peers regarding her medical issues (e.g., the need to take bathroom breaks, answering peers’ questions about illness, etc.) The psychologist also encouraged the patient to process difficult emotions and fears related to her new IBD diagnosis.

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Again, reflecting back to the “six C’s of CL,” it is easy to see how a referral to pediatric psychology in the inpatient setting might involve addressing and improving upon various domains such as coping and compliance, while also allowing for collaboration across services in order to provide the best care to the patient and family. Treatment gains in the inpatient hospital setting were then followed up with and expanded upon in an outpatient setting, again with an emphasis on continuity of care.

With patient consent, sharing of outpatient electronic medical records with GI providers allowed for continued communication and collaboration between the family, the medical team and the consulting pediatric psychologist.

Challenges and limitations: Primary challenges included difficulty completing an initial assessment at the time of intake due to the immediate procedural distress experienced by the patient, the need to speak privately to the patient’s family (which was difficult to accomplish due to acute patient needs and separation anxiety), parent distress, and time-based limitations (i.e., the patient was preparing to leave the floor for a procedure).

Other challenges that present to a pediatric psychologist during an inpatient consultation may include patient illness, ongoing medical procedures or sedation, availability of parent(s) at bedside to provide background information, parental mental health issues, cultural challenges, and potential triage needs to other services.

Benefits of collaboration between the physician and psychologist: Utilizing pediatric psychology services in an inpatient hospital setting can also be beneficial to medical providers. Pediatric psychologists are able to offer insight regarding emotional, behavioral, social, developmental, or environmental challenges that may impact the course of treatment. This information may be used to guide medical decision-making. In addition, pediatric psychologists provide a value-added service through integrated care, which also could lead to reduced health utilization and cost-offset benefits.11 Patient outcomes may be enhanced via timely and effective collaboration between physicians and pediatric psychologists.

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When there is a concern about contributions of psychological factors, physicians are encouraged to consult the pediatric psychologist as soon as possible. Earlier behavioral health consultation has been associated with shorter length of stay and lower hospitalization charges after adjusting for psychiatric functioning, physical illness severity, and psychiatric disposition.11 Key points for physicians to consider when consulting pediatric psychology are offered in Table 1.

Table 1: The Role of the Physician in a Successful Pediatric Psychology Consultation Place order for psychology as soon as psychosocial concerns are identified Provide a clear, specific referral question Inform the family of the consultation Maintain collaboration with the psychologist (through EMR, by phone, or via nursing and support staff) When relevant, include the psychologist in staffing concerning the patient Include psychologist’s recommendations for follow-up in discharge documents

Conclusion: Pediatric psychologists specialize in understanding the complementary relationship of psychology and medicine, and often serve as consultation-liaison providers on multidisciplinary and integrated care teams. Delivery of pediatric psychology services is becoming increasingly popular in inpatient medical settings, and can benefit children and their families in many ways.12 As reviewed in the case example, pediatric psychologists play an integral role in managing crises, assisting with coping, addressing and improving compliance/adherence, facilitating communication between the patient, families and medical team, enhancing multidisciplinary collaboration, and facilitating the transition to home and community. They may also assist in managing the environmental factors in the hospital to provide better outcomes for patients. Successful psychological consultation is enhanced by clear communication and close collaboration with the medical team. v

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References 1. Kagan J. The new marriage: pediatrics and psychology. Am J Dis Child. 1965 Sep;110:272-8.

2. Kazak AE. Historical analysis in Journal of Pediatric Psychology.

J Pediatr Psychol. 2015 Mar;40(2):165-6.

3. Wright L. The pediatric psychologist: a role model. Am Psychol.

1967 Apr;22(4):323-5.

4. Palermo TM, Janicke DM, McQuaid EL, et al.

Recommendations for training in pediatric psychology: defining core competencies across trainings levels. J Pediatr Psychol. 2014 Oct;39(9):965-84.

5. Buckloh LM, Schilling LM. Handbook of pediatric psychology.

5th ed. New York: The Guilford Press; c2017. Chapter 3, Professional development, roles, and practice patterns; p. 26-37.

6. Rozensky RH, Janicke DM. Commentary: Healthcare reform and psychology’s workforce: preparing for the future of pediatric psychology. J Pediatr Psychol. 2012 May;37(4):359-68.

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7. Palermo TM, Janicke DM, Beals-Erickson SE, et al. Handbook of pediatric psychology. 5th ed. Chapter 5, Training and competencies in pediatric psychology. New York: The Guilford Press; c2017. 56 p.

8. Carter BD, Kronenberger WG, Scott EL, et al. Handbook of pediatric psychology. 5th ed. Chapter 9, Inpatient pediatric consultation-liaison. New York: The Guilford Press; c2017. 105 p.

9. Kazak A. Pediatric psychosocial preventative health model (PPPHM): research, practice and collaboration in pediatric family systems medicine. Fam Syst Health. 2006;24(4):381-95.

10. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Cambridge: Harvard University Press; c1979. 330 p.

11. Bujoreanu S, White MT, Gerber B, et al. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. Hosp Pediatr. 2015;5(5):269-75.

12. Shaw RJ, Wamboldt M, Bursch B, Stuber M. Practice patterns in pediatric consultation-liaison psychiatry: a national survey.

Psychosomatics. 2006;47(1):43-49.

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Promoting Wellness in Residency Training Background: The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME).

This issue of Northeast Florida Medicine includes an article, “Promoting Wellness in Residency Training” authored by Mary S. Hedges, MD, Monia E. Werlang, MD, Chrysanthe M. Yates, BA, and Michele D. Lewis, MD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials: Mary Hedges, MD, Associate Program Director, Internal Medicine Residency at Mayo Clinic Florida. Michele Lewis, MD, Program Director, Internal Medicine Residency, Mayo Clinic Florida. Monia Elisa Werlang, MD, Assistant Professor of Medicine/Gastroenterology and Hepatology Fellow, Mayo Clinic Florida. Chrysante Yates, BA, Program Director, Mayo Clinic Florida’s Lyndra P. Daniel Center for Humanities in Medicine.

Objectives: 1. Understand the current data as it relates to physician burnout, depression, and suicide.

2. Identify barriers to physicians seeking mental health services.

3. Identify strategies to promote wellness among resident and faculty physicians.

Date of release: December 1, 2017

Date Credit Expires: December 1, 2019

Estimated Completion Time: 1 hour

How to Earn this CME Credit: 1) Read the “Promoting Wellness in Residency Training” article.

2) Complete the posttest. Scan and email your test to Kristy Williford at kristy@dcmsonline.org or mail it to 1301 Riverplace Boulevard, Suite #1638, Jacksonville, FL 32207.

3) You can also go to www.dcmsonline.org/NEFMCME to read the article and take the CME test online.

4) All non-members must submit payment for their CME before their test can be graded.

CME Credit Eligibility: A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within four weeks of submission. If you have any questions, please contact Kristy Williford at 904.355.6561 or kristy@dcmsonline.org.

Faculty Disclosure: Mary Hedges, MD, Michele Lewis, MD, Monia Elise Werlang, MD, and Chrysante Yates, BA report no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest: St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educations activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society.

St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit. TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Promoting Wellness in Residency Training

By Mary S. Hedges, MD,1 Monia E. Werlang, MD,2 Chrysanthe M. Yates, BA,3 Michele D. Lewis, MD4 1

Assistant Professor of Medicine, Mayo Clinic College of Medicine, Community Internal Medicine and Associate Program Director, Internal Medicine Residency, Mayo Clinic, Jacksonville, Florida 2 3

4

Chief Medical Resident, Internal Medicine Residency, Mayo Clinic, Jacksonville, Florida

Program Director, Mayo Clinic Lyndra P. Daniel Center for Humanities in Medicine, Jacksonville, Florida

Assistant Professor of Medicine, Mayo Clinic College of Medicine, Department of Gastroenterology and Program Director, Internal Medicine Residency, Mayo Clinic, Jacksonville, Florida

Abstract: Physician burnout levels have become alarmingly high

is recent years. At the same time, physician depression and suicide completion rates are increasing, with recent data showing that the risk of suicide among physicians is significantly higher than their non-physician age matched controls. The tendency towards depressive symptoms and suicidal ideation appears to start early in medical training, and accelerate through medical school and residency. To address burnout, depression, and suicide risk during residency, Mayo Clinic Florida has initiated a multifaceted wellness approach. Identifying wellness champions with leadership interest is important to implement specific wellness initiatives.

Wellness initiatives include: resident wellness education, duty hour and fatigue mitigation, arts and humanities, pet therapy, nutrition, counseling services, social gatherings, resilience training, access to medical care, nutritious food, and ongoing monitoring for burnout among residency programs. To lower the rates of physician burnout, depression, and suicide, it is imperative that the medical community be proactive.

Introduction Physician wellness strategies are becoming highly publicized and promoted in response to recent studies that show burnout rates of over 50 percent among physicians nationwide. 1 Additionally, there is concerning data regarding depression in up to 30 percent of medical students and residents, as well as notably higher rates of suicide in all physicians compared to the general population (relative risk of suicide among physicians compared to the general population: 1.1-3.4 in men, and

Address correspondence to: Mary S. Hedges, MD Mayo Clinic 4500 San Pablo Road Jacksonville, FL 32224 Phone: 904-953-2000 Fax: 904-953-0655 Email: Hedges.Mary@mayo.edu

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2.5-5.7 in women).2,3,4,5 Approaches from an institutional level have been recently outlined,6 but challenges remain in promoting wellness in both medical trainees and the faculty physicians who teach them. The Accreditation Council for Graduate Medical Education (ACGME) has made physician wellness a high-priority initiative in response to the reports of increasing suicide rates.7

Background Physician Burnout Physician burnout has notably increased nationwide in recent years. A study reporting on data from a nationwide survey of 6,800 physicians showed that 45.5 percent of physicians reported at least one symptom of burnout in 2011. Subsequently, when re-surveyed in 2014, the reported burnout symptom rate had increased to 54.4 percent.1 This increase in burnout was noted in all 24 medical specialties studied, with some specialties increasing by more than 10 percent during the study period. The highest increases in burnout were reported in family medicine (51 percent in 2011 to 63 percent in 2014), general pediatrics (35 percent to 46 percent), urology (41 percent to 63 percent), orthopedic surgery (48 percent to 59 percent), dermatology (31 percent to 56 percent), physical medicine and rehabilitation (47 percent to 63 percent), pathology (37 percent to 52 percent), radiology (47 percent to 61 percent), and general surgery subspecialties (42 percent to 52 percent).1,2 Physician burnout is strikingly higher than the U.S. working adult population, which has a reported burnout rate of 28 percent.1 Even when adjusted for confounding variables (such as age, gender, relationship status, and hours worked), physicians remained almost twice DCMS online . org

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as likely to suffer burnout compared to the U.S. working population (odds ratio of 1.97).1 Physicians are also less likely to be satisfied with work life balance, declining from 48 percent satisfaction level in 2011 to 40 percent in 2014, both of which are notably lower than the U.S. working population (odds ratio of 0.68).1 This concerning trend has been published in the general media as physician burnout, not only affects physicians, but also affects patient quality, safety, and access to care.8 Physicians with a higher burnout rate are more likely to make medical errors.2 In response to high rates of burnout in residency training, there has been a recent call to action in the medical education community with new requirements at a program level through regulatory bodies.9

Physician Depression Physician depression rates have remained disturbingly high.

Among physicians nationally, based on a two-question primary care depression screen, depression rates were found to be 39.2 percent in 2011 and overall unchanged at 39.8 percent in 2014.1,2 Depression rates in medical students is 15-30 percent,3 and this rate appears to rise throughout the medical education years when followed longitudinally.10 Residents suffering with depression were over six times more likely to make medication errors than residents without depression.11 Compounding this problem further, studies show that physicians are much less likely to seek or receive treatment for depression than their non-physician counterparts.3 This disparity is significant when compared to the general population rates of depression. The National Institute of Health (NIH) and World Health Organization (WHO) report the prevalence of depression among U.S. adults as 6.7 percent.12 Similarly, the Centers for Disease Control and Prevention (CDC) reported U.S. population depression rates in 20092012 of 7.6 percent.13 In 1999, the self-reported lifetime prevalence of depression among physicians was 13 percent in men and 20 percent in women, a rate already above that of non-physicians, and that has only increased further in the last two decades.14

Physician Suicide Unfortunately, insufficient mental healthcare begins early in the medical career. Of medical students who reported suicidal ideation, only 42 percent received treatment.15 This disparity appears to continue to increase with seniority. Physician suicidal ideation rates nationally were self-reported over a DCMS online . org

12-month period to be 6.4 percent in both 2011 and 2014.1,2 A study of U.S. surgeons reported suicidal ideation rate of similar numbers (6 percent) in the preceding 12 months, and most notably, only 26 percent of those reporting suicidal ideation had sought psychiatric or psychological help. Over half reported reluctance to seek help due to medical licensure concerns that require reporting of mental health history regardless of impairment.16,17 Completed suicides are higher among physicians than non-physician peers and the physician suicide numbers are increasing. It was estimated in 1977 that the U.S. lost 150 doctors per year to suicide, the equivalent of one medical school class per year.17,18 The published estimation in 2017 is that the U.S. loses 400 physicians to suicide per year, equivalent to two to three medical school classes dying by suicide yearly.8,17 In medical students, after accidents, suicide is the most common cause of death.18 In residency training, the leading cause of death is neoplastic disease and suicide.19 Data stratified by gender shows for male residents, the leading cause of death was suicide, then neoplastic disease second. For female residents, the leading cause of death was neoplasm, with suicide a close second. Patterns show higher rates of death early in residency training and also highest during the first and third quarters of the academic year.19 For physicians beyond medical training, the completed suicide rate continues to rise. Female physicians appear to attempt suicide less often than the general U.S. female population, but have a much higher completion rate of suicide— over 250-400 percent higher than the female general population (relative risk 2.4-4.0).­For male physicians, the suicide completion rate is about 70 percent higher than the general male population.15 The overall suicide completion rates appear to be similar between male physicians and female physicians.20 Physicians of both genders have a much higher suicide completion rate than the general public, which appears to be due to greater knowledge of anatomy and increased access to lethal means.

Definition Wellness is more than the absence of depression or suicidality, but conversely, a person who is depressed or suicidal is not in a state of wellness. The American Medical Association (AMA) website has a helpful framework for approaching wellness for residents and fellows.21 The Mayo Clinic has also created a wellness initiative, including a resource webpage for employees Northeast Florida Medicine Vol. 68, No. 4 2017 31

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and the opportunity to train as a Wellness Champion (published on institutional internal webpage). The frameworks are similar and both are listed in Table 1.

Table 1: Wellness Framework AMA Steps Forward 2015 – 6 key aspects of personal wellbeing

Mayo Clinic Wellness Training – 6 domains of wellbeing

Nutrition

Meaning in Work

Fitness

Work Life Integration

Emotional Health

Physical

Preventive Care

Emotional

Financial Health

Financial

Mindset and behavior adaptability Social Abbreviation: AMA, American Medical Association

Strategies to Implement To address resident wellness, initial steps include identifying trainees and faculty with knowledge or interest in wellness initiatives to provide leadership and reviewing institutional resources available. Each residency program has unique challenges and assets in this regard. At the Mayo Clinic, some of the wellness initiatives already existed in other formats, and these were adapted for residents. New initiatives were developed to address the unique stressors and schedule of medical training.

Specific wellness initiatives implemented for Mayo Clinic Residents: 1) Wellness education discussions – For trainees in all specialties, the institution offers an annual education day, which includes a wellness education lecture.

Institutional resources and wellness strategies are shared. Beyond the details of what is shared in the

Figure 1: Creative expression watercolor painting –

Arts and Humanities FERHAWI pilot program for residents.

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lecture, this raises awareness among residents and faculty and hopefully lessens the stigma in addressing future concerns when they arise.

2) Arts and Humanities – In 2014, the Mayo Clinic Internal Medicine residency started a pilot program called FERHAWI (Fellows and Residents Health and Wellness Initiative). This has been implemented with the Mayo Clinic Center for Humanities in Medicine. Specifically, one conference per month is protected for residents to participate in an arts or humanities project together, rather than a traditional lecture. This has included activities in self-care and creative expression such as watercolor painting (Figure 1), drawing, photography (Figure 2), mixed media, movement, dance, music, yoga, guided visual imagery (Figure 3), meditation, narrative and reflective writing, poetry, art analysis and interpretation, medical improvisation, and museum visits. The preliminary data has shown reduced fatigue and increased motivation compared to a regular didactic lecture. This program has been featured on the AMA website.21 3) Caring Canines – Much has been published on the benefits of canines to human health and stress relief.22 The Mayo Clinic has a Registered Pet Therapy team for animal-assisted activities for the benefit of patients.

Recently, the Internal Medicine chief medical residents initiated Caring Canine Fridays, scheduling the Registered Pet Therapy team to spend time with the residents during a 45-minute debrief session on the last

Figure 2: “Just breathe” mindfulness photography project –

Residents aimed cameras at the sky for 30 second exposure while breathing to create visual oscillation of the images, unique to each individual. The portraits were assembled into a greater wall installation display.

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Figure 3: Guided visual imagery – Resident meditation with flute player.

Friday of the rotation. During that same time, the chiefs solicit feedback from the residents on recent rotations, didactics, and their overall training experience (Figure 4).

4) Fatigue management – ACGME requires a fatigue policy be in place for all trainees. The Mayo Clinic makes every effort to ensure this is shared at orientation and several conferences throughout the year, and that this information is prominently posted on the Internal Medicine residency website. Education is provided regarding the significant adverse mental and physical effects of sleep deprivation. If a resident is too fatigued to work, coverage for clinical responsibilities will be arranged, and roundtrip taxi service will be reimbursed.

Adequate call room space is also essential for overnight or extended shifts.

5) Nutrition – In promoting wellness, residents need access to healthy food choices. To promote this, there is a new resident lounge area that has a stocked refrigerator with healthy, nutritious snacks like fresh fruits, cereal, milk, granola bars and sandwiches. This helps to ensure healthy foods are available when working night shifts and weekends, even when the cafeteria is closed.

6) Gathering institutional resources – A Resident Wellness link is available on our Internal Medicine residency webpage providing institutional resources in a central location that is easily accessible to residents.

With new trainees entering residency programs each year, keeping a wellness webpage up-to-date helps share resources that new trainees might otherwise overlook.

This includes listing a residency ombudsperson, instructions on how to establish a primary care doctor

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Figure 4: Caring Canines –

Internal Medicine residents during debrief morning report session.

within the insurance network, local gym membership discounts, employee resource groups, and Employee Assistance Program (EAP) information. Our EAP, which provides free counseling in times of crisis, is available to all employees anonymously and can be accessed without prior authorization from employer or health insurance.

7) Monitor for burnout – The education department has implemented semi-annual surveys of all residents and fellows of all specialties. The survey results are anonymous and grouped by specialty to evaluate for systems issues that may need to be addressed at the program level. These survey results are compared to national norms by specialty, and if there is an outlier residency with a higher burnout rate than the national average, this is addressed further at the program level.

This allows for early intervention and the opportunity to be proactive in addressing resident wellness.

8) Social gatherings through resident-led groups – The Mayo Clinic Fellows Association (comprised of residents, fellows, and scientists-in-training) is a very active group, coordinating winter and summer socials, community outreach programs (Figure 5), co-ed intramural sports teams (Figure 6), and an Annual Wellness Day event.

Annual Wellness Day offers several different activities to trainees in all specialties and fellowships, including free massages, guided yoga and stretching exercises, music, healthy food options, and the presence of the Caring Canines. The goals of the Annual Wellness Day are to show appreciation for the trainees’ hard work, provide the opportunity to relax and interact with peers during the workday, and expose trainees to new alternatives for

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Figure 5: Community Outreach – Residents volunteering at a local magnet school to increase awareness about heart disease.

cultivating wellness. The Mayo Clinic also supports and encourages participation in Employee Resource Groups, which are very active and diverse on campus.

9) Resilience building initiatives – The Mayo Clinic Fellows Association established bimonthly talks in which any employee can voluntarily share a past struggle and how they coped with it. Featured topics include, but are not limited to, personal or family members’ drug addiction, failing important exams during training, dealing with immigration and cultural barriers, death of loved ones, divorce, depression, etc.

While it is common to publicly praise each other’s well deserved successes, wellness is also promoted through sharing failures and how they can be overcome. By seeing vulnerability in others, especially a person who one admires, one can gain perspective on their own struggles. This initiative also aims to create new beneficial mentorship relationships.

Discussion Physicians historically have taken upon themselves the characteristic of invincibility. This mentality has been passed on by generations of physician faculty to trainees. This can be a paradoxical and detrimental reality. While we work to destigmatize mental health conditions to help our patients, physicians often do not apply the same wellness standards to themselves. This is unfortunately reinforced when physicians are required by state medical boards to report mental health histories and treatments to keep active medical licenses, regardless of any associated impairment.23 While the intention

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Figure 6: Soccer – Promoted by the Fellows Association,

trainees play soccer regularly and compete with other teams in the Jacksonville area.

of this practice is aimed at patient safety, it can prevent physicians from seeking the help they need.

Some of the Mayo Clinic wellness initiatives have been in response to the tragic suicide reports from other residency training programs.24 It is important to implement lifelong wellness habits and awareness in medical trainees.

For improved physician wellness and resiliency training, personalizing the approach in medical education should include understanding individual backgrounds, traits and coping mechanisms. The medical community needs to be more proactive going forward, rather than reactive, and to destigmatize getting help when needed.

One of the greatest challenges facing training programs is the lack of faculty awareness or wellness. Without specific leadership and wellness initiatives, this becomes “the blind leading the blind” as most faculty received no wellness training during their own medical education. Thus, wellness initiatives are important for physicians at all levels of seniority, which in turn, will best help future physicians.

Conclusion Well physicians provide better patient care, have fewer medical errors, and receive higher patient satisfaction scores.25 Today’s residents are tomorrow’s practicing physicians and faculty. High physician burnout, depression, and suicidality put an overly burdened healthcare system at risk. It also puts physicians personally at risk of the adverse and dangerous effects of untreated depression. When it comes to residency training, trainees will learn from example. Physicians must be well to teach well. v

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References 1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015 Dec;90(12):1600-13.

2. Ariely D, Lanier WL. Disturbing trends in physician burnout and satisfaction with work-life balance: dealing with malady among the nation’s healers. Mayo Clin Proc. 2015 Dec;90(12):1593-6.

3. Bright RP, Krahn L. Depression and suicide among physicians. Curr Psychiatr. 2011 April;10(4):16-30.

4. Wible P. Physician suicide letters answered. Eugene (OR): Pamela Wible, MD Publishing; 2016. 187 p.

5. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (metaanalysis). Am J Psychiatry. 2004 Dec;161(12):2295-302.

6. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc.

2017 Jan;92(1):129-46.

7. Accreditation Council for Graduate Medical Education.

Physician well-being [Internet]. Chicago (IL): ACGME [cited 2017 Apr 25]. Available from: http://www.acgme.org/ What-We-Do/Initiatives/Physician-Well-Being.

8. Oaklander M. Life/Support: inside the movement to save the mental health of America’s doctors. TIME Magazine. 2015 Sep;186(9-10):42-51.

9. Ripp JA, Privitera MR, West C, et al. Well-Being in Graduate Medical Education: A Call for Action. Acad Med. 2017 Jul;92(7):914-17.

10. Givens JL, Tijia J. Depressed medical students’ use of mental health services and barriers to use. Acad Med. 2002 Sep;77(9):918-21.

11. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depresssed and burnt out residents: prospective cohort study. BMJ. 2008 Mar 1;336(7642):488-91.

12. National Institute of Mental Health. Major depression among adults [Internet]. NIH; 2015 [cited 2017 Jul].

Available from: https://www.nimh.nih.gov/health/statistics/ prevalence/major-depression-among-adults.shtml.

15. Glaser G. Unforunately doctors are pretty good at suicide [Internet]. National College of Physicians, Journal of Medicine; 2015 Aug 15 [cited 2015 Jul]. Available from: https://www.ncnp.org/journal-of-medicine/1601unfortunately-doctors-are-pretty-good-at-suicide.html.

16. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among american surgeons. Arch Surg. 2011 Jan;146(1):54-62.

17. Andrew LB. Physician Suicide [Internet]. Medscape; 2017 Jun 12 [cited 2017 Jul]. Available from: http://emedicine. medscape.com/article/806779-overview.

18. Sargent DA, Jensen VW, Petty TA, et al. Preventing physician suicide. The role of family, colleagues, and organized medicine. JAMA. 1977 Jan 10;237(2):143-5.

19. Yaghmour NA, Brigham TP, Nasca TJ et al. Causes of death of residents in ACGME-accredited programs 2000 to 2014: implications for the learning environment. Acad Med. 2017 Jul;92(7):976-83.

20. L indeman S, Laara E, Hakko H, et al. A systemic review on gender-specifc suicide mortality in medical doctors. Br J Psychiatry. 1996 Mar;168:274-9.

21. Okanlawon T. Physician wellness: preventing resident and fellow burnout: Creating a holistic, supportive culture of wellness [Internet]. American Medical Association and STEPSforward; 2015 [cited 2017 Apr 25]. Available from: https://www.stepsforward.org/Static/images/modules/23/ downloadable/resident_wellness.pdf.

22. Freeman WD, Vatz KA. The future of health care: going to the dogs? Front Neurol. 2015 May 8;6:87.

23. Hill AB. Breaking the Stigma - A Physician’s perspective on self-care and recovery. N Engl J Med. 2017 Mar 23;376(12):1103-5.

24. White T. Surgical residents play hooky to keep healthy [Internet].

Stanford Medicine; 2014 Sep 17 [cited 2017 Apr 25]. Available from: http://med.stanford.edu/news/all-news/2014/09/surgicalresidents-play-hooky-to-keep-healthy.html.

25. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010 Jun;251(6):995-1000.

13. Pratt LA, Brody DJ. Depression in the US household population. [Internet]. Center for Disease Control and Prevention; 2014 Dec [cited 2017 Jul]. Available from: https://www.cdc.gov/nchs/data/databriefs/db172.htm.

14. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry.

1999 Dec;156(12):1887-94.

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Promoting Wellness in Residency Training CME Questions & Answers (circle one answer)/Free to DCMS Members/$55.00 charge non-members* (Return by December 1, 2019 by mail: 1301 Riverplace Boulevard, Suite #1638, Jacksonville, FL 32207 or online: www.dcmsonline.org/NEFMCME)

5. For residents during the years 2000-2014, which of the following is TRUE regarding suicide temporal distribution? a. Resident suicide is lowest during the early years of residency and appears to rise throughout training b. Resident suicide is highest during the early years of residency and is also highest during the first and third quarters of the academic year c. Physician suicide rates decline after completing residency and entering private practice d. Reducing resident work hours has led to a reduced number of resident suicides

1. A s of 2017, it is estimated that the United States loses what number of physicians to suicide yearly? a. 400 b. 300 c. 200 d. 100 2. As of 2014, the published burnout rate of physicians nationally was: a. Greater than 50 percent b. 40-50 percent c. 30-40 percent d. 20-30 percent

6. Which of the following is identified by over 50 percent of physicians with suicidal ideation as one of the main barriers to seeking help? a. Medical licensure concerns b. Lack of time c. Lack of access to care d. Financial burden of paying for services

3. Regarding female physician suicide, which of the following statements is TRUE: a. Attempted suicide rates of female physicians exceed the general U.S. female population b. Completed suicide rates of female physicians exceed the general U.S. female population c. The suicide completion rate is higher among female physicians than male physicians d. All of the above 4. For residents during the years 2000-2014, what were the top two causes of death during residency? a. Accidents and suicide b. Homicide and suicide c. Neoplasm and suicide d. Accidents and neoplasm

8. Of the activities listed below, which are included in arts and humanities strategies for wellness? a. Didactic lectures b. Mixed-media c. Independent study d. Sleep therapy 9. Objectives of arts and humanities strategies for wellness include: a. Self-care b. Increased motivation c. Reduced fatigue d. All of the above 10. Which of the following are reviewed by the authors as strategies to promote resident wellness? a. Pet therapy, arts, humanities b. Access to institutional resources c. Anonymous surveys, monitoring burnout d. All of the above

7. Which of the following is TRUE about the effects of physician burnout? a. Physicians with a higher burnout rate are more likely to make medical errors b. Physician burnout is the same as the U.S. working adult population, when adjusted for age, gender, and hours worked c. Physician satisfaction with work-life balance is improving d. The media has not been reporting on physician burnout

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Mental Health

The Collaborative Core Initiative: A Response to the Child Mental Health Crisis

By Elise M. Fallucco, MD UF Health – Jacksonville

Abstract: One in five children and adolescents in the United States (U.S.) suffer from mental illness, yet, only a minority receive treatment.

The Collaborative Care Initiative (CCI) in Northeast Florida has worked to improve child mental healthcare on a population level by integrating mental health screening and treatment in primary care. Through this initiative, primary care providers participate in: (1) clinical mental health training workshops and (2) a novel child psychiatry consultation clinic to help them co-manage youth with mental health problems (i.e., anxiety, depression, attention deficit hyperactivity disorder). The CCI shows promise to promote early identification and treatment of common child mental health problems, and to improve access to child mental healthcare. Such improved access to child mental health treatment can begin to address the major public health burden of untreated mental illness in youth. Future studies should examine the impact of this model on patient outcomes.

Introduction Childhood mental illness has reached epidemic proportions in the U.S., with an estimated 13-20 percent of youth suffering from mental illness (i.e., ADHD, depression, anxiety, autism spectrum disorders) in any given year. 1-6 Yet, only 20 percent of children and adolescents with mental illness receive treatment. 1,7 Untreated mental health problems in youth can cause major negative outcomes at school, home, and in social situations. 7 The most serious consequence of untreated mental illness is suicide, which is the second leading cause of death in children and young adults in the U.S. 8

adolescent psychiatrists in practice, yet there are at least 15 million children with serious mental health problems. 1,11 Children living in rural areas of the country and youth from low-income families are particularly affected by reduced access to specialty care.10 In Florida, there are roughly seven child and adolescent psychiatrists for every 100,000 children and adolescents.10 In Duval County, there are 5.9 CAPs per 100,000 children.12 Clay County has 4.1 CAPs per 100,000 children and St. John’s County has 14.5 CAPs per 100,000 children.12 There is no child and adolescent psychiatrist in either Putnam or Nassau counties.12 With too few specialists to care for children, many children and families suffer without treatment.

To characterize how the national shortage of child and adolescent psychiatrists affects patients and families, one study team examined the availability of outpatient child and adolescent psychiatric care in five major cities across the U.S.13 Posing as parents of a 12-year-old child with depression, the authors called 312 child and adolescent psychiatrists to schedule a new patient appointment. Appointments were obtained with only 17 percent of the psychiatrists.13 Access to child psychiatry was even more limited for children with Medicaid. The most common barriers to obtaining an appointment were that

Figure 1:

The national demand for child mental health care is staggering and has been projected to continue to increase. 9 However, the national shortage of child and adolescent psychiatrists makes it impossible to meet the demand for child psychiatry services through traditional models of care (Figure 1).10 Nationally, there are roughly 8,300 child and

Address correspondence to: Elise M. Fallucco, MD 580 West 8th Street Tower II, 6th Floor, Suite #6005 Phone: (904) 383-1038 Email: elise.fallucco@jax.ufl.edu DCMS online . org

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psychiatrists were not accepting new patients and/or were not in-network with the patient’s mental health insurance. Those patients who were able to access care had to wait an average of 43 days for the first available appointment.13 Families in North Florida face similar problems with limited access to CAPs. In the words of a local patient’s father: “My son is very sick and we want to get him help… but every place we called told us they are either not accepting new patients, or we would have to wait 2-3 months for an appointment. We cannot wait that long – we need help now!”

Pediatricians, child psychiatrists, and pediatric psychologists in North Florida have worked to transform the current system of mental health care through the Collaborative Care Initiative (CCI). The CCI created a partnership with over 120 local primary care providers from over 20 practices in Duval, St. Johns, and Clay counties, and a team of child and adolescent psychiatrists and pediatric psychologists to improve access to mental health care for children. One of the main goals of the CCI is to provide clinical training for primary care providers to adequately screen, diagnose and treat at-risk youth. Through the CCI model, PCPs participate in clinical workshops where they are given strategies and tools to care for patients with less complicated cases of mental illness in the primary care setting.

Trained PCPs learn to identify early signs of mental health problems, and to determine patient- and family- centered treatment plans for attention deficit hyperactivity disorder (ADHD), depression, and anxiety. PCPs are given clinical resources (i.e., screening tools, psychotropic medication dosing strategies, and clinical algorithms), as well as local referral information. Providers are challenged to practice these clinical skills during the trainings, and receive real-time feedback about communicating with families about mental health problems.

Results CCI clinical training improves adolescent depression identification in primary care In a 2015 study conducted by the CCI team, PCPs (n=31) from across Northeast Florida who participated in CCI training demonstrated significant improvement in screening adolescent patients for depression.14 Prior to training, around half of the adolescent patients (49 percent) seen at wellvisits reported being screened for depression by their PCP.14 Two months after training, depression screening increased significantly to 68 percent of the adolescents patients seen at well-visits. This improvement was maintained up to two years following training with 74 percent of adolescent patients screened at well-visits (p<0.001).14 Now, with over 120 PCPs properly trained in North Florida, many adolescents with mild-to-moderate severity depression are identified and treated by their PCP. PCPs have valued the training, and one of the CCI PCPs commented, “Our entire practice found that the depression training was very helpful! We now all use the [depression screening tool] at well-visits – it is short and easy for patients to fill out. It helps us target in who needs to be referred.”

CCI Consultation Clinic improves access to CAP care The CCI team studied the impact of the CCI consultation clinic by following the first 81 patients (mean age = 12.1 ± 3.6 years) referred to the CCI clinic.15 Families were able to be seen for an initial CAP consultation appointment within

Figure 2:

Once primary care providers participate in CCI clinical training, they are eligible to refer more complicated patients for evaluation by a child and adolescent psychiatrist through the CCI Psychiatric Consultation Clinic. This collaborative model is truly unique from the traditional model (Figure 2) in that it allows primary care providers to co-manage mental health problems using recommendations from a partnering child and adolescent psychiatrist. The CCI psychiatrist provides a one-time face-to-face, outpatient consultation with evaluation and treatment recommendations communicated to the referring PCP. Then, youth can be seen for up to three additional visits, with the plan to transfer the youth’s longterm management back to the referring PCP. 38 Vol. 68, No. 4 2017 Northeast Florida Medicine

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an average of 18 ± 11 days. 15 At this initial consultation, patients were commonly diagnosed with anxiety (57 percent), attention deficit hyperactivity disorder (ADHD) (53 percent), and depression (39 percent). 15 Over half (57 percent) of the patients seen for consultation were discharged back to their PCP after a few appointments with the CAP.16 Only a small minority (10 percent) of patients required long-term care by a psychiatrist due to the severity of their mental illness. 15 The remainder of the patients were still in the process of consultation (12 percent) or did not follow-up with the clinic (20 percent). 15 Since the majority of patients in the CCI returned to the care of their PCP, the consulting psychiatrists maintained ongoing availability for new patient consultations. This collaborative approach allowed more children to receive mental health care by efficiently using the team of PCPs and psychiatrists.

Discussion The CCI team has established an integrated network of pediatricians, child psychiatrists, and pediatric psychologists to improve mental healthcare for children in Northeast Florida. Recent studies show that the CCI model has helped to improve early identification and treatment of adolescent depression in primary care. In addition, the CCI consultation clinic has helped to improve access to child mental health care. The CCI model shows promise to meet the needs of children, families, primary care providers, and child and adolescent psychiatrists alike.

• Early identification and treatment of child mental health problems: The CCI estimates more than 25,000 adolescents in Northeast Florida are screened for depression and suicide risk each year.16 Once identified, these children can receive early intervention before their symptoms progress. Such early intervention has the potential to reduce the morbidity and mortality associated with mental illness in youth.

• Improved access to child mental health care: Patients and families can receive treatment for mental health problems from their trusted primary care provider. If needed, patients have expedited access to child psychiatric consultation through the CCI Psychiatric Consultation Clinic. The average wait time for an initial CCI consultation (18 days)15 was much less than what has been reported in other community studies (43 days).13

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• Coordination of physical and mental health care: In the traditional system of healthcare, there is often a lack of communication between primary care and mental health providers. In the author’s experience, many primary care providers have expressed concern that, in the past, they had rarely received copies of progress notes and evaluations from their patients’ mental health providers. This made it difficult for them to understand what medications and psychotherapy their patients were receiving, and if/ how it was helping them. In the CCI, PCPs and child psychiatrists coordinate physical and mental health care and share relevant documents so that all providers are aware of the patient’s ongoing treatment plan.

• Improved mental health care in primary care: PCPs build their skills in caring for children with mental health problems through a combination of formal mental health clinical trainings and individual patient consultations. The CCI enables PCPs to build skills to care for more children with mild-to-moderate severity mental health problems.

Conclusion Ultimately, the CCI model is one practical way to improve access to mental health on a population level. By leveraging the sheer number and expertise of primary care providers, more children and adolescents with mental health problems can receive treatment.

In short, the CCI model shows promise to promote early identification and treatment of child mental health problems, and to also improve access to child mental healthcare. Given the major public health problem of untreated mental illness in youth, the CCI model should be considered for adaptation and dissemination to other communities. With the expansion of the CCI model, many more children and adolescents with mental health problems would have the potential to receive timely treatment. If successful, the CCI model could help prevent the long-term consequences of under-identified, untreated mental health problems. v

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Acknowledgements: None of this work would have been possible without generous grants from the Partnership for Child Health, the Jacksonville Children’s Commission, the Substance Abuse and Mental Health Services Administration, the Hall-Halliburton Foundation, Nemours Children’s Healthcare, and Wolfson Children’s Hospital. The author would like to thank Peggy Greco, PhD and the reviewers for their editorial suggestions; and Valentina Bolanos, MPH and Kitty Leung, MD, for their assistance with manuscript preparation.

For more information on the Collaborative Care Initiative, please visit our website at: http://partnershipforchildhealth.org/collaborative-care/

References

8. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS) [Internet].

Atlanta (GA): 2017 [cited 2017 Apr 10]. Available from: https://www.cdc.gov/injury/wisqars/leadingcauses.html.

9. US Health Resources and Services Administration. Bureau of Health Professions. HRSA State Health Workforce Profiles.

Rockville (MD): Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Health Resources and Services Administration, DHHS; 2000.

10. Thomas CR, Holzer CE. The continuing shortage of child and adolescent psychiatrists. J Am Acad of Child Adolesc Psychiatry.

2006 Sep 17;45(9):1023–31.

1. Centers for Disease Control and Prevention. Mental health surveillance among children- United States, 2005–2011.

MMWR 2013;62 (Suppl; May 16, 2013):1-35.

11. American Medical Association. Physician Characteristics and Distribution in the U.S. Chicago (IL): American Medical Association, 2013.

2. National Research Council and Institute of Medicine.

Preventing mental, emotional, and behavioral disorders among young people: progress and possibilities. Washington (DC): The National Academic Press; 2009.

12. American Academy of Child and Adolescent Psychiatry.

Workforce maps by state [Internet]. Washington (DC): 2017 [cited 2017 Apr 10]. Available from: http://www.aacap.org/ aacap/Advocacy/Federal_and_State_Initiatives/Workforce_ Maps/Home.aspx.

3. Angold A, Erkanli A, Farmer EM, et al. Psychiatric disorder, impairment, and service use in rural African American and white youth. Arch Gen Psychiatry. 2002 Oct;59(10):893–901.

4. Merikangas KR, He JP, Brody D, et al. Prevalence and treatment of mental disorders among U.S. children in the 2001–2004 NHANES. Pediatrics 2010 Jan;125(1):75–81.

5. World Health Organization. Mental health: a state of wellbeing. [Internet]. Geneva, Switzerland: 2011 [cited 2017 Aug 23] Available from: http://www.who.int/features/factfiles/ mental_health/en/index.html.

6. National Institute of Mental Health. Any disorder among children [Internet]. Maryland: 2017 [cited 2017 Apr 10].

Available from: https://www.nimh.nih.gov/health/statistics/ prevalence/any-disorder-among-children.shtml.

7. U.S. Department of Health and Human Services. Mental health: A report of the surgeon general. Rockville (MD): U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999. 487 p.

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13. Cama S, Malowney M, Smith AJB, et al. Availability of outpatient mental health care by pediatricians and child psychiatrists in five US cities. Int J Health Serv. 2017 Jan 1: 20731417707492.

14. Fallucco EM, Seago RD, Cuffe SP, et al. Primary care provider training in screening, assessment, and treatment of adolescent depression. Acad Pediatr. 2015 Mar 29;15(3):326-32.

15. Fallucco EM, Blackmore ER, Bejarano CM, et al. Collaborative care: A pilot study of a child psychiatry outpatient consultation model for primary care providers. J Behav Health Serv Res. 2016;44(3):386-98.

16. Partnership for Child Health. Collaborative care initiative: a partnership between pediatrics and psychiatry [Internet].

Jacksonville (FL): 2017 [cited 2017 Aug 23]. Available from: http://partnershipforchildhealth.org/collaborative-care/.

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Mental Health

The Medical-Behavioral Health Home: A Case Study

By Jeffrey L. Goldhagen, MD, MPH and Jennifer Peace, RN University of Florida College of Medicine-Jacksonville

Abstract: Twenty percent of children in any given year will experience a mental illness.1 Advances in understanding of the impact of pediatric mental health conditions and trauma on early brain development,2 and the effects on child and adult mental health and well-being,2 make it increasingly important that society address children’s mental health.

The paucity of child mental health professionals in the United States has established the need for pediatricians to care for these children as a critical priority. Innovative systems of care and approaches to the integration of behavioral health services into pediatric primary care are being developed nationally to help meet this need for pediatric mental health care. The University of Florida Pediatric Wellness Center (PWC) that establishes an interdisciplinary Medical Home for children with complex mental health conditions is one such model that is demonstrating success in the care of these children.

Introduction Among Duval County’s 275,000 children under 18 years of age, an estimated 55,000 experience a mental health illness in any given year, and 21,000 have a form of a severe emotional disorder (SED).3 In the United States, relatively few children with mental health conditions receive treatment. 1 In Northeast Florida, fewer than 50 percent of this population receive care.4 Studies suggest that up to 80 percent of children in foster care are at risk or have significant mental health issues, compared to 18-22 percent of children in the general population. 5 The American Academy of Pediatrics Healthy Foster Care American Initiative identifies mental and behavioral health as the “greatest unmet health need for children and teens in foster care.”6 Sentinel indicators for monitoring the regional epidemiology of SED reveal that suicidal ideations and attempts among middle and high school students are increasing substantially in Duval County. 7 An

Address correspondence to: Jeffrey Goldhagen, MD, MPH University of Florida College of Medicine-Jacksonville 841 Prudential Drive, Suite #1330 Jacksonville, FL 32207 Phone: (904) 383-1713 Email: Jeffrey.Goldhagen@jax.ufl.edu 42 Vol. 68, No. 4 2017 Northeast Florida Medicine

estimated 70 percent of youth arrested have some degree of SED7 and more than 1,000 children are admitted annually to crisis stabilization units in the region—with the largest increases among children less than five years-old. (Table 1) In response to this status quo and with funding from the federal Substance Abuse and Mental Health Services Administration (SAMHSA), the Duval County community successfully implemented a six-year initiative to implement a system of care for children’s mental health (2010-2016).

The system of care initiative focused on the mental health conditions of at-risk populations of children. Systems of care were established for these children and families that ensured they were culturally and linguistically relevant, youth and family guided, evidence-based and provided care in the least restrictive environment. Intense “wraparound” services were implemented to support the most severely affected children, and hundreds of providers were trained in trauma-informed and new approaches to care.

Based on the success of this initiative, Jacksonville was awarded sustainability funding to advance innovative approaches using the development of integrated MedicalBehavioral Health Homes to address the critical mental health needs of children and the dearth of professionals to care for them.

Informed by the success of the University of FloridaWolfson Children’s Hospital Bower Lyman Center, which cares for children and young adults with complex medical conditions from birth through age 26, and with ongoing support from SAMHSA, an innovative Medical-Behavioral Health Home for children with complex mental and behavioral health conditions was established as a model for the holistic care of these children and families. In partnership with Wolfson Children’s Hospital (WCH), the University of Florida established the (UF) Health Pediatric Wellness Center (PWC) as a new approach to the care of some of the most vulnerable children and youth in Northeast Florida.

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Mental Health Table 1: Baker Acts by Age and Number of Admissions

The following table of crisis stabilization unit admissions (Baker Act) was generated from local data from the Baker Act facilities.

Age

Number

Avg Stay

1 Adm

2 Adm

3 Adm

4 Adm

5 Adm

5

1

4.00

1

6

10

3.10

8

2

7

14

1.64

13

1

8

18

3.89

15

2

9

24

4.54

19

3

10

34

9.74

25

4

3

11

25

6.68

17

5

2

12

55

6.02

37

8

6

2

13

89

4.11

75

6

4

3

14

6

14.00

2

1

1

15

120

4.05

100

16

2

1

1

16

161

6.32

122

22

9

5

1

17

139

4.09

117

16

5

18

96

5.47

83

9

2

2

19

4

4.25

6 Adm

7 Adm

8 Adm

1 1

1

1

1 1 1

1 1

2 2 1

3

1

Total Youth

637

96

34

15

8

5

0

1

796

Total Admissions

637

191

100

60

32

30

0

8

1058

What is a Medical-Behavioral Health Home?

The Agency for Healthcare Research and Quality (AHRQ) defines integrated health and behavioral health services as, “The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.

This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stressrelated physical symptoms, and ineffective patterns of health care utilization.”8 The SAMHSA-HRSA (Health Resources and Services Administration) Center for Integrated Health Solutions identifies six levels of collaboration-integration: Minimal Collaboration, Basic Collaboration at a Distance, Basic Collaboration Onsite, Close Collaboration Onsite with Some System Integration, Close Collaboration Approaching an Integrated Practice, and Full Collaboration in a Transformed/ Merged Integrated Practice.9 (Table 2) It is important to note that integration occurs along a continuum.10,11,12 While Level 6 integration is ideal, it is not currently feasible for most practices to achieve, due to the DCMS online . org

resources and expertise required. What is critical, though, is that mental and behavioral health services be available, accessible and integrated. The Collaborative Care model described by Fallucco in this issue of Northeast Florida Medicine is an example of Level 2 collaboration that has proven successful as a community-wide systems approach to medical-behavioral health integration.13 The PWC, described in the following section, is an example of a hybrid Level 2 and 5 practice, which sees far fewer patients than a traditional pediatric practice, but cares for children who need far more intense care for their mental health conditions.

The UF Health Pediatric Wellness Center - Prudential Over the past decade, the care of children with complex medical conditions has received increasing attention. This focus has been driven by the recognition that five percent of children with complex and chronic health conditions generate the majority of pediatric health care costs.14 Multiple models to care for these children have been developed and studied, including one at the University of Florida-Wolfson Children’s Hospital Bower-Lyman Center for Children with Complex Health Conditions. The Bower-Lyman Center Northeast Florida Medicine Vol. 68, No. 4 2017 43

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model includes linkage to community-based palliative and hospice care provided through Community Hospice and Palliative Care’s (formerly Community Hospice of Northeast Florida) Community PedsCare program.

Building on the experience of the Bower Lyman Center’s care of children with complex medical conditions, and the system of care developed with the support of the initial SAMHSA funded System of Care Initiative, a subsequent proposal was submitted to SAMHSA in 2015 to develop a Medical-Behavioral Health Home for children with complex mental health conditions. Thus, the PWC was born as a collaboration between UF, WCH, the Partnership for Child Health and several community-based mental health providers. Co-located with the new WCH Children’s Center for Behavioral Health, and staffed by a pediatrician, nurse and social worker, the PWC has established a unique and innovative approach to integrating medical and mentalbehavioral health care for the most vulnerable children in the

Duval County community. The PWC is focusing initially on children being released from crisis stabilization units (Baker Act facilities) and will soon expand care to other high-risk populations of children and adolescents.15 The following case studies provide insight to the challenges many children and families are confronting with access to care for mental and behavioral conditions for their children.

Case Study 1 The patient is a 9-year-old male diagnosed with attention deficit and hyperactivity disorder (ADHD), anger, and disruptive mood dysregulation disorder (DMDD) referred to the UF Health Pediatric Wellness Center by SEDNET (the severely emotionally disturbed network). The patient has a history of five Baker Act admissions, the most recent of which was three months prior to his first appointment at PWC, when he became angry, threatened self-harm, and attempted to jump from a third-floor window.

The patient has a history of self-harming behaviors (e.g., cutting

Table 2: Six Levels of Collaboration/Integration in a Medical-Behavioral Health Home. Adapted from Reference 9 Coordinated Care  Level 1 — Minimal Collaboration Behavioral health and primary care providers work at separate facilities and have separate systems.

Providers communicate rarely about cases. When communication occurs, it is usually based on a particular provider’s need for specific information about a mutual patient.  Level 2 — Basic Collaboration at a Distance Behavioral health and primary care providers maintain separate facilities and separate systems. Providers view each other as resources and communicate periodically about shared patients. These communications are typically driven by specific issues. For example, a primary care physician may request copy of a psychiatric evaluation to know if there is a confirmed psychiatric diagnosis. Behavioral health is most often viewed as specialty care.

Co-Located Care  Level 3 — Basic Collaboration Onsite Behavioral health and primary care providers co-located in the same facility, but may or may not share the same practice space. Providers still use separate systems, but communication becomes more regular due to close proximity, especially by phone or email, with an occasional meeting to discuss shared patients. Movement of patients between practices is most often through a referral process that has a higher likelihood of success because the practices are in the same location. Providers may feel like they are part of a larger team, but the team and how it operates are not clearly defined, leaving most decisions about patient care to be done independently by individual providers.  Level 4 — Close Collaboration with Some System Integration There is closer collaboration among primary care and behavioral healthcare providers due to colocation in the same practice space, and there is the beginning of integration in care through some shared systems. A typical model may involve a primary care setting embedding a behavioral health provider. In an embedded practice, the primary care front desk schedules all appointments and the behavioral health provider has access and enters notes in the medical record. Often, complex patients with multiple healthcare issues drive the need for consultation, which is done through personal communication. As professionals have more opportunity to share patients, they have a better basic understanding of each other’s roles.

Integrated Care  Level 5 — Close Collaboration Approaching an Integrated Practice There are high levels of collaboration and integration between behavioral and primary care providers. The providers begin to function as a true team, with frequent personal communication. The team actively seeks system solutions as they recognize barriers to care integration for a broader range of patients. However, some issues, like the availability of an integrated medical record, may not be readily resolved. Providers understand the different roles team members need to play and they have started to change their practice and the structure of care to better achieve patient goals.  Level 6 — Full Collaboration in a Transformed/Merged Practice The highest level of integration involves the greatest amount of practice change. Fuller collaboration between providers has allowed antecedent system cultures (whether from two separate systems or from one evolving system) to blur into a single transformed or merged practice. Providers and patients view the operation as a single health system treating the whole person. The principle of treating the whole person is applied to all patients, not just targeted groups.

44 Vol. 68, No. 4 2017 Northeast Florida Medicine

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and biting himself ), violence against his siblings and classmates, and being destructive at home. With the most recent Baker Act, the patient was started on Concerta ER 36 mg, Seroquel 50 mg, and Intuniv 1 mg, and discharged after four days. The patient had seen PSI Behavioral Health for counseling in the past, but was discharged from their service due to missed appointments.

Upon receiving the referral, lack of transportation was identified as a barrier. The social worker arranged transportation for the appointment. On exam, the patient was stable and without suicidal-homicidal ideation. The patient’s mother reported that he had been taking all of his medications since discharge from the Crisis Stabilization Unit (CSU) three months ago, and only “just ran out” of the medications. The mother was interested in medication management, though there was concern for medication non-compliance, given that the CSU typically only provides a 30-day supply of medication, and the patient was last seen 90 days ago.

The medications were refilled with future medication management provided by the Pediatric Wellness Center.

The patient was referred to Daniel Kids’ therapeutic behavioral on-site service (TBOS). Wrap-around services and care coordination were initiated. A one-month follow up appointment at Pediatric Wellness Center was scheduled.

Case Study 2 The patient is an 8-year-old female referred to the UF Health Pediatric Wellness Center for a seven-day post-CSU follow-up appointment. The patient was admitted to the CSU for concerns of psychosis. She reported hearing voices telling her “bad things.” Her parents reported compulsive behaviors such as watching where she steps and frequent handwashing.

The patient was treated for strep throat two weeks prior to CSU admission. At the CSU, the patient was diagnosed with pediatric autoimmune neuropsychiatric disorders (PANDAS) with obsessive compulsive disorder (OCD) and was started on Zoloft 25 mg. [There is a hypothesis that a subset of children with rapid onset of obsessive-compulsive disorder (OCD) or tic disorders exists that are caused by group A beta-hemolytic streptococcal (GABHS) infections.]16 On exam, the patient was diagnosed with a viral upper respiratory tract infection (URI) and education was provided on supportive care. The patient reported hearing voices telling her that if something gets into her mouth it would kill her. She stated that the voices make her feel afraid. She reported that the

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voices do not tell her to hurt herself or anyone else. The patient had experienced no side effects with Zoloft, and education was provided that it takes several weeks for the medicine to begin to be effective in the treatment of her OCD. Concern for ongoing voices, though unchanged, poses a risk of self-harm and an increase in the patient’s anxiety. Urgent referral was made for outpatient psychiatric care and therapy at Wolfson Children’s Center for Behavioral Health. A safety plan was created and reviewed with the patient and her mother.

Care coordination was provided to assist the patient’s mother in establishing insurance for the patient. Northeast Florida Legal Aid referral was submitted due to the mother’s concerns with immigration status. A follow-up appointment with the Pediatric Wellness Center was scheduled for three weeks for re-evaluation and medication management.

Case Study 3 The patient is a 14-year-old female with depression and attention deficit and hyperactivity disorder (ADHD) presenting to transition care to UF Health Pediatric Wellness Center from patient’s PCP. The patient had been on Prozac 10 mg for one month.

On exam, the patient reported being depressed and cutting herself following her grandfather’s death a few months ago and a recent break-up with her girlfriend. She reported multiple stressors including discord with her biological father, cyber-bullying related to her sexual orientation, and poor grades in school. The patient denied suicidal-homicidal ideation and expressed interest in taking medication and participating in therapy.

The patient reported no side effects with Prozac and her dose was increased to 20 mg PO daily. Depression and SSRI use was discussed. Per the patient’s mother, the patient had trials of Strattera, guanfacine and Vyvanse for her ADHD three years ago, but discontinued all meds because they unmasked a tic disorder and Tourette’s. A referral was made to PSI Behavioral Health for psychiatry to optimize ADHD management that would not worsen tics/Tourette’s. A referral was also made for therapy through grief counseling with Hope and Healing Center and to Daniel Kids’ for wraparound services. She was also referred to the Jacksonville Area Sexual Minority Youth Network (JASMYN) for support. She was then scheduled for a one-month follow-up appointment with Pediatric Wellness Center or sooner, if needed.

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Mental Health

Conclusion The PWC combines the principles of the Medical Home with those of medical-behavioral health integration to establish a unique approach to the care of a vulnerable population of children. Children with behavioral health conditions receive holistic care that includes physical and mental health services from providers who are knowledgeable and compassionate in an environment that is respectful and nurturing. Though it is early in the development and implementation of the model, anecdotal evidence indicates that CSU readmissions are decreasing. The three case studies reflect the compelling necessity to respond to the often-times overwhelming needs of these children and families.

The PWC applies a clinical-systems approach to ensure the most effective outcomes are achieved most efficiently for the greatest number of children. Access to psychiatry and psychotherapy must be assured in order to address these children’s mental health conditions. Case management and care coordination is critically important to ensure care is optimized and fully integrated. Based on experience with the care of children with complex medical conditions, it is anticipated that both improved outcomes and cost efficiencies for these children will be demonstrated. Rigorous evaluation will enable the knowledge and experience gained through the development and implementation of the Pediatric Wellness Center to inform local and national efforts to advance integrated health-mental solutions for the care of children with complex mental health conditions. v

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