Childhood Mental Health Strategies for Rural NYSPresentation Transcript
Childhood Mental Health: Strategies for Rural NYS 9/10/07 Thomas C. Rosenthal MD Director: NYS AHEC System Editor: Journal of Rural Health Professor and Chair UB Dept of Family Medicine
1. Making the Diagnosis
Requires team of family, school, primary care physician and patient.
PCPs diagnose psycho-social problems in 19% of visits. (Koppelman, 2004)
Specialty consult obtained for 50% of these cases.
2. Urgent Care
Usually the primary care office or the ER.
3. Continuity and maintenance care.
Requires integration of family, school, primary care physician, mental health specialty support.
Rural Pediatric Mental Health Visits
5% of child ER visits are for MH (rural ~ urban).
10% of psychiatric ER visits are children. (Hartley, 2005)
Childhood mental health ER visits 102%. (Shah, 2006)
Only 1 in 5 children receive definitive care. (Rosenkranz, 2006)
Rural adolescent rates of anxiety, depression, thought problems, attention problems, delinquency, substance abuse and aggressive behavior are equivalent. (Hartley, 1999)
Suicide is higher in rural America. (Hartley, 1999)
Only 79% of Rural US Counties have mental health services. (Hartley, 1999)
Agricultural Worker’s Need Needs somewhat unique to farming Source: American Farm Bureau Strategy : Problem: Reducing stigma, education. Lack of knowledge of mental health problems. Crisis services. Access to firearms. Access to recovery programs. Alcohol, prescription drug misuse. Build professional networks Poor problem solving, rigidity, change. business and family management resources. Business Pressures Markets, regulatory, climatic
Solutions: Integrated Care (PCP)
Mental Health Care in Primary Care
Mental and physical health are indivisible.
50% of patients refuse referral. (Olfson, 1991)
PCPs deal with mental symptoms as part of a larger, more general problem:
Mental symptoms are concentrated in patients who visit their PCP for other reasons.
Mental health symptoms are imbedded in a matrix of physical symptoms.
The Rural PCP remains “stuck” with difficult patients .
Limited opportunity for “passing” the patient onto specialty care. (Farley, 1998)
Disease and Illness Disease The Broken Part Illness Feelings Ideas Function Expectations (Stewart, 1995; Rosenthal, 2007)
Bio-physiological Mechanism Primary Care Model of Disease Heterogeneous neuroendocrine-immune dysfunction Stress Trauma Predisposition Infection Inflammation Pain Aberrant central pain mechanism Fatigue Depression/Anxiety Poor sleep Fatigue Mental stress Physical deconditioning Sympathetic Activity Trauma Environmental stimuli Poor posture
Why Primary Care? (PCP)
“ Distress” brings patients into the PCP Office
An emotion that may arise out of physical or mental trigger.
10-20% of people visit a PCP for a mental health problem each year.
26% have a DSM diagnosis. (deGruy, 1996)
50% of high utilizers have significant distress.
8-15% of PCP Pediatric contacts are for psycho-social problems. (Costello, 1987)
Team Care is inherent to Primary Care. (Rosenthal, 2001)
Why Primary Care? (PCP)
Americans accept the inter-relationship of mind and body more than clinicians. (Wolsko, 2004)
88% of patients accept management of mental illness by their primary care physician. (Smith, 2003)
Patients expect their PCP to facilitate referrals and consultations. (Rosenthal, 1991)
Patients expect PCPs to continue participation in their care after referral. (Rosenthal, 1996)
Solutions: Expand the Team
Advance Practice Psychiatric Nurses:
Clinical outcomes of high quality.
Both diagnosis and treatment (Merwin, 1995)
Licensed with prescription authority in NYS.
Their holistic framework is essential for rural practice.
9.6% of NY’s APPNs practice in rural NY. (Hartley, 2004)
8% of NYS is considered rural.
There are 40 APPNs in rural NYS as of 2004.
Most training programs do not include rural experiences. (Hartley, 2004)
Integrate Care: Examples Chevy Version
Bag Lunch Model:
Letchworth Family Medicine, Perry, NY
Established in 1978 as a solo (fee-for-service) practice.
Now has 3 Family Physicians and 2 NPs.
Friday noon lunch in PCP office:
The physicians, NPs and nursing staff.
Clinical psychologists, MHSWs from county mental health office and private practices in county.
Agenda: 1) referred cases, 2) problem cases, 3) medically complicated cases, 4) un-referrable cases.
Enhanced number of referrals, fewer visits per referral, greater patient satisfaction, greater professional comfort. (Rosenthal, 1990)
Integrate Care: Examples Buick Version
Tount, Texas (Federally Qualified Health Center est 1993.)
Step 1 : Established grant funded Family violence intervention program.
New York State AHEC System www.AHEC.buffalo.edu AHECs: Brooklyn AHEC, Brooklyn Bronx AHEC, Bronx Catskill-Hudson AHEC, New Palz Central NY AHEC, Cortland Erie Niagara AHEC, Buffalo Hudson-Mohawk AHEC, Glens Falls Manhattan/Staten Island AHEC Northern AHEC, Potsdam Western New York Rural-AHEC, Warsaw Regional Offices : 1998 Statewide Office, UB 1999 Central Region Office, Upstate Med. Univ. 2000 Eastern Region Office, Albany Med. Col. 2000 NY Metropolitan Region Office, The Institute for Urban Family Health AHEC Districts
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Suicide Rates in Rural America
NY Times article:
Social Isolation, Guns and a Culture of Suicide. February 13, 2005.
Byline: Fox Butterfield.
“Americans in small towns and rural areas are just as likely to die from gunfire as Americans in Major cities. The difference is in who does the shooting.”