Teen Depression Screening

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Incorporating Mental Health Check-Ups Into Adolescent Primary Care Visits.

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  • Introduction of TeenScreen Primary Care Teen mental illness and suicide are significant and prevalent problems for adolescents. One in ten American children suffer from mental illness, but only 2/3 of them get the help that they need. Further, suicide is the third leading cause of death for youth ages 11-18 in our country. Mental health checkups are a routine screening test for adolescent patients that can quickly identify underlying mental health problems that may be undiagnosed, contributing to physical symptoms or creating risk for harmful behaviors (drug, alcohol abuse or suicide). The way these checkups work is by having patients complete a brief validated screening questionnaire that can alert the child’s primary care provider if that patient may be suffering from mental health problems – screening can easily be incorporated into regular healthcare visits for adolescent patients. TeenScreen Primary Care is a mental health checkup initiative being offered through the TeenScreen National Center for Mental Health Checkups. This presentation will review how to incorporate mental health check-ups into routine adolescent office visits, as part of a comprehensive approach to healthcare.
  • Columbia University’s model for providing mental health checkups to adolescent patients gives doctors and medical professionals evidence-based practices and tools to screen adolescent patients for mental illness and suicide risk. Columbia University makes tools, materials and resources available to providers who are interested in implementing mental health check-ups for 11-18 year old patients at no cost. Mental health checkups through screening are becoming a standard of care in medicine and are being recognized at the national level. The AAP calls for and supports confidential screening and referral for behavioral and mental health problems in patients, one of the many groups who support screening. SAM supports the early identification of mental illness as a critical standard of care Mental health check-ups are a quick and easy way for medical providers to evaluate teen patients for potential mental health problems and concerns. Screening can be incorporated into a number of regular visits with adolescent patients, like well child visits, sports or regular health physicals, sick visits, etc. The primary focus of mental health checkups is three-fold: The early identification of mental illness Suicide prevention And, the piece that takes that identification one step further – not only identifying those who may be at-risk for mental illness and suicide, but to also linking them and their families with appropriate services or help. In other words, it is not just the process of completing a questionnaire, but also providing options for how to assist patients and their families once they are identified as being at possible risk.
  • In order to begin thinking about how this process may work best for you, there are a few things that it will be helpful to consider as you prepare to implement mental health checkups in your practice. The points on this slide highlight some of the logistical pieces that will be helpful to consider as you think about mental health checkups and how they might work in your setting. Determining when and to whom screening will be offered and administered Establish a referral network and develop a list of providers to share with families of patients who receive a referral Discuss how the questionnaire will be administered and scored and how the results will get into the hands of the PCP Where will the post-screening interview/ exam be conducted Who will notify parents of the screening results, assist families in need of a referral and activate the referral process. Columbia University also has other tools and supportive materials to provide additional supports in the implementation of screening, available at your request.
  • This section provides an overview of the screening questionnaire, the Pediatric Symptom Checklist (PSC-Y).
  • PSC-Y The Pediatric Symptom Checklist, Youth Completion version, was developed by clinicians at Harvard University. It is a 35-item self-report that identifies patients at-risk for psychosocial dysfunction and has questions that cover attention, externalizing and internalizing problems. In addition to the 35 items, there are two items from the Columbia Suicide Screen that ask specifically about suicidality. Takes less than 5 minutes to complete and score. PSC is a very widely used questionnaire and has been validated for use in pediatric primary care settings. Administering the PSC-Y It is recommended that the questionnaire is administered and scored before the patient’s exam with the PCP to ensure that once the patient takes the questionnaire, their results are reviewed by the doctor. The questionnaire can be administered during the office visit and can be scored by a nurse, med technician or other office staff. Recommended that patients are left alone in a private location to complete the questionnaire (to ensure that they feel comfortable answering the questions honestly) and that they are informed of their rights to confidentiality. It’s also a good idea to inform parents that a mental health checkup will be administered as part of their child’s regular exam.
  • Here is a sample of the PSC. There are 35 items, each item has 1 of 3 answer choices, (never, sometimes and often). You will also notice that toward the bottom of the screen, the 2 questions that focus on suicidality. Previous research has shown that there is a 14-20% screen positive rate (just to give you a general idea of what to expect). There also a little space on the bottom to write in the total score, comments and also to record the recommended next steps for that particular patient.
  • Each of the rankings (never, sometimes and often) are assigned a number value to help calculate the score (0, 1, 2). To calculate the score of the questionnaire, you add all of the item scores together (which will give you a range 0-70). For the purposes of scoring, you should note if either suicide question has been endorsed. You should also note if any items are left blank. If any of the 35 items are left blank, they are scored as 0, however if 4 or more items are left blank, the questionnaire is considered invalid. If either of the suicide questions are left blank, the PCP should address this in their post-screening interview with the patient.
  • An overall score that is greater than or equal to 30, or endorsement of either suicide question, defines a positive score. Previous research has shown that there is a 14-20% screen positive rate on the PSC (without the suicide questions; just to give you a general idea of what to expect).
  • A positive score on the PSC-Y suggests the need to further evaluate the patient to further assess the symptoms reported on the questionnaire to determine if they are significant, causing impairment and warrant a referral for further evaluation or treatment. The results of the PSC-Y are not meant to be a diagnosis – both false positives and false negatives can occur, which underscores the importance of the post-screening interview with the PCP, with all patients. Studies on PSC-Y show that 2 out of 3 teens who score positive are correctly identified as having moderate to serious impairment 96% accuracy on negative screens (1 out of 20 teens who score negative may be impaired)
  • This slide highlights the main problem areas addressed by the PSC-Y and the most critical items associated with them. If a patient scores positive and their answers are weighted toward one problem area, it suggests the need to further evaluate the patient for disorders commonly associated with that problem area. Symptoms reported on the PSC-Y as “often” are of greatest significance. PSC-Y also contains questions about functioning and impairment, which should also be reviewed with the patient. It is recommended that the PCP also briefly reviews the symptoms endorsed as “sometimes” and “often” with patients that score negative.
  • Once the provider has reviewed the results of the PSC-Y, it is recommended that they conduct a post-screening interview as part of the patients exam to discuss the results of screening.
  • It is suggested that the results of the screening are discussed with all patients as part of their exam, regardless if their score is positive or negative. Patients that score positive on the questionnaire are briefly evaluated by the PCP to explore symptoms endorsed on the questionnaire, including those related to functioning and impairment (to determine level of impairment caused by symptoms at school, at home or with peers). This discussion with the patient should focus on the main areas of concern identified by the screen. It may be helpful to see if the answers cluster by internal, external or attention problems. It is recommended that you inquire about suicidal thoughts and behaviors with all patients that score positive. Parent Notification & Referral It is recommended that the PCP provides feedback to the parents regardless of the screening results. For those who are identified as positive, we recommend informing parents of the positive results, clinical recommendations, suicidal thinking or any suicidal behavior reported. You may want to educate parents about their children’s mental health needs to underscore the importance of obtaining appropriate services. When a referral is recommended, staff should assist the family with connected to a local mental health provider, who can provide a complete mental health evaluation. In addition, it is recommended that you pull together a list of referral resources to share with parents who receive a referral for their child. TeenScreen has additional materials and tools to assist with conducting the post-screening interview, including a suicide risk assessment, checklist and sample questions by symptom area and with notifying parents and making a referral.
  • AACAP has developed a number of recommendations for primary care providers on when to seek a referral or consultation with a child psychiatrist; these recommendations may be useful as you determine when to refer patients for mental health concerns. Referrals for ongoing evaluation and treatment Referral for evaluation and initial treatment with referral back for continued care Consultation and evaluation with continued supervision of treatment provided by other practitioners Consultation without face-to-face evaluation of the patient
  • Additional Guidelines developed by AACAP to provide guidance around when PCPs should refer patients: If there is a threat to safety of the patient or of others (e.g., actively suicidal) If there is a significant change in emotional or behavioral functioning for which there is no obvious or recognized precipitant The child’s primary caretaker has serious emotional impairment or substance use problem If there is evidence of significant disruption in day to day functioning If the adolescent has had a course of treatment for 6 to 8 weeks without meaningful improvement If the adolescent presents with complex diagnostic issues If there is a history of abuse, neglect or removal from home If symptoms and family psychiatric history suggests that treatment with medication may result in adverse response If child has had only a partial response to a course of medication When a behavior seriously interferes with the treatment of a chronic medical condition
  • TeenScreen has put together references and information on obtaining reimbursement for screening. Mental health assessments and discussions with patients and families can be time and resource intensive. The information provided on the following slides is designed to assist providers with helpful tips for obtaining reimbursement through a number of insurance carriers. It is recommended that providers consult with their office’s coding and billing staff to determine the combination of codes that will work best for mental health checkups. It may be helpful to first determine what type of visit mental health checkups will be incorporated into (e.g., well-child, sick visits, sports physicals, etc) and to examine what codes are currently being used for that type of visit to determine if the codes provided below can be used in conjunction with what is already being used.
  • There are a number of Evaluation and Management CPT Codes that can potentially be used to bill for screening. When counseling and/ or coordination of care dominates (more than 50%) the physician patient and/ or family encounter, then time may be considered the controlling factor to qualify for a particular level of E/M service. These codes use time as the key factor in the patients appointment. When using these codes, a modifier 25 can be added to the visit. Modifier 25 tells insurers that the particular visit is different; it should be added to the office/ outpatient visit to indicate that a significant, separately identifiable E/M service was performed in addition to the preventive medicine visit. Please note, however, many insurers do not recognize nor reimburse for modifier 25.
  • ICD-9 Diagnosis Codes/ V Codes for preventative health visits that may be used: V20.0 – typically used to code for general well child visits V79.8 – can be used to code for negative screening results V40.9 – can be used to code for positive screening results
  • This slide highlights a fact sheet that was developed by the AAP that provides guidelines on coding for pediatric preventative care, and includes information about some the CPT and ICD-9 codes we just discussed. This fact sheet is available in the Mental Health Checkup Resource Guide, available at your request.
  • In 2003, the two CPT codes below were approved by the Centers for Medicare and Medicaid Services (CMS) specifically relating to developmental and behavioral screening in pediatrics. Reimbursement rates for these codes are determined at the state level and generally cover the cost of administering and scoring one screening questionnaire. 96110: Developmental Screening 96111: Developmental Testing
  • This fact sheet developed by the AAP provides additional information for the two CMS codes and how they may be used. It lists the PSC as one of the sample screening tools that can be used in primary care under the 96110 CPT code. This fact sheet is also available in the Mental Health Checkup Resource Guide, available at your request.
  • The Mid-America Coalition on Health Care developed a work group of key stakeholders to collaboratively address the complexities surrounding diagnosis, coding and reimbursement for the management of depression in primary care. As a result, two fact sheets for primary care depression reimbursement were developed – some of the codes we just discussed are explored. Two fact sheets, available in Mental Health Checkup Resource Guide.
  • AAP Bright Futures Toolkit also has a section that provides information on CPT codes that may be used for screening. Bright Futures: The information and resources in this guide provide primary care health professionals with the tools they need to promote mental health in children, adolescents and their families. This excerpt from the toolkit provides information on selected CPT codes, and also includes a template letter that providers can use for documentation of the reimbursement.
  • Teen Depression Screening

    1. 1. TeenScreen Primary Care Incorporating Mental Health Checkups Into Adolescent Visits The 360° Checkup
    2. 2. TeenScreen Primary Care and Mental Health Checkups <ul><li>The American Academy of Pediatrics calls for annual confidential screening and referral for behavioral health problems and the Society of Adolescent Medicine supports early identifications as a critical standard of care. </li></ul><ul><li>TeenScreen Primary Care provides PCPs with evidence-based practices and questionnaires to screen 11-18 year-old patients. </li></ul><ul><li>Mental health checkups can be incorporated into regular preventative healthcare visits for adolescent patients. </li></ul><ul><li>Primary focus on: </li></ul><ul><li>Early identification of mental illness </li></ul><ul><ul><li>Suicide prevention in youth </li></ul></ul><ul><ul><li>Linking those in need with services </li></ul></ul>
    3. 3. Mental Health Checkup Procedures
    4. 4. Screening Logistics <ul><li>When and to whom screening will be offered and administered </li></ul><ul><li>Mental health referral network/ list of providers to share with families </li></ul><ul><li>How the screening questionnaire will be administered and scored and how the results of the screening will be shared with the primary care practitioner (PCP) </li></ul><ul><li>Who will conduct the post-screening interview/ exam and where it will be conducted </li></ul><ul><li>Who will notify parents of the screening results and assist families in need of referral </li></ul>As you prepare to implement mental health checkups in your practice, it may be helpful to consider the following: Additional information about integrating mental health checkups into your practice is available in a slide presentation, upon request by emailing [email_address]
    5. 5. Screening Questionnaire (PSC-Y) Administration, Scoring and Interpretation
    6. 6. Pediatric Symptom Checklist (PSC-Y) <ul><li>35-item youth self-report questionnaire </li></ul><ul><li>Designed to detect behavioral and psychosocial problems </li></ul><ul><li>Questions cover internalizing, attention, externalizing problems </li></ul><ul><li>Takes 5 minutes to complete and score </li></ul><ul><li>Validated and widely used (Murphy et al., 1992, 1996; Gall et al., 2000; Pagano et al., 2000) </li></ul><ul><li>Two items from the Columbia Suicide Screen (CSS) (Shaffer et al., 2004) </li></ul>
    7. 7. Pediatric Symptom Checklist (PSC-Y) <ul><li>Available in English, Spanish, French, Haitian-Creole and Brazilian-American Portuguese </li></ul><ul><li>Includes two questions addressing suicide from the Columbia Suicide Screen </li></ul>
    8. 8. Scoring the PSC-Y <ul><li>Items are scored as follows: </li></ul><ul><li>Never = 0 </li></ul><ul><li>Sometimes = 1 </li></ul><ul><li>Often = 2 </li></ul><ul><li>To calculate the score of the questionnaire, add all of the items scores together </li></ul><ul><li>Total Score = (range 0-70) </li></ul><ul><li>Note if either suicide item has been endorsed (Questions 36 & 37) </li></ul><ul><li>If items are left blank they are scored as 0 </li></ul><ul><li>If four or more items are left blank, the questionnaire is considered invalid </li></ul>
    9. 9. Defining a Positive Screen Cut-off point defining a positive screen: Total Score ≥ 30 - 14% of 13-18 year olds in a SBHC located in a small city scored positive - 20% of 9-14 year olds in an inner-city public school OR Recent Suicidal Ideation Reported - 3% of 11-18 year olds endorsed SI on the DPS in a PC sample OR Past Suicide Attempt Reported - 2% of 11-18 year olds endorsed SA on the DPS in a PC sample
    10. 10. Interpreting the Results <ul><li>The PSC-Y results are not a diagnosis. </li></ul><ul><li>A positive score suggests the need for further evaluation. </li></ul><ul><li>Both false positives and false negatives occur. </li></ul><ul><ul><li>Studies on the PSC-Y show that 2 out of 3 teens who score positive are correctly identified as having moderate to serious impairment in psychosocial functioning. </li></ul></ul><ul><ul><li>The one teen incorrectly identified usually has at least mild impairment. </li></ul></ul><ul><ul><li>Data on PSC-Y negative screens indicate 96% accuracy (1 out of 20 teens who score negative may be impaired). </li></ul></ul><ul><li>All youth who score positive on the PSC-Y should be further evaluated by their PCP to determine if referral or follow-up is needed. </li></ul>Bright Futures, 2008; http://www.brightfutures.org
    11. 11. Interpreting the Results These are the problem areas addressed by the PSC-Y and the most critical items associated with them. Symptoms endorsed as “often” are of greatest significance.
    12. 12. Conducting the Post-Screening Interview/ Exam
    13. 13. Post-Screening Interview <ul><li>Look to see if answers cluster by internal (anxiety/depression); attention (ADHD); and/ or external (conduct/oppositional defiant disorder) </li></ul><ul><li>Explore symptoms that were endorsed on the screening questionnaire, including those related to functioning and impairment </li></ul><ul><li>Inquire about suicidal thoughts and behaviors </li></ul><ul><li>Assess the level of impairment caused by the symptoms at school, at home and with peers </li></ul>
    14. 14. The American Academy of Child and Adolescent Psychiatry: “When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist” <ul><li>Practitioners should consider the following types of referrals: </li></ul><ul><li>Referral for evaluation and ongoing treatment. </li></ul><ul><li>Referral for evaluation and initial treatment with referral back for continued care. </li></ul><ul><li>Consultation and an evaluation but without the assumption of ongoing medical responsibility. </li></ul><ul><li>Consultation and an evaluation with continued supervision of treatment provided by other practitioners. </li></ul><ul><li>Consultation without a face-to-face evaluation of the patient; this may occur through a treatment team within a clinic or an intervention team within a school. </li></ul>
    15. 15. American Academy of Child and Adolescent Psychiatry: “When to Seek Referral or Consultation with a Child and Adolescent Psychiatrist” <ul><li>Specific Criteria for Referrals : The primary care practitioner should refer when: </li></ul><ul><li>There is a threat to the safety of the adolescent or the safety of others. </li></ul><ul><li>A significant change in emotional or behavioral functioning for which there is no obvious or recognized precipitant. </li></ul><ul><li>The primary caretaker has serious emotional impairment or substance abuse problem. </li></ul><ul><li>Evidence of significant disruption in day-to-day functioning or reality contact. </li></ul><ul><li>The adolescent has had a course of treatment intervention for six to eight weeks without meaningful improvement. </li></ul><ul><li>When the adolescent presents with complex diagnostic issues involving cognitive, psychological, and emotional components that may be related to an organic etiology or complex mental health/legal issues. </li></ul><ul><li>There is a history of abuse, neglect and/or removal from home, with current significant symptoms as a result of these actions. </li></ul><ul><li>When symptoms and family psychiatric history suggests that treatment with psychotropic medication may result in an adverse response. </li></ul><ul><li>When a child or adolescent has had only a partial response to a course of psychotropic medication or when any child is being treated with more than two psychotropic medications. </li></ul><ul><li>When a behavior that seriously interferes with the treatment of a chronic medical condition. </li></ul>
    16. 16. Reimbursement Codes
    17. 17. Reimbursement Codes The Modifier 25 should be added to the visit to indicate that a significant, separately identifiable E/M service was performed in addition to the preventive medicine visit. Evaluation/ Management CPT Codes Initial assessment can involve a lot of time determining the differential diagnosis, a diagnostic plan and potential treatment options. Therefore, most pediatricians will report either an evaluation and management code using time as the key factor or a consultation code for the initial assessment. New Patients 99201 99202 (20 minutes) 99203 (30 minutes) 99204 (45 minutes) 99205 (60 minutes) Established Patients 99212 (10 minutes) 99213 (15 minutes) 99214 (25 minutes) 99215 (40 minutes) 99216
    18. 18. Reimbursement Codes ICD-9 Codes V20.0 – Well-child visits V79.8 – Negative screening results V40.9 – Positive screening results
    19. 19. Reimbursement Codes <ul><li>The AAP has developed a fact sheet on coding for pediatric preventive care that provides additional information about CPT and ICD-9 codes that may be used. </li></ul>– AAP Coding for Preventive Care –
    20. 20. Reimbursement Codes 96110: Developmental Screening 96111: Developmental Testing In 2003, two CPT codes were approved by the Centers for Medicare and Medicaid Services (CMS) specifically related to developmental and behavioral screening in pediatrics:
    21. 21. Reimbursement Codes <ul><li>The AAP has developed a “Coding Fact Sheet for Primary Care Physicians” about the two CPT codes specific to developmental and behavioral screening. </li></ul><ul><li>The PSC is listed as one of the sample testing tools that can be used under the 96110 CPT code. </li></ul>– AAP Coding Fact Sheet –
    22. 22. Reimbursement Codes The Mid-America Coalition on Health Care developed a work group of key stakeholders to collaboratively address the complexities surrounding diagnosis, coding and reimbursement for the management of depression in primary care. As a result, two fact sheets for primary care depression reimbursement were developed. – Mid-America Coalition on Health Care – <ul><ul><li>Primary Care Depression Reimbursement: Tips for Physicians and Practice Managers </li></ul></ul><ul><ul><li>Primary Care Depression Reimbursement: Myths vs. Facts </li></ul></ul>
    23. 23. Reimbursement Codes The information and resources in this guide provide primary care health professionals with the tools they need to promote mental health in children, adolescents and their families. This excerpt from the toolkit provides information on selected CPT codes, and also includes a template letter that providers can use for documentation of the reimbursement. – AAP Bright Futures in Practice Mental Health Toolkit – <ul><ul><li>Selected General Medicine and Behavioral Current Procedural Terminology (CPT) Codes </li></ul></ul><ul><ul><li>Template letter </li></ul></ul><ul><ul><li>http://brightfutures.aap.org/materials.html </li></ul></ul>
    24. 24. Free Materials Available Through the National Center
    25. 25. TeenScreen Primary Care Quick Start Guide Free, comprehensive resource for healthcare providers to assist with the implementation of mental health checkups in a primary care setting. <ul><li>Includes the following: </li></ul><ul><li>Overview of TeenScreen Primary Care </li></ul><ul><li>Screening Questionnaire Administration & Scoring Instructions </li></ul><ul><li>Screening Questionnaire (Pediatric Symptom Checklist-Youth) </li></ul><ul><li>Interpreting the Screening Results </li></ul><ul><li>Making a Referral </li></ul><ul><li>Coding and Reimbursement Information </li></ul>
    26. 26. Teen Brochure with PSC-Y A free brochure designed for adolescent patients that contains the PSC-Y screening questionnaire and information about mental health screening. This brochure can be placed in the waiting room so that patients can access the screening questionnaire on their own or it can be handed out to patients as they come in for their appointment. Available in English and Spanish.
    27. 27. Preparing Office Staff to Implement Mental Health Checkups <ul><li>Helpful tools to help involve and prepare office staff to implement mental health checkups </li></ul><ul><li>Sample staffing roles and responsibilities as they relate to tasks associated with screening </li></ul><ul><li>Screening implementation checklist/ worksheet </li></ul><ul><li>Also available at no cost </li></ul>
    28. 28. Free, Supplemental Materials Available Upon Request Mental Health Checkup Resource Guide Provides additional materials you may find helpful to your implementation of mental health checkups. Post-Screening Interview Resources Includes post-screening interview checklist, information for conducting a suicide risk assessment and sample questions by symptom area. Tips for Integrating Mental Health Checkups into Your Practice A slide presentation is available for providers who are interesting in learning more about the logistics of mental health screening and receiving tips for integrating mental health checkups into their practices. TeenScreen Web Site Learn more about TeenScreen Primary Care at: http://www.teenscreen.org/teenscreen-primary-care
    29. 29. Get Involved! Enroll in TeenScreen Primary Care <ul><li>Visit TeenScreen’s Web site www.teenscreen.org and sign-up to receive materials </li></ul><ul><li>You can also call the National Center at 800-673-7714 or email: </li></ul><ul><li>[email_address] . </li></ul><ul><li>Upon receiving your information, you will be sent a copy of the </li></ul><ul><li>TeenScreen Primary Care Quick Start Guide and up to 100 teen brochures. </li></ul><ul><li>Upon receiving the new materials, you are free to begin screening! </li></ul>If you are interested in starting a TeenScreen Primary Care initiative:

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