childhood mental health: strategies for rural people

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childhood mental health childhood mental health: strategies for rural people * rural challenge 1. making the diagnosis requires team of family, school, primary care physician and patient. pcps diagnose psycho-social problems in 19% of visits. 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 need rural pediatric mental health visits 5% of child er visits are for mh (rural ~ urban). 10% of psychiatric er visits are children. childhood mental health er visits 102%. only 1 in 5 children receive definitive care. rural adolescent rates of anxiety, depression, thought problems, attention problems, delinquency, substance abuse and aggressive behavior are equivalent. suicide is higher in rural america. only 79% of rural us counties have mental health services. * agricultural worker’s need needs …

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he 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 * here i have tried to simplify the mechanics of primary care. * 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) mind/body integration: americans accept the inter-relationship of mind and body more than clinicians. …

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. 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. step 2: hired clinical psychologist (cp) initially supported by grant. step 3: weekly office pcp, cp and staff conferences focusing on patient care. step 4: referrals to cp expanded to other diagnoses. step 5: patient billings evolved to support cp. step 6: grant funding was no longer needed. (farley, 1998) * integrate care: examples cadillac version inter-professional partners for appalachian children (ipac) assessment and comprehensive treatment of behavioral and developmental needs …

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gle message” teaching brochures. improved outcomes and lowered recurrance rates by 2/3rds. (gustafson, 1994) * why doesn’t the ideal just happen? competing demands competing demands confound pcp visits: most pts have psychosocial and physical co-morbidities. they present new problems at every visit long problem lists interfere with providing prevention and treatment of chronic disease. (jaen, 1994) “the attention depression gets during a visit is less associated with the severity of the patient’s emotional symptoms than with the number of other problems the patient has.” (rost, 2000) * strategies: bringing the pcp into the team 1. in-office training: treatment of child pscyho-social conditions: 6 hours proved feasible and acceptable to all fps in study. 93% fps believed that learning were achieved. 82% felt more confident in care of complex patients. (morriss, 2006) specific diagnoses were not essential to management. (clark, 2006) lowers use of medications. (salmon, 2006) * strategies: bringing the …

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d cognitive care works best. (march, 2004) * in 2002 aap created a subspecialty called developmental and behavioral pediatrics. (koppelman, 2004) * strategies: bringing the pcp into the team 6. case management: advanced practice psychiatric nurses mental health social workers special service agencies 7. school performance: semi-annual case conferences required. each member of team may bill the equivalent of an office visit for each patient conference. * solutions: integrated care (pcp) key feature: case management at multi-levels. overall costs are significantly less. (baldwin, 1993) specialty and social services cost the same. emergency and inpatient care costs were much lower. outcomes measures better. (schulberg, 1995; katon, 1995) most of the data is from adult care. clinical care pathways develop. (bertram, 1996) specialty consultation is distributed. impact is expanded to more patients. european model of health care. (rosenthal, 2000) * there is no reason to believe pediatric care would be different.

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О "childhood mental health: strategies for rural people"

childhood mental health childhood mental health: strategies for rural people * rural challenge 1. making the diagnosis requires team of family, school, primary care physician and patient. pcps diagnose psycho-social problems in 19% of visits. 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 need rural pediatric mental health visits 5% of child er visits are for mh (rural ~ urban). 10% of psychiatric er visits are children. childhood mental health er visits 102%. only 1 in 5 children receive definitive care. rural adolescent rates of anxiety, depression, thought problems, attention …

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