Title of Program or Project

Healthcare Integration

Web Site URL

https://www.cgfs.org/

Services

• PCP education
• PCP consultation
• Co-located therapy
• Care coordination
• Telepsychiatry
• Patient/family education/self-management

Service Site

• Primary care clinic
• Community health center

Service Area

• Community

Geographic Population

• Urban
• Inner city
• Migrant

Service Provider

• Pediatrician/adolescent medicine
• Advanced practice nurse
• Child & adolescent psychiatrist
• Social worker
• Mental health counselor
• Other mental health professional
• Medical student

Service Recipient

• Child
• Adolescent
• Parents
• Family

Funding

• Medicaid
• Other

Program or Project State

Ohio

Program or Project Description

Co-Location of behavioral health services in private and hospital affiliated pediatric practices, family medicine residency program, and FQHC. Providing psychiatry consultation services, tele-psychiatry, counseling, case management, and care coordination. Home-based counseling for medically compromised children, and the refugee population.

Co-Location of an advance practice nurse at our community mental health center providing education to clients, families, and our staff on medical concerns, and linkage to medical providers. Case consultation with PCP and Psychiatrist. RN care coordinator addressing medical issues of clients.

Incorporation of groups that promote exercise and healthy eating: Girls on The Run and Heart and Soul, Hip Hop 2 Health, Gardening Groups.

Program or Project Leadership

Dr. Steve Jewell MD: Vice President and Medical Director
Hattie M. Tracy LISW-S, LCDCIII, MPA: Director, Healthcare Integration
Child Guidance & Family Solutions
18 North Forget Street
Akron, Ohio 44304
330-762-0591

Program or Project Evaluation

PHQ-9
SCARED
GAD-7
Mood and Feeling Questionnaire (long version)
Vanderbilt
Functional Outcomes(hospitalizations, well care visits, er visits, school, work, living situation, BMI, screen time, exercise drug use, etc.)

Program or Project Successes

• Improved scores on screeners for clients
• Improved functional outcomes
• Increased demand for services from physician offices
• Decreased cancel/fail rates for services
• Satisfaction of clients and parents for services provided
• Increased capacity and access for our community

Program or Project Challenges

• Funding for psychiatric consultation
• Integration of different EHR systems
• Funding for warm handoffs and brief interventions before someone is a client
• Shortage of child psychiatrists
• PCP's willingness/unwillingness to prescribe psychiatric medications

Program or Project Curricula/Materials

Peer-Reviewed Journal Articles

Other Publications

Contact Name

Hattie Tracy

Email

trach@cgfs.org

Title of Program or Project

Project COPE, CARE and IMPACTT

Web Site URL

http://my.clevelandclinic.org/services/neurological_institute/epilepsy/patient-education/patient-family-support

Services

• PCP education
• PCP consultation
• Care coordination
• Telepsychiatry
• Patient/family education/self-management

Service Site

• Specialty clinic
• Hospital

Service Area

• Community
• State-wide
• National

Geographic Population

• Urban
• Inner city
• Suburban
• Rural

Service Provider

• Pediatrician/adolescent medicine
• Developmental behavioral pediatrician
• Advanced practice nurse
• Physician assistant
• Other medical professional
• Child & adolescent psychiatrist
• Psychologist
• Social worker

Service Recipient

• Pediatrician/adolescent medicine
• Other medical professional
• Psychologist
• Mental health counselor
• Other mental health professional

Funding

• Federal

Program or Project State

Ohio

Program or Project Description

Strategic Approaches to Improving Access to Quality Health Care for Children and Youth with Epilepsy”. Our project, entitled IMPACTT (Integrating Mobile Provider Access for Telemedicine and Transition), addresses the needs of children and youth with epilepsy and their families in three designated Medically Underserved Areas (MUAs). The goals of the project are: (1) to provide care to CYE through a patient/family-centered medical home; (2) to provide transition planning for CYE; (3) to implement telemedicine with CYE and their families at CCF main and 9 clinical sites; (4) to establish a Learning Collaborative involving 9 pediatric primary care sites; and (5) to increase outreach and family engagement, using educational webinars. These goals will be accomplished by 1) implementing evidence-based and innovative models of using health information technologies; 2) implementing the Got Transition Six Core Elements Framework to help youth successfully transition from the pediatric to adult system of health care; and (3) facilitating outreach and education regarding epilepsy among pertinent stakeholders. Five advanced technology programs will be include in the project: (1) telemedicine, including face to face cameras for consultation with patients and between primary care doctor and specialist; (2) use of MyChart, the Cleveland Clinic technology based record keeping and communication system available to all patients and physicians; and (3) mHealth for patients, a phone-based or computer based application, (4) webinars, and (5) the StandUp bully prevention program.

Program or Project Leadership

Cleveland Clinic - Neurologic Institute
Center Director Imad Najm MD
Program Director Tatiana Falcone MD
Pediatric Epilepsy Team
Adult Epilepsy Team
Research Coordinator Diane Zemba RN
Sammy Juhn LSW

Evaluation Team- Jane Timmons- Mitchell PhD (CWRU)

Prochange- Stand Up Program (a bullying prevention Program) - Debbie Levesque PhD

Northwestern University- Department of Preventive Medicine Project Tech (Depression App for Kids with Epilepsy) Joice Ho PhD

Coordinating center American Academy of Pediatrics

Program or Project Evaluation

Project activities and evaluation will follow a Continuous Quality Improvement framework. The 9 sites will participate in a Learning Collaborative that will provide both training and access to expert consultation for primary care providers. Over the three years of the grant, Cleveland Clinic Pediatric Epilepsy and the 9 clinical sites combined will serve at least 1,000 CYE; all of the CYE served by the project will have a seizure action plan in place. Of the nine clinical sites, three are in HRSA designated medically underserved areas (MUAs), constituting about 38% of patients served by the grant. Partnering with families and CYE, Pediatricians, Primary Care providers as well as with Case Western Reserve University, the project will further engagement and outreach in a broader geographic region in Ohio. Resulting in improving services for CYE in Ohio.

Program or Project Successes

The purpose of this project is to improve the quality of life for youth with epilepsy, which will be achieved through:

1. Improving care coordination
2. Providing patient and family education
3. Increasing access to early mental health screening
4. Increasing family/patient engagement
5. Improving healthy relationship skills (to decrease bullying in children with epilepsy)

During the 3 years of project CARE to date- we have served 2’200 unique families of CYE. 454 families on the care coordination clinic, 132 families assisted with the transition workbook, 42 families that actively participated in the transition clinic, 1’490 families participated in the webinars, 45 families of CYE participated in the facebook groups, 37 CYE participated in the StandUp bullying prevention intervention. Other number not included in the 2’200 count are : We actively participated in the cross-site evaluation process collecting more than 728 surveys from parents of CYE. 5’184 mental health tool kits were disseminated between professionals in epilepsy care and families. We provided lectures to 500 physicians in 9 national conferences during the 3 year grant (epileptologist, psychiatrist, pediatricians). We provided psychoeducation to 40 teachers about epilepsy. We provided psychoeducation about epilepsy to 12 classrooms from 2 grade to highschool with more than 250 students participation. We provided psychoeducation to families about epilepsy in 4 local meetings from epilepsy association with more than 50 CYE families participating in these events.

Goal 1. To Establish a Care Coordination Clinic for children and youth with epilepsy.

Objective 1. To create a Care Coordination Clinic (according to the AAP definition of medical home).Results: We have provided care coordination services for a total of 454 families; 75 have agreed to complete measures to evaluate the benefits of the care coordination clinic.

Goal 2. To Establish a Transition Clinic for teenagers with epilepsy.

Objective 1. To create a transition clinic for youth with epilepsy that complies with the six core elements of health care transition identified by the National Healthcare Transition Results: We prepared and published a “Journey to Adulthood” workbook for patients and families enrolled in the Transition Clinic. 132 transition workbooks have been disseminated to CYE ages 14-18 and 42 patients have participated in the transition clinic.

Goal 3. To conduct educational webinars for families of youth with epilepsy.

Objective 1. To increase knowledge about epilepsy. Objective 2. To decrease stigma and increase knowledge about mental health problems in CYE and their families. Objective 3. To increase use of advanced technology for families of youth with epilepsy.Results: During project CARE we produced 7 webinars. To date, our 7 webinars have been viewed 10,430 times. If we account for unique families seeing the webinar series (14,430/7) 1,490 families.

Goal 4. To Establish and monitor 2 Facebook groups for youth with epilepsy and their families.

Objective 1. To increase social and emotional support for youth with epilepsy and their families.

Results: We have a total of 45 enrolled into our Facebook groups.

Goal 5. Disseminate the Mental Health and Epilepsy Toolkit to professionals and their families.

Objective 1. The Mental Health and Epilepsy Toolkit to be disseminated to 3000 professionals in epilepsy care and family members of CYE.

Results: The Mental Health and Epilepsy Toolkit developed as part of our previous HRSA funded grant, Project Cope. 5184 tool kits have been disseminated during this grant cycle. From this 4078 tool kits were disseminated to professionals in epilepsy care including, and all the pediatricians in Ohio.

Program or Project Challenges

Challenges in Completing Webinar Surveys. We would like everyone who views a webinar to complete an 11-question survey to describe demographics and to determine whether new knowledge was gained. In the past cycle, the link to the survey was displayed, but it was difficult to open. Only 13 surveys were completed compared with the over 10,000 webinar views.

Challenges with Recruitment of Youth with Epilepsy for the Standup Bullying Prevention Intervention. During our pilot of the StandUp program in a community high school in Ohio, 115 adolescents were recruited, with a limited number of CYE. To overcome this barrier, the program was extended to the 7 other grantee sites from HRSA. Thirty-seven additional patients were recruited during project CARE. During the live session at the school, patients had immediate access to their passwords and hence were able to complete session 1. They however forgot their passwords later on and were unable to complete sessions 2 and 3. During the live session, staff were on site to help with any system difficulties. We will ask for permission to contact the family up to 5 times prior to each session to assure that CYE finish session 2 and 3.

Potential Solutions

Completion of webinar surveys. In order to address this challenge, we will be posting the webinars on a different server. The web design group has received the survey we would like to link. They are testing it for ease of access prior to rolling out the next round of webinars.

Recruitment of youth with epilepsy for the StandUp bullying prevention intervention: The primary barrier identified has been lack of remembering passwords to complete sessions 2 and 3. Using a Continuous Quality Improvement process, we will generate ways to address this barrier. When CYE are given their password, we will work with them to record it and store it in a safe place. We will also work with the program developers to introduce a password linking feature so that CYE who return for sessions 2 and 3 can be linked with their previous program experience.

Program or Project Curricula/Materials

Mental Health Toolkit

Peer-Reviewed Journal Articles

Other Publications

Contact Name

Tatiana Falcone

Email

falcont1@ccf.org

Title of Program or Project

Stark County Pediatric Medical Home Project/Medical Services Redesign

Web Site URL

https://candapediatricmedicalhomes.wordpress.com

Services

• PCP education
• PCP consultation
• Care coordination
• Other

Service Site

• Primary care clinic
• Specialty clinic
• Community health center
• School/child care
• Remote (phone or electronic)

Service Area

• Community

Geographic Population

• Urban
• Inner city
• Suburban
• Rural

Service Provider

• Pediatrician/adolescent medicine
• Family Practitioner
• Advanced practice nurse
• Other medical professional
• Child & adolescent psychiatrist

Service Recipient

• Pediatrician/adolescent medicine
• Family Practitioner
• Advanced practice nurse
• Physician assistant
• Other medical professional

Funding

• County
• Foundation

Program or Project State

Ohio

Program or Project Description

Our plan for medical services redesign has three overarching goals:

1. Enhancing the capacity of patient-centered pediatric medical homes to identify kids at risk of significant mental illness and to support local pediatricians in broadening their ability to provide evidence-based medical intervention for children and teens with common mental health conditions.

2. Building upon the agency’s established training program in psychology to develop a Center of Excellence for Interdisciplinary Training of medical and mental health professionals.

3. Establishment of a new medical services team and rightsizing the department’s current caseload.

Program or Project Leadership

Child and Adolescent Behavioral Health (C&A) is the largest provider of mental health services to children, teens and families in Stark County. The agency offers an array of school-based and outpatient mental health and case management services, a school-based day treatment program and outpatient psychiatric services. C&A is serving as the lead agency for the project.

Stephen Grcevich, MD is currently serving as the agency's Transitional Medical Director and is responsible for overseeing the project. The project is an outgrowth of recommendations Dr. Grcevich made in 2016 to the Stark County Mental Health and Addiction Recovery Board and C&A's Board in response to a lack of access to psychiatric services for children, teens and families in the county and systemic changes resulting from the Ohio Department of Mental Health's planned behavioral health redesign.

Dr. Elizabeth Hayford was hired in August, 2017 as C&A’s first full-time Medical Director since 1997 and began work on August 1st. Dr. Hayford is Board Certified in Family Medicine and General Psychiatry, and is scheduled to take her certification exam in Child and Adolescent Psychiatry in September. Dr. Hayford worked in Alliance for two years as a family practitioner before pursuing training in general and child psychiatry at Akron General Hospital and Akron Children’s Hospital. She and her family reside in North Canton. She will be working 32 hours/week. Dr. Hayford’s principal responsibility during her first six months of employment will be provision of clinical care. She will gradually assume responsibility for providing support to pediatric medical homes and supervision/collaboration with APNs. We plan for her to fully assume the Medical Director’s role by the third quarter of 2018.

Program or Project Evaluation

Supporting Patient-Centered Pediatric Medical Homes:

• Provide direct access for pediatricians and pediatric nurse practitioners to “curbside consultation” offered by a child and adolescent psychiatrist during normal working hours.

To date, we’ve introduced the project to five pediatric groups in Stark County - Akron Children’s Pediatrics (Alliance), Akron Children‘s Pediatrics (North Canton), Community Health Care Pediatrics (Jackson), Primary Care Physician Associates (Jackson) and Shipley Clinic (Canton). These practices represent approximately half of the practicing pediatricians and pediatric nurse practitioners in Stark County.

The “Curbside Consultation” service launched on March 1, 2017. To date, the service has processed four consultation requests through the established process. Three of the four requests were for children or teens with primary diagnoses of anxiety disorders, one with depression. One family was seen through Dr. Grcevich’s private office for consultation and stabilization and subsequently returned to their local pediatrician for follow-up. All other patients continued to be served through their local pediatric practice.

• Assist pediatric practices in setting up screening tools for kids at risk of common mental health conditions.

We launched a website in March to serve as a resource hub for the project: https://candapediatricmedicalhomes.wordpress.com

Primary care physicians in Stark County have been provided access to a comprehensive library of free children’s mental health screening tools and rating scales in the public domain through the project website. Instruments are available for screening and monitoring response to treatment for children and teens with ADHD, anxiety disorders, Bipolar Disorder, depression, disruptive behavior disorders, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Schizophrenia, substance use disorders and tic disorders. Screening tools are also available for suicide risk and monitoring movement disorders associated with antipsychotic medication. The screening tool library is available here: https://candapediatricmedicalhomes.wordpress.com/child-psychiatry-rating-scales-for-primary-care-physicians/

The website also houses links to access the “curbside consultation” service and a complete set of practice parameters for specific conditions published by the American Academy of Child and Adolescent Psychiatry.

• Establish quarterly “lunch and learn” meetings with each participating pediatric practice in the county tailored to the unique practice needs of their group.

We will have completed quarterly lunch and learns for two quarters with CHC Pediatrics and one quarter with Primary Care Physician Associates by the end of this quarter. We are still in the process of introducing other groups to the pediatric medical home project. Community Healthcare Pediatrics requested and received training on the following topics:

Understanding DMDD (Disruptive Mood Dysregulation Disorder) Risks and Benefits of Serotonin Reuptake Inhibitors in Children and Teens

• Monthly videoconferences to discuss common topics of interest among pediatricians from participating practices.

• Explore availability of offering Continuing Medical Education credits and events.

• Assist with development of Quality Improvement projects related to child and adolescent mental health necessary for pediatricians to meet Maintenance of Certification (MOC) requirements.

• Partner with Northeast Ohio Medical University’s TACT (Integrated Care Technical Assistance and Consultation) Team to provide training and support in implementing the Collaborative Care model in primary care practices and assistance in developing multidisciplinary training opportunities for professionals.

We’ve been partnering with Northeast Ohio Medical University’s (NEOMED) Department of Psychiatry in implementing education-related goals associated with supporting pediatric medical homes and interdisciplinary training of students in mental health-related fields. NEOMED has grant funding through the Ohio Department of Mental Health to implement Project Echo in the region. Here’s a summary of what we’re working on from Nichole Ammon at NEOMED:

Northeast Ohio Medical University has partnered with the University of New Mexico’s ECHO Institute to become a Project ECHO® replication partner. Project ECHO® is a hub and spoke knowledge-sharing networks create a learning loop where community providers learn from specialists, community providers learn from each other, and specialists learn from community providers as best practices emerge. Through technology-enabled collaborative learning, ECHO creates access to high-quality specialty care in local communities.

As an ECHO hub (Project ECHO: NEOMED Ohio Alliance), NEOMED’s the Department of Psychiatry, Best Practices in Schizophrenia Treatment (BeST) Center has been working on the development of an Integrated Primary and Mental Healthcare Tele-ECHO Clinic, with an initial focus on youth patient populations. The BeST Center team has developed a draft curriculum to be covered during the ECHO Clinic Sessions and they are in the process of working with the Continuing Education Office at NEOMED, so that participants in the community will be able to earn CE credit (Ohio MD, Nursing, Counseling, Social Work, Psychology and Pharmacy). The BeST Center team has been working with Dr. Grcevich, consultant to C&A, on the development of a survey and an initial list of providers to target for participation. NEOMED’s Department of Public Relations and Marketing is assisting the BeST Center Team in creation of promotional materials. More information will be available for distribution online and printed materials, as soon as possible.

NEOMED’s goal is to disseminate the survey and promotional materials to an initial target audience in September, with a tentative ECHO Clinic launch date in late October 2017. In the meantime, a shared email has been established so that the BeST Center team is able to start fielding questions and interest in Project ECHO® - IntegratedCareECHO@neomed.edu

Individuals and organizations with interest and/or questions about the Integrated Care ECHO Clinic can contact the team at this email, or they can contact the project lead: Nichole Ammon, M.S.Ed., LPCC-S, Manager for Integrated Healthcare Initiatives/IPE Faculty Educator at nammon@neomed.edu or at 330.325.6613.

• Access to a “Care Coordinator” or “Care Concierge” from C&A‘s Medical Services team to help facilitate appropriate (and timely) referrals of pediatric within the agency and clinical communication between C&A and participating pediatric groups.

Delays in the implementation of behavioral health redesign in Ohio caused us to postpone Meredith Skotschir’s planned transition into the Care Coordinator role until January 1st. Staffing transitions within the Medical Services department necessitated that Meredith continue to serve primarily as a clinician until that time. Recent staff additions will free Meredith to assume these responsibilities after the first of the year. In the interim, Georgene Voros (the agency’s Clinical Director) is assuming responsibility for ensuring that kids and families from primary care practices with acute mental health needs can access specialized services in a timely fashion.

Other potential components of a pediatric medical home project:

• Exploration of a partnership with Shipley Clinic to develop a “Quadrant IV” pediatric medical home for children in Stark County with high acuity behavioral and physical health needs and/or a partnership with Aultman Family Practice to provide ongoing pharmacotherapy for “Quadrant I” kids currently treated at C&A who are stabilized on medication without acute physical health needs who lack a primary care medical home.

We’ve had one preliminary meeting to date with the Executive Director and medical team at Shipley as well as a meeting with Dr. John Sutton of Aultman Hospital, who is leading the hospital’s efforts to launch a federally qualified health center (FQHC) in Stark County.

Program or Project Successes

See above

Program or Project Challenges

The greatest challenges we’ve faced in implementing the project have been getting access to and engagement from the pediatric practices in Stark County, a lack of accurate baseline data regarding the psychiatric diagnoses of kids seen by the Medical Services department and the identity of their primary care physicians, and our inability to quickly and easily gather data regarding existing patients through the agency’s electronic medical record.

Access/Engagement with Primary Care Practices:

We’ve only accessed a little less than half of the pediatric practices to date in the county to introduce the project. We’ve received some very harsh, but helpful feedback during meetings with two practices.

Why are they reluctant to engage?

Taking care of more kids with mental health concerns represents an additional burden to their practices. Kids with mental health concerns are messy and complicated. Their needs don’t easily fit within the brief follow-up appointments necessary to sustain the business model of their practices. In retrospect, we shouldn’t have been surprised to have experienced significant resistance and pushback when we asked them to take kids back into their practices who had been stabilized when we haven’t been willing or able to accept their most complicated patients.

C&A developed a negative reputation among pediatricians in the county. The agency has historically communicated very poorly with pediatricians. For many years, C&A’s capacity to provide psychiatric care offered has been very limited. They can’t directly refer families to a psychiatrist, psychologist or counselor within the agency as they would for families with private insurance.

What are we doing to overcome the obstacles?

• We’ve implemented a system to improve communication with primary care practices. First, we’ve begun systemically collecting and recording information regarding each client’s primary care physician. At the outset of the project, the Medical Services Department had information regarding the child’s primary care physician (PCP) on only 7.0% of patients served. By the end of July, we obtained PCP information on 56.2% of our patients.

• Notifications are sent to primary care physicians whenever a child presents to C&A for mental health services. In addition, a notification is faxed to the primary care physician is when a child is initially seen by the Medical Services department including the child’s diagnosis and medication regimen, whenever the child’s medication regimen is changed or discontinued, and when a child discontinues treatment through Medical Services.

• We’ve trained our non-medical clinicians on appropriate methods of communication for coordinating care with primary care physicians. Clinicians serving children and teens with mental health conditions with pharmacotherapy needs appropriate for primary care are to speak with primary care physicians by phone before referring parents to those practices for medical services.

• NEOMED has agreed to assist with promotion of Project ECHO among primary care physicians in Stark County. Mailings and announcements will be sent out under the medical school’s letterhead.

• Most importantly, we’re going to be able to provide pediatric practices to access to psychiatric services when their kids have need. We haven’t been positioned to develop a truly reciprocal relationship with these practices when it comes to referrals for a long time. When they recognize that we can provide services to children and teens in from their practices in a timely fashion, we believe they’ll be far more likely to engage.

Peer-Reviewed Journal Articles

Other Publications

Contact Name

Stephen Grcevich

Email

sgrcevich@neomed.edu