Lynn Wegner

Identifying infants and young children with developmental disorders in the medical home: An algorithm for developmental surveillance and screening

Early identification of developmental disorders is critical to the well-being of children and their families. It is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals. This statement provides an algorithm as a strategy to support health care professionals in developing a pattern and practice for addressing developmental concerns in children from birth through 3 years of age. The authors recommend that developmental surveillance be incorporated at every well-child preventive care visit. Any concerns raised during surveillance should be promptly addressed with standardized developmental screening tests. In addition, screening tests should be administered regularly at the 9-, 18-, and 30-month visits. (Because the 30-month visit is not yet a part of the preventive care system and is often not reimbursable by third-party payers at this time, developmental screening can be performed at 24 months of age. In addition, because the frequency of regular pediatric visits decreases after 24 months of age, a pediatrician who expects that his or her patients will have difficulty attending a 30-month visit should conduct screening during the 24-month visit.) The early identification of developmental problems should lead to further developmental and medical evaluation, diagnosis, and treatment, including early developmental intervention. Children diagnosed with developmental disorders should be identified as children with special health care needs, and chronic-condition management should be initiated. Identification of a developmental disorder and its underlying etiology may also drive a range of treatment planning, from medical treatment of the child to family planning for his or her parents.

Promoting Optimal Development: Screening for Behavioral and Emotional Problems

By current estimates, at any given time, approximately 11% to 20% of children in the United States have a behavioral or emotional disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Between 37% and 39% of children will have a behavioral or emotional disorder diagnosed by 16 years of age, regardless of geographic location in the United States. Behavioral and emotional problems and concerns in children and adolescents are not being reliably identified or treated in the US health system. This clinical report focuses on the need to increase behavioral screening and offers potential changes in practice and the health system, as well as the research needed to accomplish this. This report also (1) reviews the prevalence of behavioral and emotional disorders, (2) describes factors affecting the emergence of behavioral and emotional problems, (3) articulates the current state of detection of these problems in pediatric primary care, (4) describes barriers to screening and means to overcome those barriers, and (5) discusses potential changes at a practice and systems level that are needed to facilitate successful behavioral and emotional screening. Highlighted and discussed are the many factors at the level of the pediatric practice, health system, and society contributing to these behavioral and emotional problems.

Developing Effective Child Psychiatry Collaboration with Primary Care: Leadership and Management Strategies

By working in collaboration with pediatric primary care providers, child and adolescent psychiatrists have the opportunity to address significant levels of unmet need for the majority of children and teenagers with serious mental health problems who have been unable to gain access to care. Effective collaboration with primary care represents a significant change from practice-as-usual for many child and adolescent psychiatrists. Implementation of progressive levels of collaborative practice, from the improvement of provider communication through the development of comprehensive collaborative systems, may be possible with sustained management efforts and application of process improvement methodology.

Services for Children and Adolescents with Autism Spectrum Disorders : Payment Issues

Primary care physicians have an important role in assuring that children with autism are identified as early as possible and have a medical home providing appropriate care and care coordination. Understanding efficient methods of care and modifying practice habits to minimize services not currently supported by procedural codes will permit the primary clinician to be paid for this medical care. Current medical procedure codes can be legitimately used to bill for care related to developmental and behavioral health needs and consistent use of these codes will help address payment barriers.

A+KIDS, a Web-Based Antipsychotic Registry for North Carolina Youths: An Alternative to Prior Authorization

OBJECTIVE The rise in use of antipsychotics among U.S. children is well documented. Compliance rates with current safety-monitoring guidelines are low. In response, the North Carolina Division of Medical Assistance established the Antipsychotics-Keeping It Documented for Safety (A+KIDS) registry. The initial objectives of the project were to successfully establish a Web-based safety registry and to obtain and evaluate clinical information derived from the registry. METHODS In April 2011, A+KIDS began asking prescribers of antipsychotics for children age 12 and under to respond to a set of questions regarding dose, indication, and usage history. Antipsychotic registrations were examined by linking North Carolina Medicaid prescription claims to registry entries. Prescribers were classified into different types, and the number of patients and registrations per prescriber were examined. RESULTS In the initial six months, 730 prescribers registered 5,532 patients, 19% below age seven. By month 6 of the registry, 72% of all fills were registered with the program. Top diagnosis groups for registry patients were unspecified mood disorders, autism spectrum disorders, and disruptive behavior disorders. Top target symptoms were aggression (48%), irritability (19%), and impulsivity (11%). Psychosis accounted for 5% of the target symptoms. Twenty-eight percent of children were receiving no form of psychotherapy. Twenty-five percent of all A+KIDS prescribers were responsible for 81% of the registrations. CONCLUSIONS The A+KIDS registry initiative has been successful, as measured by rapid uptake, and is providing clinical information not available from claims data alone. Future efforts will allow for detailed examinations of antipsychotic utilization and further safety improvement.

1800 – Improvement of attention deficit hyperactivity disorder management in the primary medical home through psychiatrist-taught psychopharmacology

Introduction US primary care clinicians (PCCs) are increasingly assuming the medical management for psychiatric disorders. Clinical practice guidelines (PCGs) remain gold standard for professional care, yet physician adoption is not universal. We sought identification of methods to increase evidence-based mental health practices for the most commonly diagnosed pediatric behavioral condition, attention deficit hyperactivity disorder (ADHD). Objective Test two psychiatric interventions of different intensity levels, both designed to increase primary care clinicians’ use of PCGs for managing ADHD. Aims Increase PCCs’ use of PCGs for managing ADHD. Methods Participants : 70 North Carolina (NC) PCCs ; 70 case managers; 35 to 40 pediatric resident physicians; 420 pediatric government-insured patients ages 6-18 years (chart abstraction only). Procedures : PCCs were randomized to: (1) PCC training and follow-up support only; or (2) PCC, case manager, and office staff training (collaborative) and follow-up support interventions. Differences in knowledge, skills, attitudes, and ADHD assessment and treatment practices assessed by participant selfcompleted surveys at baseline, 6, and 12 months. Six of their patient charts were abstracted to determine the extent they followed American Academy of Pediatrics (AAP) treatment guidelines. NC Medicaid (government insurance) claims for children and adolescents of participating practices and a group of control practices were reviewed for diagnostic documentation. Results For collaborative trained PCCs: (1) increased use of ADHD symptom screeners and greater frequency of F/U visits; (2) greater identification of children with ADHD, but decrease in the probability of receiving an ADHD medication (3) lower rate of prescribing above dosing guidelines.

857 – Findings from an online drug monitoring and safety registry for children prescribed antipsychotics

Introduction There is widespread concern over the perceived indiscriminant prescribing of antipsychotic medications in children, particularly for those residing in low-income households or foster care. Ongoing safety and efficacy monitoring is suggested by many professional associations. Objectives Describe reported diagnosis and symptomology for over 15,000 children prescribed antipsychotics in the 17- month period from April 2011 through August 2012. Aims Increase appropriate monitoring of children who are prescribed antipsychotics. Methods A policy was developed by the North Carolina Division of Medical Assistance, in collaboration with Community Care of North Carolina, that requires prescribers to register patients via a web portal before reimbursement is allowed to the pharmacy. Required registration elements include a patients primary diagnosis, target symptom for medication use, initiating prescriber, caregiver support of medication use, adverse drug event reporting, and metabolic monitoring deemed best practice by the literature review. Results From April of 2011 through August 2012, a total of 1,241 prescribers have written 29,691 prescriptions for 15,194 patients in the A+KIDS program. Unspecified Mood Disorder was the first most common representing 22%.of patients. Bipolar Disorder, Autism Spectrum Disorder, and ADHD, followed at 14%, 12%, and 12% respectively. “Aggression towards others,” “Irritability” and “Tantrums/temper” were the most common target symptoms (representing 63.6% of patients).

Tips on getting paid for providing mental, behavioral health care

Caring for children and adolescents with mental and behavioral health (M/BH) needs in the medical home is important. The current payment system, however, functions as though providing M/BH care is no more demanding than treating strep throat. ![Figure][1] Dr. Wegner While clinicians may

Of Two Minds: An Anthropologist Looks At American Psychiatry

Well, someone can decide by themselves what they want to do and need to do but sometimes, that kind of person will need some of two minds an anthropologist looks at american psychiatry references. People with open minded will always try to seek for the new things and information from many sources. On the contrary, people with closed mind will always think that they can do it by their principals. So, what kind of person are you?