Victor Fornari

Frequency and correlates of inappropriate pediatric psychiatric emergency room visits.

BACKGROUND Despite increasing pediatric psychiatric emergency room service (PPERS) visits, data are lacking regarding visit characteristics and appropriateness. METHOD This retrospective cohort study consecutively assessed youngsters aged < 18 years between January 1 and December 31, 2002, utilizing data from a 12-page semistructured institutional evaluation form. Appropriateness, severity, acuity, and harm potential of PPERS visits were rated on a Likert scale. RESULTS Of 1,062 PPERS patient visits (mean +/- SD age: 13.5 +/- 3.1 years, 51.1% male, and 51.2% white), 305 (28.7%) led to hospitalization. Although most patients (68.7%) were in outpatient care, only 21.9% sought and 11.5% completed an outpatient evaluation prior to reaching the emergency room. As many as 34.4% of PPERS visits were somewhat/very inappropriate (optimal care: outpatient evaluation/treatment, even if delayed), 26.6% were somewhat appropriate/neutral (best served by outpatient evaluation/treatment, but timely appointment unavailable), and only 39.0% were fully appropriate. Main reasons for inappropriate PPERS visits were direct emergency room referral from school (P = .0056) or mental health provider (P = .0438) without prior psychiatrist evaluation, or unavailable appointment (P = .0304). Multivariate predictors of inappropriate PPERS visits (r(2) = .296, P < .0001) included current Global Assessment of Functioning score > 48 (P < .0001), absent suicidal ideation/attempt (P < .0001), low harm potential (< 4.4, P < .0001) and severity (< 4.8, P = .0136) (1- to 7-point scale) of presenting complaint, and absent psychosis (P = .0008). CONCLUSIONS Over one third of PPERS visits were inappropriate, characterized by better functioning, low harm potential or severity of presenting complaint, and absent suicidality or psychosis. Development of and improved access to urgent child and adolescent psychiatric outpatient care services in the community and referral agent educational programs may minimize inappropriate PPERS visits.

Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC

OBJECTIVE Although, child mental health problems are widespread, few get adequate treatment, and there is a severe shortage of child psychiatrists. To address this public health need many states have adopted collaborative care programs to assist primary care to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of New York state. PROGRAM DESCRIPTION CAP PC, a component program of New York States Office of Mental Health (OMH) Project TEACH, has provided education and consultation support to primary care providers covering most of New York state since 2010. The program is uniquely a five medical school collaboration with hubs at each that share one toll free number and work together to provide education and consultation support services to PCPs. METHODS The program developed a clinical communications record to track information about all consultations which forms the basis of much of this report. 2-week surveys following consultations, annual surveys, and pre- and post-educational program evaluations have also been used to measure the success of the program. RESULTS CAP PC has grown over the 6years of the program and has provided 8013 phone consultations to over 1500 PCPs. The program synergistically provided 17,523 CME credits of educational programming to 1200 PCPs. PCP users of the program report very high levels of satisfaction and self reported growth in confidence. CONCLUSIONS CAP PC demonstrates that large-scale collaborative consultation models for primary care are feasible to implement, popular with PCPs, and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.