Objectives of Presentation 1. To determine if it is feasible to - PDF document

APNA 30th Annual Conference Session 3023: October 21, 2016 Purpose and Description of this Presentation ASSESSING CLINICAL OUTCOMES IN A COMMUNITY PURPOSE: To describe a community outpatient, BASED OUTPATIENT CHILD AND ADOLESCENT developing a database, assessing treatment progress, and MENTAL HEALTH SERVICE (CAMHS) using data to inform clinic care. DESCRIPTION: In effective care parents and children stay American Psychiatric Nursing Association – Hartford, CT with the treatment interventions. This research looked October 21, 2016 specifically at responder status versus non-responder status. Responder status was associated with the number of appointments in the clinic. Responding to treatment was greater for every subsequent appointment. The practice Ge ra ldine S. Pe a rso n, PHD, APRN, F AAN changes involve increased training around engagement Unive rsity o f CT Sc ho o l o f Me dic ine strategies, improving clarity of realistic treatment expectations. Objectives of Presentation 1. To determine if it is feasible to develop a systematic measurement ‐ based and client specific outcomes The speaker has no conflicts of interest to disclose monitoring methodology under resource ‐ limited treatment as usual clinic conditions. 2. To assess outcomes from a psychotherapeutically sensitive, evidence ‐ based, and measurement ‐ based clinical disease management standard of care 3. Identify Implications of this research emphasizing continuous quality improvement , viewing care as beginning with the first phone call, aiming all clinical activities at client engagement, and educating trainees about measuring progress in treatment NURSING ROLE IN THE CLINIC Importance of this Research • Limited to one psychiatry faculty position – my role as the • This is an era of expanding “Big Data” Clinic Director administrative oversight and a payer • Previously an APRN/prescriber who left the clinic for environment increasingly characterized by family reasons and was not replaced “Pay for Performance.” • Currently one nursing student in a master’s program at Yale School of Nursing working with me • It is important to assess the effectiveness of pediatric mental health treatment delivered • TRADITIONALLY A PHYSICIAN/PSYCHIATRIST DOMINATED CLINIC under usual conditions. • Please keep this in mind as you listen to my presentation – Unlikely that ineffective treatments will be supported in the future, i.e reimbursed Pearson 1

APNA 30th Annual Conference Session 3023: October 21, 2016 History of UHP Child/Adolescent Background of Study Psychiatry Clinic • Increasing evidence ‐ base for pediatric psychotherapy • Began in 2006 at the beginning of the child psychiatry (James et al., 2015) and psychopharmacology (Cox et al., fellowship training at UCONN 2014) treatment efficacy from research RCTs. • Developed as an academic training site for psychiatry • More limited evidence of what works (effectiveness) under TAU conditions. where the primary mission of the clinic is educational with – Limited evidence about “what works for whom” in treating a strong clinical component children and adolescents (Fonagy et al., 2005; Kennedy, 2015) • Primary child ambulatory and continuity of care training – In randomized clinical trial studies “evidence based” outpatient clinic for child and adolescent psychiatry fellows, general mental health treatments for children were generally superior to usual care BUT effect size was small and in some studies TAU psychiatry residents, psychology interns, and third year was superior to evidence based care (Weisz et al., 2013) medical students (participatory in ambulatory care) – Poor documentation of evidenced based or usual care in child and adolescent psychiatric services in naturalistic outpatient clinic settings (Bearman & Weisz, 2015) Implications of Research Literature • Serves 6 to 17 year old children and adolescents with behavioral and mental health disorders of varying severity • Not clear who gets better under TAU conditions • All referrals are triaged by the second year chief resident • Not clear what type of treatment is most effective for in child fellowship and the clinic director specific subgroups (disorder type, age, gender, ethnicity) under TAU conditions • Referrals come from primary care pediatrics, allied mental health professionals, child protective services, juvenile • Not clear what predicts clinical outcomes under TAU court, other mental health clinics, schools and self-referral conditions • Model of in vivo faculty supervision of psychiatric • Not clear what the role of treatment engagement means evaluations and medication follow-ups for outcomes under TAU conditions • Psychotherapy services available in clinic and also • Not clear how to make the clinician more effective under collaboratively in community TAU conditions Multiple Dimensions of the UCONN Model of Treatment Child/Adolescent Psychiatry Clinic • Combination of disorder-specific medication and/or individual cognitive-behavioral therapy/parent management Clinical • Delivered within a psychotherapeutically sensitive, evidence-based, and measurement-based disease management standard of care model (Connor & Banga, 2014) Research Educational Pearson 2

APNA 30th Annual Conference Session 3023: October 21, 2016 Demographics and Population Characteristics Clinic Today • Patients between 6-17 years (mean age 12.42 + 3.04) • 32.2% single parent households • Staffed by 0.4 FTE child psychiatry faculty, 0.6 FTE child • High school education or greater attained by 79.5% of psychology faculty, and 0.4 FTE APRN’s. 4 child mothers (14.5 % unreported) and 69.3% of fathers psychiatry fellows and 2 general adult psychiatry (24.1% unreported) residents see patient ½ to 1 day/week • 64% past or current mental health services at intake • Additional ½ day/week for child fellows of outpatient psychotherapy experience with a focus on trauma • 27% families reported current or past involvement in child protective services • 3 days/week of outpatient treatment experiences for graduate students in psychology • 9% reported current or past involvement with juvenile justice • Systematic collection of data and then a traditional formulation and treatment plan • 33% history special education services • 8-12% reported past traumatic stress experiences including abuse or witnessing domestic violence Clinic Diagnosis Yearly Prevalence Population Demographics and Characteristics 2014 70 Annual Income Commercial Health 60 Insurance: 56.8% Total visits 2014: 2002 • <20,000: 14.7% New Intakes 2014: 133 Percent of Visits 50 Medicaid: 39.3% • 20-40,000: 16.9% Average number of diagnoses: 1.8 40 Self-pay: 1.1% • 40-75,000: 22% 30 Not reported: 4.3% • more than 75,000: 22% 20 • not reported: 17.6% 10 0 Population Demographics and Study Objectives Characteristics • To determine if it is feasible to develop a systematic, 70% 67.3% measurement-based, and patient specific outcomes 62% 60% monitoring methodology under resource-limited, treatment-as-usual clinic conditions. 50% • To assess outcomes from a psychotherapeutically 40% 38% sensitive, evidence-based, and measurement-based clinical disease management standard-of-care model in 30% pediatric mental health (Connor & Banga, 2014). 20% 11% • To identify predictors of outcome in a clinic sample 10% treated under usual conditions. 0% Caucasian: Black/AA: Latino/Hispanic: Male: Female: Pearson 3