Sunday, March 23, 2008

More questions. Ever more questions.

More questions from the RFI:

(1) How should CSAs ensure that Care Planning Teams have access to needed medical and psychiatric expertise? 
The medical and psychiatric needs of the members of the Rosie D. class are likely to vary from case to case;  most children with Serious Emotional Disturbance will need a primary care provider and some sort of specialist in diagnostic evaluation and treatment (child psychiatrist, child neurologist or developmental/behavioral pediatrician).   However, I would not separate them from the rest of the team-  the physicians need to be tightly integrated with the team, not just consultants who intermittently offer opinions.  One of the problems with the current model of "medication consultation" is that the psychiatrist is not afforded time to understand the patient and family before being forced to offer an opinion.  Medical and psychiatrists serve several roles on the team:
1)  Diagnostic:  Sorting out these symptoms requires a physician who understands child development, the wide range of normal, and the various diagnoses we need to consider.  They also are key to understanding the role of social factors and physical illness in the process.
2)  Therapeutic:  Physicians (generalist and specialist) often have a better idea of what is possible in the mileau in which the patient lives.  They are also able to prescribe medications, although one must be careful of over-medicating or "off-label" use of medications.
3)  Monitoring:  Efficacy and side -effects.  This approach has been well addressed in the "chronic disease model mentioned earlier.
4)  Advocacy:  A doctor can be of great assistance to the family in navigating the system.
A few ideas, which depend on the model of care:
1)  If the CSAs serve mostly to link families and services through care coordination, then is incumbent on the CSAs to make connections with local resources.  In areas that are currently devoid of services, the CSA may need to be the conduit for care.
2)  In areas with little access to needed services, the MCPAP program can serve to support primary care physicians who often serve the role that would be better served by child psychiatrists.
3)  CSAs in areas with few resources may wish to pursue telepsychiatry as a means of access for child psychiatry.
4)  Supporting the expansion of the profession:  All three of the subspecialists mentioned above are not well compensated for caring for these complex children.  That needs to be addressed.

(2) Which of the needs listed above are likely to occur most often, or require most extensive use of medical or psychiatric expertise?
It seems to be that the hardest thing in all of this is the diagnostic formulation;  in the ideal world that takes the most time, and requires clear thinking and a comprehensive overview of what is going on.  Over and over again, we hear from families that "no one has truly evaluated my child", while the child is on a regime of 4 or 5 psychotropic medications, each one treating the side effects of the medication prescribed previously.  The diagnosis in children has to be developmental and fluid, but as important is that the diagnostic process allow that family to be heard.
After that is the sorting of therapeutic options:  medications (mostly prescribed off-label, with limited evidence), various forms of therapy, educational planning.  In the new model, there will need to be an integration of things with the wraparound components.

(3) Based on your program experience and knowledge of the clinical workforce issues in your region of Massachusetts, what staffing arrangements make most sense for CSAs in providing medical and psychiatric expertise? Which disciplines (e.g., child psychiatrist, child-trained APRN, child-trained RN, behavioral pediatrician, or other medical professionals) can be most useful in which roles?
In Central Massachusetts, we have a strong group of primary care pediatricians who are interested and willing to work with children with SED, but who are beginning to feel the time pressure of practice-  i.e. how do I make time in the day to be part of a multi-disciplinary team.  We have a number of agencies working with children with mental health issues in Worcester and a robust private practice community in the Worcester city;  psychiatric resources outside of the city are almost non-existent, especially in the South Central and Blackstone Valley regions.  We have no access to behavioral pediatrics for children under 5 and one behavioral pediatrician for children over 5 IN THE ENTIRE COUNTY!  Child psychiatry is a bit better- there are limited services for children in Worcester through 5 or 6 or so FTE child psychiatrists in the City, and 1.5 FTE in South Worcester County.  Child neurology is similarly limited.  The MCPAP program is robust, but is asked to see complex children frequently (given the conditions mentioned about)

4) What suggestions/lessons learned do you have regarding collaboration with community medical professionals, including child psychiatrists?
1)  Enable multiple modes of communication (beeper, phone, e-mail)
2)  Allow short term consultation
3)  Recognize the limits of the model.
The MCPAP has shown that the most important component of providing collaborative care is the development of an on-going relationship between the PCPs and the child psychiatrist;  both professions can provide better care from the ability to converse in person and via e-mail.  The program has allowed us to "leverage" existing resources in the County, which has been useful for both the SED kids and the kids who are "one notch below" SED.  THe relationship must include a recognition by the consultant that, in most cases, when the PCP asks the consultant to meet with the family in person, that is a serious request that must be honored.  Also, there are some kids where the MCPAP relationship is not enough-  the system should have flexibility to allow psychiatry to move from a consultative to a therapeutic role, and back again.

(5) What are pros and cons of the CSA providing ongoing psychopharmacology services for enrolled children?
Given the overall shortage of providers for psychopharm services in the Commonwealth, it is difficult to think of any downside to the CSA providing services to clients. Except this: perhaps our shortage of providers is the only thing preventing a higher degree of overmedication than what we see already. The evidence base for much of our management of children with mental illness is small, and needs to grow. I would submit that any psychopharm services provided through the newly established CSA include a strong evaluation components, recognizing the quasi-experimental nature of much of this and serving as an entry point to a multitude of clinical trials designed to answer the question- is this medication in this situation worth the risk? The downside of providing more psychopharmacology is that the market will drive us to overmedicate, if we let it do so.

(6) Is there a role for regional or statewide collaboration in ensuring access to medical and psychiatric expertise for ICC?

Yes. I think that is inherent in the responses lists above.

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