Friday, January 2, 2009

A New Year: How Fares the Screening?

Last year at this time, we were implementing universal behavioral health screening in primary care practices around the Commonwealth, and there was much concern that it would take to long and that the findings would overwhelm the mental health system.  Our practice has been doing the screens pretty consistently now for a while- let me talk about in the context of a typical winter day in the office.
After Staff meeting (new influenza vaccine shipment arrived, so be sure to offer shots to those who want it), we start with the patients.  My morning has 4 check-ups, an ADHD follow-up and three children with acute illness (light morning, lots of folks away over Christmastime, I guess).  The first is an 18 month old, new to the practice, with a positive M-CHAT.  After introductions (both parents are here for the visit), we discuss the findings- turns out the child is already seeing a developmental specialist and early intervention because of prematurity.  The new two are school-aged siblings with normal PSC scores;  life for them seems to be going well.  The last young man is a 14 year/old with a history of a depression, who we referred for mental health services last spring, here for his annual physical.  His Y-PSC and CRAFFT are both negative, and yet, in conversation, I find that I am concerned: he still seems depressed to me, despite the negative screen.  He is not interested in reconnecting with counseling, and happy with his schoolwork and friends at the present time.  Not sure about him;  I feel like we've missed something, and yet, we followed all of the rules and protocols.I am way behind now, and must move along.  The illnesses are indeed routine-a cold, an ear infection, a cough of unknown origin.  The young lad with ADHD, however, is a bit interesting.  Diagnosed by me and a psychologist 3 years ago, he improved with stimulant medication which developing headache and major weight loss, so much so that we elected to go with behavior modification and no medications.  Now he is older and bigger and not doing well in the 5th or 6th grade.  The family wants to try medication again.  We discuss side effects and identify behavioral markers for his treatment, and, after 30 minutes, we part, to check in in a month to see what his weight has done.  And I've worked through lunch.
Screening for behavior health in our office has gotten to be so routine that I don't think that it takes up much time for us; what takes time is dealing with behavioral health issues we identify, and in this morning, that was 37% of my patients at three different developmental stages and with three different sets of problems.  Two of them are already hooked into the developmental health/ mental health systems;  why did I have to spend so much time with them?  Well, I may be getting slow in my old and curmudgeonly way, but the reality is that I spent the time talking to be sure that they were in the right place and comfortable with the management that they were getting.  In point of fact, I spent another 10 minutes with one of those families in the evening, double checking things and being sure that they were comfortable with the plan.  Screening is not taking up my time.  Management is.
The afternoon has 4 well child visits, 3 ADHD follow-up and 9 acute sick visits- pretty typical for this time of year.  The screenings at all of the well-visits are negative- well three are negative, one wasn't completed by the family of a three year old and, since I was a bit late getting into the room, I didn't ask the father to fill it out at that point.  One of the ADHD checks was a 17 year old who wanted to stop taking medication, a request that I am always joyful to honor.  He thinks that he has matured to the point where he can manage his ADHD without medication, and indeed has been doing so for the last month.  We discussed the need for honest self-assessment and assuring that he graduates and I wished him good luck.  I will see him for his pre-college physical in the spring, so we will see if it indeed has gone according to plan.  The sick visits back up a bit toward the end of the day; a couple of kids need x-rays, and that always slows us down.  Still, when I don't have to actively manage mental health issues, I actually get done on time.
So, we had 8 physicals, 7 of whom were screened as per protocol, and 1 of whom was positive, as well as 4 other visits focusing on mental/ behavioral health issues in a day with 24 patient visits booked.  Our screening rate for the practice as a whole is about that, our positive rate is still about 10% and our success at referring the positives for more complete evaluation is running about 30%, usually because the family is ambivalent about the need,  the intake process is time-consuming and services are available at inconvenient times and places.  Screening hasn't transformed our practice;  as I have said in the past, I worry more about the kids that the screening misses, like my 14 year/old patient from the morning.    For our practice, at least, it has served mainly to remind us that 20%-30%  of our patients have mental health issues, and that they are likely to be active at the time of a check-up about 10% of the time.  I am curious to see if that experience is similar to folks in other parts of the state.  Drop me a comment one way or the other.

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