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CAC1 AAP Chapter Chat: May 21, 2024

Cal-MAP Consultations: Helping You Manage Patients with Mental Health Challenges

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7:05 - 7:10 Purpose of the Chapter Chat

Renee Wachtel, MD

7:10 - 7:15 Introduction of Speakers

Renee Wachtel, MD

7:15 - 7:30 Overview of the CA Children and Youth & Behavioral Health Initiative

Sohil Sud, MD, Director

7:30 - 8:10 Cal MAP Part 1: Providing Mental Health Consultation

Petra Steinbuchel, MD and Joan Jeung, MD MPH

8:10 - 8:25 Discussion & Questions

8:25 - 8:30 Next Chapter Chat May 28: Delving Deeper into Mental Health Supports for Patients

Agenda

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Introductions

Please use the chat to share:

Your name, role
Your organization and location

Then use this QR code to share your hopes for today's meeting:

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Another day in the office…

Petra does brief intro, then we do role play

Role Play: [Joan’s first time starting an anti-depressant]- cap at 15 minutes

[Petra]: Hello, this is Petra Steinbuchel from Cal-MAP returning your call. How are you doing today?

[Joan, picking up phone]: Thanks for calling! I’ve got a 15 yo girl with a history of daily, severe headaches, crying and begging me for help, saying that she’s at the brink of just wanting to quit everything. She doesn’t know how she’s going to handle the stress of her parents’ arguments and dad’s alcohol and drug use. She says she thinks about suicide but hasn’t made any real attempts. She has started to cut, though, and I can see the scars near her wrists. Parents are refugees who fled racial/religious persecution and have both endured horrible wartime trauma. Our clinic’s social worker doesn’t feel comfortable counseling kids (only Chinese-speaking adults), and I know that our psychiatry wait list lasts for many months. I’ve made the referral, but don’t feel comfortable telling her to just wait as she keeps cutting and despairing. I have never started an anti-depressant medication because of the black-box warning, but I’m wondering if now is the time to try.

[ad lib from here]

Main take-aways:

Coaching/validation
What makes for an effective consultation
Rating scales – trouble finding
Safety assessment- no active SI, no plan or prior attempts, signs of old cuts (last time was about a month ago)
Supports from school, friends; SBHC- counseling
Trust- longitudinal care

Joan: End with brief statement- this is the patient who first got me to prescribe SSRI's and seek more training because I didn't get any training in SSRI use in residency and very little mental health (just enough to know there was a black box warning and that's why we didn't use SSRI's in kids). It mattered a lot for me to be able to talk with a psychiatrist in the moment the first time I did this

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The Youth Mental Health Crisis

Pre-COVID, 1 in 5 US children had a diagnosable mental health disorder (CDC 2018)
Average 2-4 year (up to 11 year) lag between symptom onset and diagnosis (Wang 2004)
Pediatric primary care providers (PCPs) are critical to early screening and intervention in pediatric MH disorders
PCPs provide mental health care in an integrated, accessible and low-stigma setting, with continuity of care
50% of all mental health care is provided by PCPs (Kessler 2005) and 79% of anti-depressants are prescribed by PCPs (Barkil-Oteo 2013)

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Severely limited MH specialist workforce

From https://www.aacap.org/aacap/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx. Accessed May 18, 2021

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Bridging the gap in access to care: Pediatric Mental Health Care Access Programs

From https://www.nncpap.org/map (Updated 1/1/22)

Common Components of Pediatric Mental Health Care Access Programs (PMHCAs):

Real-Time Consultation for PCPs with MH Specialists
Education / CME offerings
Resources, Referrals and Care Coordination

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What is Cal-MAP?

California’s pediatric mental health care access program designed to increase timely access to evidence-based, trauma-informed and culturally responsive mental health care for youth 0-25 throughout California’s communities, especially in the state’s most rural and underserved areas
Empowering Primary Care Providers with increased knowledge, skills, confidence, and interprofessional collaboration can help identify and address many more mental health problems earlier, with continuity of care in lower-stigma primary care settings

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UCSF CAPP -> Cal-MAP

2018-2019

UCSF Philanthropic Funding

Site visits to MCPAP & PAL

September 2019

UCSF CAPP Launch

Feb 2021-Dec 2022 DHCS Prop 56 BHI Central Valley Expansion

August 2021 HRSA Funding

September 2022 HRSA supplemental funding to expand SBHC consultation & training

September 2023 HRSA 2023 – 2026 supplemental funding supports SBHC consultation & training

April 2024 CA DHCS CYBHI launches Cal-MAP

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Advance Equity

Designed for Youth by Youth

Start Early, Start Smart

Center around Children & Youth

Empower Families & Communities

Right Time Right Place

Free of Stigma

California’s Child Youth Behavioral Health Initiative Aims

Increase behavioral health care access youth 0-25 by building PCP workforce capacity to address behavioral health needs within PC settings

Synchronous and asynchronous expert consultation and PCP support in the treatment of common behavioral health conditions

Support identifying and connecting with local/telehealth behavioral and other necessary resources & referrals

Disseminate accessible, culturally responsive evidence- and measurement-based care, especially in rural & underserved communities

Cal-MAP Aims

Access

Equity

Connection

Workforce

Development

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Partnership with AAP-CA Chapter 1

Since 2019, collaboration on a series of educational offerings and grants:

Partnership to reach out to NorCal counties during HRSA-funded expansion
Regular AAP/CAPP meetings
AAP Chapter 1 membership on CAPP Advisory Council
Chapter Chats, newsletter articles, e-blasts
Focus Groups

HRSA

Partnership as CAPP rebrands as Cal-MAP and spreads state-wide (with CAFP & NAPNAP)
Focus groups
Social media posts/newsletters
Outreach activities (CME conferences, professional meetings, etc)

AAP – PMHCA

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What does Cal-MAP offer?

Consultation: Real-time, direct-connect PCP-to-child and adolescent psychiatrist telephone consultation for California-based primary care providers regarding screening, diagnosis, and treatment for youth ages 0-25.
Education: PCPs and school-based clinicians and staff can access no-cost trainings that offer accredited continuing medical education (CME) and continuing education units (CEUs).
Resource Navigation: LCSW and MSW social workers can provide guidance on resources and referrals to PCPs and direct support for families facing significant linkage barriers to connect with services.

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Continuum of Tech-Enabled�Behavioral Health Integration

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Current Footprint

4177 consults on ~3277 unique lives

277 practices

2527 PCPs

44 of 58 CA counties

Cal-MAP

Connecting for Care

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Provider-to-Provider Curbside Telephone Consultations

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Provider-to-Provider Curbside Telephone Consultations

Call 1-800-253-2103 or “Request a Consultation” on https://cal-map.org
Monday – Friday from 8:30am – 4:30pm
Receive call from psychiatrist within 5-10 minutes or schedule a consultation time

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Information Collected Prior to Consult

Provider demographic information
Preferred call-back time, and consultation letter method (fax, email)
With parent / youth verbal or written consent:

Patient demographic information (name, DOB)
Patient insurance (for resources/referrals, no billing)

Without consent:

Patient initials and age

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Known /Suspected Diagnoses	Primary	Secondary
Anxiety Disorder	29.4%	34.8%
Depressive Disorder	24.3%	22.2%
ADHD	24.3%	11.4%
Substance-Related Disorder	0.5%	1.0%
Autism Spectrum Disorder	7.3%	3.7%
Trauma & Stressor-Related Disorder (e.g. PTSD)	4.3%	3.9%
Feeding & Eating Disorder	2.3%	2.3%
Suicidality or Self-Harm	0.6%	1.0%
Other	5.2%	6.6%

48% of consults involved 2+ psychiatric diagnoses

22% 3+diagnoses

CAPP Consult Questions & Diagnoses

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User Satisfaction Survey July '21 - March '24
Question	Mean Satisfaction	n
Calling for consultation fits well within my day-to-day practice.	4.51	306
I am able to consult in a timely manner.	4.77	307
The consultant provides recommendations that are helpful for my patients.	4.89	307
I consult when I have a question about the mental health care of my patients.	4.77	306
I am able to implement the consultant’s recommendations in my clinical care.	4.79	305
I will continue to consult in the management of my patients' mental health concerns in the next year.	4.92	306
Overall, I am satisfied with the guidance I receive through this consultation	4.89	304
Through CAPP, I am deepening my knowledge, skills, and comfort in managing behavioral health conditions	4.7	304

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Consult modality: Phone Consults

Aug 2023 AAP Chapter Chat Focus group

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

When interactivity, urgency, complexity, real-time connection are priorities

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Consult modality: e-Consults

Aug 2023 AAP Chapter Chat Focus group

Takeaway:

Provide both phone & e-consult options to accommodate different preferences & needs.

When scheduling flexibility is a priority, & for non-urgent cases, & straightforward questions

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Did receiving consultation lead to changes in any of the following areas?

My practice has made at least one practice-level change in processes to address pediatric mental/behavioral health

My ability to speak with parents/caregivers about their child's mental/behavioral health issues

My referral patterns

My use of diagnostic tools and approaches

My use of psychotropic medications to address pediatric mental/behavioral health conditions

My use of nonpharmacological interventions to address pediatric mental/behavioral health conditions

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

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Key Themes (Focus Group)

Facilitators

Relationship-building between PCPs and consulting psychiatrists builds PCP trust and confidence and promotes consultation utilization
Integration of CAPP into the workflow
Support and buy-in from leadership at the practice and health system level

Barriers:

Lack of time
Major systemic barriers that limit mental health care access
Gaps in PCP knowledge/comfort
Billing/reimbursement challenges

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Supporting Cal-MAP Implementation & Usage

From: Integrated Care: A Guide for Effective Implementation. 2017 edited by LE. Raney MD, GB. Lasky PhD, MAPL, C Scott, LCSW.

2020 PMHCA MCPAP study:

86% of families expressed satisfaction with PCP’s handling of their child’s mental health after MCPAP consultation
Recommendations made by MCPAP to PCPS aimed to strengthen the PCP’s role as a mental health provider

Before Implementation of Integrated Care	After Experience with Integrated Care
This is going to slow me down	This takes a load off my plate
I don’t have time to address one more problem	This speeds me up
I already do a good job of treating mental illness	I always want to practice like this. I am giving better care to my patients.
This is going to drag me down like an anchor	This gives me time to finish my notes

Cama et al 2020. Impact of Child Psychiatry Access Programs on Mental Health Care in Pediatric Primary Care: Measuring the Parent Experience

Identify a Site Champion

Point-person who shares information about Cal-MAP, encourages Cal-MAP use and may act as a liaison

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Benefits of Enrolling in Cal-MAP

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Feedback from PCPs

”[Cal-MAP] consultation helps to address Provider Burnout, so that you can keep your FQHC staff around, which is beneficial for everyone. I think if there is a pressure to see volume, you get compassion fatigue. You start feeling more unsure that you're actually making a difference, or how to really do that effectively. Having resources and tools available increases your feeling of confidence and willingness to keep trying and not to just send everybody to the emergency room. It makes you want to schedule that 2 week follow up appointment and squeeze them in."
"I believe it saves lives."

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More Feedback...

"It has increased my self-confidence in managing these issues. I am more likely to try things because I have CAPP as a safety net. It gives my patients comfort because they know that I am consulting an expert."

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How to Enroll

https://cal-map.org/s/registration?language=en_US

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Questions? Suggestions?

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Connecting For Care

Sunflowers communicate with each other underground through their root system, to ensure optimal growth for all.

Similarly, we want to ensure we are connecting for care with you, to ensure optimal development of California’s youth.

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Questions?

Contact: Petra Steinbuchel, MD

Petra.Steinbuchel@ucsf.edu

Joan Jeung, MD FAAP

Joan.Jeung@ucsf.edu