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MNAAP Newsletter

Minnesota Collaborative Psychiatric Consultation Service: Progress and Programming

By Peter S. Jensen, MD, Vice Chair for Research, Department of Psychiatry and Psychology, Mayo Clinic

The Minnesota Collaborative Psychiatric Consultation Service has been in place since August 1, 2012. On April 1, Allina Health joined Mayo Clinic, PrairieCare, Sanford Health, and Essentia. Together, the partners’ child and adolescent psychiatrists and triage mental health professionals are available from 7 am to 7 pm, Monday through Friday, for primary care and psychiatric providers seeking consultation for their most complex patients.

Service categories and specifics include (but are not limited to):

1. Outreach and education enabling collaborative partnerships between mental health and primary care, specifically training and CME for local practitioners to create a cadre of primary care “champions” providing quality mental health services in primary care and ongoing coordination with other collaborative efforts, such as medical homes.

2. Daily psychiatric consultation services to primary care and other health providers using evidence-based, state-approved protocols

3. Claims authorization and consultation procedure codes. Consultees can now code for their participation in the consultation. Claims can be submitted by both primary care providers and psychiatric consultants using the 99499 procedural code and can submit claims online. Providers may bill for a same-day office visit and a consultation when appropriate (see www.mnpsychconsult.com/voluntary-consultations.html).

4. Tools for locating available mental health services, namely Fast-Tracker, an online searchable database of mental health referral resources across Minnesota that provides region-by-region information about available mental health services and is accessible by mental health providers, primary care staff, and/or patients and families.

Data collected through March 19 shows that of the 396 consultations that have taken place, most were mandatory, resulting from prescriptions exceeding medication thresholds determined by the DHS Medication Threshold Workgroup made up of experts in child and adolescent psychiatry.

Consultations were for very complex cases with nearly 40 percent involving ASD Diagnosis. Of the 127 providers who had contact with the service, 88

(69.3 percent) were psychiatric specialists (MDs, CNS/CNP), 29 (22.8

percent) specialized in pediatrics (e.g., pediatricians, developmental and behavioral pediatricians, and pediatric CNS/CNP), 7 (5.5 percent) were family physicians and nurses, and 3 (2.4 percent) were neurologists.

The service also offers education and referral support through the coalition’s nonclinical partners, REACH and the Minnesota Mental Health Community Foundation. REACH has trained 65 to date with openings for 160 more through June 2015.

Trainings are scheduled in Duluth May 10-12, Rochester August 9-11, Moorhead September 20-22, and the Twin Cities October 11-13. The 2-day trainings (Friday 1 pm – Sunday 1 pm) offer a highly interactive training format to train champions for children’s mental health in their clinics. Trainees also benefit from six months of semi-monthly follow-up calls for case discussions. These trainings are integral to one of the service’s goals – building a stronger, more integrated network of providers in every region.

Fast-Tracker, a single source for providers and those seeking services, is available at www.fast-trackermn.org Call 1-855-431-6468 to access the Minnesota Collaborative Psychiatric Consultation Service.

Non-Medical Use of Prescription Stimulants on Campus: Not Just Media Hype

By Pamela K. Gonzalez, MD MS, FAAP, Diplomate ABAM, pediatrician and addiction medicine specialist at Abound Health LLC, adjunct assistant professor at the University of Minnesota and a member of AAP’s Committee on Substance Abuse.

While tobacco, alcohol and marijuana remain the most used and abused substances among adolescents, non-medical use (NMU) of prescription medications remains a serious problem. Reports on NMU, often dubbed “prescription drug abuse,” frequently focus on opioids. This may be due in part to relative greater overall use prevalence and overdose burden.

However, NMU of prescription psychostimulants by adolescents is quite prevalent, especially among US college students. The lay press often refer to these medications as ”study drugs”; a characterization that may minimize potential negative consequences, and miss the nuances of individual motivations for use, and the associated risks.

Before discussing prescription stimulant NMU, it is important to clarify some definitions. NMU may lead to, but is not the same as substance abuse or addiction. NMU generally involves taking a medication for which one does not have a prescription and/or taking one’s prescribed medication in a way other than prescribed (e.g., extra doses, increasing dose on one’s own, etc.) Many can suffer negative consequences from NMU, while their symptoms and behavior may be sub-threshold for a formal substance use disorder diagnosis.

According to Monitoring the Future, prescription amphetamine NMU has trended up since 2009, to current 12 percent by 12th graders. Use is more prevalent among college students, as illustrated by the College Life Study, where nearly two-thirds endorse being offered prescription stimulants by year 4, and just below one-third endorse trying them at least once. Almost 75 percent report the drug they used came from a student with a legal prescription. Other sources suggest that at least 1 in 7 youth receiving prescription stimulants for ADHD endorse diverting their medication.

Why are college kids taking these? A majority endorses academic pressure, needing a competitive edge, and enhanced focus provided by NMU. In fact, prescription stimulant NMU correlates with lower GPA, more class skipping, excessive alcohol use and other drug use, and more complaints of emotional distress and depressed mood. Non-medical users also endorse lower perceived harmfulness.

What is the harm? Common complaints include appetite suppression and sleep disruption. Potentially deadly complications can include hyperthermia, arrhythmia, MI, or stroke. Non-medical users frequently combine with alcohol or other drugs, contributing to drug interactions, unintended overdosage, and development of abuse or addiction. At its psychiatric extremes, some may experience psychotic symptoms (e.g., hallucinations, paranoid delusion) or become acutely suicidal, either during acute dysphoria of intoxication or post-intoxication “crash” when acute depression may ensue. Long-term effects of stimulant NMU remain unknown.

What can pediatricians do? First, ensure the accuracy of an ADHD diagnosis. Shockingly, only about one-quarter of physicians use all recommended components for establishing ADHD diagnosis. Develop a mental health provider network with which you feel comfortable collaborating and referring. This network ideally includes providers with expertise in youth substance abuse. If you are unsure of the ADHD diagnosis or management, refer to an appropriate specialist in your mental health network and/or utilize the Minnesota Collaborative Psychiatric Consultation Service.

Second, advise patients and caregivers against using prescription stimulants as academic enhancers, and educate them about the realities and pitfalls. In patients with established ADHD who are prescribed psychostimulants, reinforce the importance of never sharing or otherwise diverting medication.

Finally, screen for substance use problems at every adolescent encounter, including ADHD follow-up visits, according to the AAP recommended Screening, Brief Intervention and Referral to Treatment framework. Motivational Interviewing is an excellent approach to delivering such brief interventions.

 

What is Developmental-Behavioral Health Pediatrics?

By Tom Scott, MD, FAAP, Interim Director, Developmental-Behavioral Pediatrics Residency Program, University of Minnesota

The care of all infants, children and adolescents involves Developmental-Behavioral Pediatrics (DBP), whether by primary pediatricians or DBP specialists. Composing a relatively new sub-specialty, DB pediatricians provide care for a range of patients with developmental, learning, emotional, and behavioral disorders. Similar to primary care pediatricians, DB pediatricians also focus on healthy child and adolescent development, identifying strengths, promoting resilience, and reducing risk.

DB pediatricians work as individual consultants or in teams. Team members from other disciplines may be on site or in the community and include speech and language pathologists, audiologists, psychologists, nurses, education specialists, occupational therapists, physical therapists, nutritionists, neurologists, geneticists, and child psychiatrists. Sometimes primary care pediatricians consult directly with these other team members.

Whether a patient should be referred to a DB pediatrician, a child psychologist, or child psychiatrist and whether to an individual consultant or to a team depends on the nature and complexity of the problem and availability of specialty resources. Sometimes a referral to a person on the team will result in a recommendation for additional assessment by other team members. There may be overlap in the clinical expertise of specialists on the team, and in complex cases, additional perspectives may be particularly helpful diagnostically. DB pediatricians in Minnesota have varying areas of specialization, including autism, early childhood issues, ADHD, learning disorders, Down’s syndrome, sleep, self-regulation, and hypnosis. Also, some general pediatricians have special interests in DBP and serve as resources for other clinicians.

The following are general guidelines in making referral and consultation requests to DB pediatricians, child psychologists, and child psychiatrists:

Referral/consult request to Developmental-Behavioral pediatrician:
- Complicated school learning,attention, and behavior problems
- Questions of autism spectrum diagnosis and management
- Anxiety and depression
- Persistent somatic symptoms
- Persistent elimination and soiling problems
- Sleep issues

Referral/consult request to child psychologist:
- Questions of co-morbidity with learning and attention problems
- Questions of cognitive status
- Differential diagnosis of anxiety, depression, behavioral issues
- Questions of autism spectrum diagnosis and management
- Individual or family therapy
- Cognitive behavioral therapy

Referral/consult request to child psychiatrist:
- Out of control behavior
- Suicidal issues
- Questions of bi-polar disorder
- Questions of psychosis

Pediatricians in Minnesota, like those throughout the country, have concerns about the availability of DB pediatricians and long waiting lists. At present, almost all DB pediatricians in Minnesota are located in the metro area. A recent study found 86 percent of primary care pediatricians in the United States reporting too few DB pediatricians and 95 percent reporting too few child/adolescent psychiatrists to meet the needs of patients in their practices. In 2011 only 35 first-year DBP fellows were in training in the United States.

In order to address the shortage of DB pediatricians, advocacy at a federal, state and local level is essential.

References:
The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, Third Edition, Marilyn Augustyn, Barry Zuckerman, Elizabeth B. Caronna, editors, 2011.
Encounters with Children, Pediatric Behavior and Development, Fourth Edition, Suzanne D. Dixon and Martin T. Stein, 2006
Primary Care Pediatricians’ Satisfaction with Subspecialty Care, Perceived Supply, and Barriers to Care, Journal of Pediatrics, 2011, Vol. 156, No. 6,1011-1015

Member Profile: Kathleen Kulus, MD, FAAP Pediatrician at CentraCare Clinic

Tell us a little about yourself. Where did you complete your training?

I joined St. Cloud Women and Children’s Clinic right after residency 18 years ago.  About a year and half later, we joined CentraCare Clinic and I was the 12th member of what has now become a 20-person group of pediatric providers.  I attended high school in Edina, undergrad at the College of St.

Benedict, medical school at Mayo and residency at the University of Utah Medical Center/Primary Children’s Hospital. At CentraCare, I work as a general pediatrician. I have special interests in hematology-oncology and work with two other physicians here to cover our outpatient chemotherapy infusion center in conjunction with Children’s Pediatric Hem-Onc Group.

Are there any special programs or initiatives you’ve been involved with?

Our entire group has been involved with improving asthma care for our patients over the last several years and our rates of optimal asthma care have dramatically increased. We were also one of the first sites in the state to be certified as a health care home and continue to improve on that process. We are now working on initiatives to improve immunization rates and improve access to the electronic medical record for our patients.

What are some of the biggest challenges you (and/or your patients) face on a daily basis?

I think some of my biggest challenges are vaccine hesitancy/refusal among our patients’ families, economic disparity and the increasing costs of health care affecting patients directly (particularly with self-funded HRAs/HSAs and high deductibles,) and keeping up with available technology. I continue to keep open discussions with my patients’ families regarding immunizations and provide as much information as possible to them. I am hopeful that health care reform will continue to improve access to care for children, and in terms of technology, I continue to be involved with our EMR… and my kids help keep me up to date!

What do you enjoy most about being a pediatrician?

I love being in the exam room with my patients and their families. Seeing children grow and develop and the relationships we have built over the years has been amazing. I also enjoy watching a hospitalized child become well again.

 If you weren’t a pediatrician, what would you be and why?

I love all of the weather apps on my phone, the Weather Channel and watching for storms, so I think I’d have to say a meteorologist.

What do you enjoy in your spare time? Any hobbies/interests outside of medicine? Family?

I am a hockey mom!  All four of my children play hockey and I love watching them play and my husband coach.  They are also involved in theatre, soccer, softball, tennis, and football and I try to attend as many events as I can.

I also love to read, sew, knit, ski (alpine and Nordic), in-line skate, bike, run, hike, canoe, camp, kayak…..maybe I’m too busy to be a pediatrician!

 Anything else fellow members might be interested to know?

We own property on Turtle Lake just north of Grand Rapids and are in the process of building a log cabin. We have been using trees from the property to do this – my husband cuts them down, we help to peel them, then hand scribe and notch them. So far, it has been about 7 years, and will probably take that many more!

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