RECENT PERINATAL MENTAL HEALTH POLICY CHANGES: CLINICAL IMPLICATIONS - - PowerPoint PPT Presentation

RECENT PERINATAL MENTAL HEALTH POLICY CHANGES: CLINICAL IMPLICATIONS IN PRIMARY CARE

NANCY W SELIX, DNP , FNP-C, CNM UNIVERSITY OF SAN FRANCISCO SCHOOL OF NURSING AND HEALTH PROFESSIONS SAN FRANCISCO, CALIFORNIA

LEARNING OBJECTIVES

• IDENTIFY CURRENT PERINATAL MENTAL HEALTH POLICY CHANGES FROM:
• 2010 AMERICAN PEDIATRIC ASSOCIATION (APA)
• 2014 MENTAL HEALTH ASSOCIATION OF AMERICA (MHA)
• 2105 AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS (ACOG)
• 2016 UNITED STATES PREVENTIVE SERVICES TASK FORCE (USPSTF)
• COMPARE DIFFERENCES AND GAPS BETWEEN THESE POLICIES
• DESCRIBE CLINICAL IMPLICATIONS OF THESE RECENT POLICY CHANGES AND HOW CARE CAN

BE IMPROVED

AMERICAN PEDIATRIC ASSOCIATION (APA)

• 2010 APA RELEASED BRIGHT FUTURES PROGRAM AND RECOMMENDATIONS TO SCREEN

MOTHERS FOR DEPRESSION

• RECOMMENDS SCREENING AT 1, 2, 4, 6 MONTH WELL-BABY VISITS
• RECOMMENDS EPDS OR PHQ-2
• RECOMMENDS USING COMMUNITY RESOURCES FOR MATERNAL TREATMENT AND REFERRAL

Mental Health Association of America (MHA)

• 2014 MHA RELEASED POSITION #49: PERINATAL MENTAL HEALTH
• IDENTIFIED VALUE OF SCREENING, TREATMENT, AND REFERRAL OF PREGNANT AND POSTPARTUM

WOMEN

• INCLUDED SUGGESTIONS FOR TIMING OF SCREENING PRENATALLY, POSTPARTUM, DURING CHILD

WELLNESS VISITS, AND AS A CONDITION FOR RETURN TO WORK FOR WORKING MOTHERS, AND IMPORTANCE OF COORDINATED PROGRAM OF FOLLOW UP FOR THOSE WHO SCREEN POSITIVE

• RECOMMENDS CO-LOCATED MENTAL HEALTH PROFESSIONAL (IN PERSON OR BY TELEHEALTH)

WHERE SCREENING IS DONE

• PHQ-9 OR EPDS

American College of Obstetricians and Gynecologists (ACOG)

• 2015 CREATED PERINATAL MENTAL HEALTH POLICY THAT REPLACED PREVIOUS POLICY
• RECOMMENDS SCREENING TREATMENT AND REFERRAL
• SCREEN ONCE IN PERINATAL PERIOD FOR DEPRESSION AND ANXIETY
• MORE FREQUENTLY FOR THOSE WOMEN AT INCREASED RISK, WITH POSITIVE HISTORY, OR

SYMPTOMATIC

• TREAT OR REFER IF SCREENS POSITIVE
• CREATE SYSTEM TO FOLLOW UP FOR THOSE WHO SCREEN POSITIVE OR ARE SYMPTOMATIC

United States Preventive Services Task Force (USPSTF)

• 2016 INCLUDED PERINATAL MENTAL HEALTH FOR THE FIRST TIME AS A PREVENTABLE AND

TREATABLE MENTAL HEALTH PROBLEM

• LISTED PERINATAL MENTAL HEALTH ALONG WITH GENERALIZED DEPRESSION AS A CATEGORY B

RECOMMENDATION FOR SCREENING TREATMENT AND REFERRAL

• DESCRIBES PHQ-9, EPDS AS CHOICES FOR SCREENING
• RECOMMENDS CBT OR NON-PHARM TREATMENT PRIOR TO USING PHARMACOLOGIC

TREATMENT IN PREGNANT WOMEN

• DOES NOT RECOMMEND SPECIFIC TIMES FOR SCREENING

MEDICAID

• IN 2016, MEDICAID (MEDI-CAL) BEGAN REIMBURSEMENT TO ALL PROVIDERS WHO SCREEN

AND REFER FOR PERINATAL MOOD DISORDERS

• REIMBURSEMENT TIED TO EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT)

PROGRAM

• MATERNAL SCREENING BY MATERNITY CARE PROVIDERS NOT COVERED

21ST CENTURY CURES ACT

• PROVIDES FUNDING TO STATES FOR CREATING PROGRAMS THAT SCREEN AND TREAT WOMEN

WITH PERINATAL MENTAL HEALTH PROBLEMS

• MAY BE TREATED WITH OR WITHOUT CO-OCCURRING SUBSTANCE USE DISORDER
• SOME STATES HAVE ALREADY RECEIVED FUNDING FOR SUCH PROGRAMS
• EXCELLENT OPPORTUNITY FOR GRANT WRITING TO CREATE NEW PROGRAMS AND

COORDINATE EXISTING CARE

COMPARISON OF POLICIES

POLICY SCREENING FREQUENCY SCREENING TOOLS TREATMENT APA AT WELL CHILD VISITS: 1, 2, 4, 6 MONTH VISITS PHQ-2 EPDS USE COMMUNITY RESOURCES FOR TREATMENT MHA DURING PREGANANCY, POSTPARTUM, AT WELL CHILD VISITS, ER VISITS, WIC VISITS, BEFORE RETURN TO WORK PHQ-9 EPDS CO-LOCATION OF MENTAL HEALTH SERVICES IN PRIMARY CARE, TELE-MENTAL HEALTH ACOG AT LEAST ONCE IN PERINATAL PERIOD, MORE FREQUENT IF SYMPTOMATIC PHQ-9 EPDS OTHERS PROMPT TREATMENT OR REFERRAL USPSTF NO SPECIFIC FREQUENCY, MUST HAVE ADEQUATE SYSTEMS FOR TREATMENT IN PLACE PHQ-9 EPDS RECOMMENDS CBT, OTHER NON-PHRAM TREATMENT PRIOR TO MEDS IN PREGANANCY

CLINICAL IMPLEMENTATION

Tool Screening Frequency Location for Screening EPDS, PHQ-9 Prenatal visits – at least once Postpartum period Maternal care providers WIC service providers Emergency or urgent care providers if pregnant or postpartum 12 moths

• f less

EPDS, PHQ-2 Well child visits – 1,2, 4, 6 months Pediatric care providers WIC service providers EPDS, PHQ-9 As condition for return to work Maternal care provider or Occupational health provider

GAPS IN IMPLEMENTATION IN CLINICAL CARE

ACCORDING TO THESE PUBLISHED POLICIES, GAPS IN SCREENING EXIST

• ROUTINE PERINATAL SCREENING AT SPECIFIED TIMES DURING ANTENATAL AND POSTPARTUM

PERIODS NOT CLEARLY DEFINED

• SCREENING NOT SPECIFICALLY DEFINED AFTER 6 MONTH WELL CHILD VISIT
• PROVIDERS MUST USE INDIVIDUAL JUDGMENT TO DETERMINE WHICH WOMEN NEED

ADDITIONAL SCREENING AT TIMES NOT LISTED IN POLICIES BASED UPON RISK FACTORS AND CLINICAL PRESENTATION

WHERE DO WE GO FROM HERE?

• CREATE A LIST OF PERINATAL MENTAL HEALTH RESOURCES IN YOUR COMMUNITY
• PROVIDE TRAINING FOR STAFF MEMBERS AND PROFESSIONALS (CNM, NP

, MD, LACTATION SPECIALISTS, WIC NUTRITIONISTS) WHO IMPLEMENT SCREENING AND REFERRAL

• INCLUDE MORE THAN JUST DIRECTIONS FOR SCREEN ADMINISTRATION-
• DE-STIGMATIZATION AND NORMALIZATION OF SCREENING
• VALUE OF A COORDINATED PROCESS FOR TREATMENT AND REFERRAL FOR THOSE WHO SCREEN ABOVE

THE CUT OFF SCORE

• TYPES OF TREATMENT THAT ARE PHARMACOLOGIC AND NON PHARMACOLOGIC
• EMOTIONAL SUPPORT AS WOMEN TRANSITION FROM PCP TO MENTAL HEALTH PROVIDERS

(COORDINATION OF THAT CARE AND WARM HAND OFF WHEN POSSIBLE)

THANK YOU

• NANCY SELIX DNP

, FNP-C, CNM

• NWSELIX@USFCA.EDU