Caring Wisely FY 2023 Project Contest

UCSF Peds-Psych Collaborative Pathway

Submitted by Dimitri Macris on March 21, 2023 - 9:54am Last revised by Catherine Lau on June 12, 2023 - 10:25am.
Proposal Status: 
Awarded
PROJECT LEAD(S): Anne Glowinski, Dimitri Macris
EXECUTIVE SPONSOR(S):
ABSTRACT-One paragraph summary of your proposed initiative–Limit 1500
characters (with spaces)
  • In December 2021, the United States Surgeon General declared a Mental Health Crisis for the US Youth. With rising rates of depression, anxiety, suicidal thoughts, and attempts, the number of youths requiring mental health services continues to rise. However, there is limited capacity within our healthcare system to meet these surging needs. In addition to the public health impact, this results in an undue burden on other parts of our healthcare system, in particular increased emergency visits and increased boarding in EDs and on general pediatric wards. The Collab clinic aims to reduce the impact and cost of care in these settings by utilizing an established Child and Adolescent Psychiatry teaching clinic to provide a combination of services for UCSF Pediatricians, including eConsults and a brief consultation component for patients. The clinic will take place one half-day a week with three Child Psychiatry Fellows and one Faculty during which patient’s pediatric providers will receive guidance on measurement-based tracking of symptoms, treatment response, and other resources. In addition to reducing costs by preventing worsening mental health challenges including suicide, the third leading cause of death in adolescents,this initiative will generate revenue by leveraging novel eConsult billing codes developed in 2020 and established billing codes for an estimated combined total savings plus revenue generated of about $260,000.

TEAM-Core implementation team members and titles.
  • Anne Glowinski MD
    • Robert Porter Distinguished Professor of Child and Adolescent Psychiatry
    • Division Director, Child and Adolescent Psychiatry
    • UCSF Child, Teen and Family Center and Children Benioff Hospitals
    • Medical Director, UCSF/UCB Schwab Dyslexia and Cognitive Diversity Center
  • Dimitri Macris MD
    • Child and Adolescent Psychiatry Fellow
  • Noel Rosales MD
    • Professor, UCSF Pediatrics at Mt. Zion 
PROBLEM-Background of the problem. What is the cost associated with this problem?
Why address this problem now? What is the current condition?
 
At the end of 2021, the US surgeon General released a report, Protecting Youth Mental Health officially stating that US Youth are experiencing a Mental Health Crisis due to the experiences of their generation.1 Even prior to the COVID-19 pandemic, Mental Health issues were already rising and the leading cause of disability and poor life outcomes in young people, with up to 1 in 5 children ages 3 to 17 in the US with a reported mental, emotional, developmental, or behavioral disorder.2 From 2011 to 2021, the proportion of high school students reporting: persistent feelings of sadness or hopelessness increased by 50%; the number of students seriously considering attempting suicide increased by 38%; and the number of students creating a suicide plan increased by 38%.3  Between 2007 and 2018, suicide rates among youth ages 10-24 in the US increased by 57%.4 Within the Surgeon General’s report, there was a call to action for healthcare systems to build multidisciplinary teams to implement mental health services that are tailored to the needs of children and their families.1 This crisis has not escaped the attention of UCSF leadership, who recognize that it is imperative to work collaboratively on imagining and implementing alternatives to our care as usual with its long waitlists and long retention times in Psychiatry clinic for existing patients. 

Across the country there is a shortage of Child and Adolescent Psychiatrists. AACAP’s recommends that there are 47 child psychiatrists per 100,000 youth. In a report from 2022, California had 11.8 child psychiatrists per 100,000. Within the Greater Bay Area, there were 18.7 per 100,000.5 With an estimated population of 1.2-1.5 million children and teens in the Bay Area, we have a disparity of 336-425 Child and Adolescent Psychiatrists. Over the next decade there is an estimated 45% of psychiatrists will be over the age of 60 and likely to retire. 6 The time to establish a network of expanding collaborative access to care is now to prepare for a worsening shortage in child psychiatry capacity. 

Currently at UCSF, our waitlist to receive outpatient child and teen psychiatric care is about 1 year, which leaves our patients with minimal psychiatric care in the interim or forces existing UCSF pediatric patients’ families to seek care elsewhere resulting in fragmented care. With more youth experiencing mental health crises and the dearth of providers, there is a concomitant rising burden on existing systems of care,that already cannot adequately treat those in need. With limited access to care, many of our patients’ symptoms worsen over time and families turn to our emergency department for support. Between 2011 and 2015, youth psychiatric visits to emergency departments for depression, anxiety, and behavioral challenges increased by 28%.7 

With more youth presenting to the ED for care, there is an additional strain on the broader healthcare system. In a review, McEnany et al in 2020, found that 23%-58% of youth requiring inpatient psychiatric care experienced boarding and 26-49% experienced boarding on pediatric wards. The average boarding duration ranged from 5-41 hours in the ED and 2-3 days on wards. 8 Pre-pandemic, Caudius et al examined the question of mental health care received while boarding and found suboptimal care suggested by only 6.1% of youth admitted for isolated psychiatric reasons with documented receipt of individual or family counseling and 20.1% had received psychiatric medications (relative to 53.3% who had received psychiatric medications before hospitalization).9 Furthermore, reductions in outpatient services compound the problem of decreased numbers of psychiatric beds. Community patients with psychiatric illnesses cannot access timely outpatient care, because resources have become more limited. This creates a “revolving door” in the ED, with patients failing to connect to outpatient care.10 

This pathway fulfills Caring Wisely’s central aims of improving outpatient access to psychiatric care as well as improving health equity.  This is a proof-of-concept study that will guide the transformation of child psychiatric care services in our Division; and help change current practice patterns and habits across UCSF Child Psychiatry including in our Oakland clinic, which renders care to under-served Bay Area communities. Additionally, it serves to meet 2 of the 3 health needs identified in UCSF's 2022 Community Needs Health Assessment by addressing improving access and improving behavioral health. In that report, a community health service provider said, "[m]ental health has been one of those things where you really feel helpless....they can't even engage in services." We have the opportunity to address our helplessness through action.

References: 

  1. United States. Public Health Service. Office of the Surgeon General. (2021). Protecting Youth Mental Health. U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General. https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf 

  1. Perou, R., Bitsko, R. H., Blumberg, S. J., Pastor, P., Ghandour, R. M., Gfroerer, J. C., Hedden, S. L., Crosby, A. E., Visser, S. N., Schieve, L. A., Parks, S. E., Hall, J. E., Brody, D., Simile, C. M., Thompson, W. W., Baio, J., Avenevoli, S., Kogan, M. D., Huang, L. N., & Centers for Disease Control and Prevention (CDC) (2013). Mental health surveillance among children--United States, 2005-2011. MMWR. Morbidity and Mortality Weekly Report Supplements, 62(2), 1–35. 

  1. Centers for Disease Control and Prevention. (2022). Youth Risk Behavior Surveillance Data Summary & Trends Report: 2011-2021. Retrieved from https://www.cdc.gov/healthyyouth/data/yrbs/pdf/YRBS_Data-Summary-Trends_Report2023_508.pdf 

  1. Curtin, S. C. (2020). State suicide rates among adolescents and young adults aged 10–24: United States, 2000–2018. National Vital Statistics Reports; vol 69 no 11. Hyattsville, MD: National Center for Health Statistics. 

  1. California Health Care Foundation. (2022) Mental Health in California: Waiting for Care. https://www.chcf.org/wp-content/uploads/2022/07/MentalHealthAlmanac2022.pdf 

  1. Coffman, J., Bates, T., Geyn I., and Spetz, J. (2018). California’s Current and Future Behavioral Health Workforce. California’s Current and Future Behavioral Health Workforce | Healthforce Center at UCSF. https://healthforce.ucsf.edu/publications/california-s-current-and-future-behavioral-health-workforce 

  1. Kalb, L. G., Stapp, E. K., Ballard, E. D., Holingue, C., Keefer, A., & Riley, A. (2019). Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US. Pediatrics, 143(4), e20182192. https://doi.org/10.1542/ peds.2018-2192 

  1. McEnany FB, Ojugbele O, Doherty JR, McLaren JL, Leyenaar JK. Pediatric Mental Health Boarding. Pediatrics. 2020 Oct;146(4):e20201174. doi: 10.1542/peds.2020-1174. Epub 2020 Sep 22. PMID: 32963020. 

  1. Claudius I, Donofrio JJ, Lam CN, Santillanes G. Impact of boarding pediatric psychiatric patients on a medical ward. Hosp Pediatr. 2014; 4(3):125–132 

  1. Bender D, Pande N, Ludwig M. A literature review: Psychiatric boarding. US Department of Health and Human Services, 2008. Available at: http://aspe.hhs.gov/daltcp/reports/2008/psybdlr.htm. 

  1. Evan Fieldston, Jennifer Jonas, Alexander M. Scharko; Boarding of Pediatric Psychiatric Patients Is a No-Fly Zone for Value. Hosp Pediatr May 2014; 4 (3): 133–134. https://doi-org.ucsf.idm.oclc.org/10.1542/hpeds.2014-0029 

TARGET-What is the goal? What are the expected benefits, both qualitative and quantitative?
 
The goal of this project is to improve access to mental health care through an
eConsult model.The goal of this project is to improve access to mental health care through an eConsultand Brief Consultation model. 
  • Benefits: children and teenswill get access to appropriate mental health assessments and treatment faster, which will prevent worsening of illness, thus reducing the number of youth presenting to the ED for psychiatric care; reducing the wait times form mental health care at UCSF; and improving the quality of life of our youth and their parents. 
  • As part of the treatment, measurement-based care would help to track psychiatric symptoms and response to treatment. We would utilize the Mirah platform, a unique compilation of all clinically validated psychometric rating scales in one single platform, which doesn’t exist on the market elsewhere and would allow for use of screening and treatment monitoring assessments at a lower price than paying for individual licensing agreements: https://mirah.com/ 
  • Additionally for cost savings, we can compare the number of ED visits, inpatient hospitalizations, and ED boardings for psychiatric ICD-10 codes 6 months pre and post initiation of the intervention.             
GAPS-Why does the problem exist? Describe system issues; technological gaps;
educational gaps

  • This is a national problem, not unique to UCSF. It is complex and multifactorial thus requiring an innovative approach to help support and reach youth faster.
  • There is a significant care gap for access to mental health care within the bay area as well. Based on epidemiological data, we estimated need for psychiatric services within the San Francisco County and Alameda County. 
    • Per UCSF’s 2022 Community Health Need Assessment (CHNA), 13% of San Francisco County’s 815,201 inhabitants are under 18: 105,976 youth 
    • Per UCSF CHO’s 2022 CHNA, 23% of Alameda County’s 1,671,329 inhabitants are under 18: 384,405 youth.
    • Total youth: 490,381 
    • Per California Health Care Foundation (CHCF)’s 2022 report, the percentage of youth with depression was 2.5%  in 2018 and 2019.  
    • Based on these numbers, the estimated youth within SF and Alameda County with  depression is 12,259. 
    • Per the CHCF report, 63.6% of Adolescents did not receive care for depression between the years of 2016-2019. This wouls estimate 7,796 youth with untreated depression within SF and Alameda County. 
    • The report did not have a percentage of youth who did not receive care for other psychiatric diagnosis and thus we believe this is a significant underestimate.
    • https://www.chcf.org/wp-content/uploads/2022/07/MentalHealthAlmanac2022.pdf 
INTERVENTION-Describe your proposed intervention and rationale for approach. Describe your practice setting and target population (e.g. department, unit, clinic, patient characteristics, diagnosis group, procedural group, provider characteristics, staff characteristics, etc.). Describe potential barriers to implementation. What are the possible adverse outcomes that may occur that may affect quality of care and patient safety as a result of your proposed intervention?
  • The UCSF Child and Adolescent Psychiatry Fellowship currently has a new rotation for second-year fellows who spend 1 half day a week in a Collaborative care clinic. This clinic was established in July 2022 with atriple intent of (I) transitioning stable psychiatric patients within the Department back to community pediatricians to increase our capacity; (ii) better support pediatricians in managing patients with mental health disorders; and (iii) reducing the waitlist time for existing patients of UCSF pediatricians by offering a brief consultation. The new eConsult method would help establish the bridge between those services and would potentially decrease our waitlist time for other patients who require more intensive psychiatric care already.  The consultant will provide guidance on value-based care utilizing measurement-based tools to track symptoms and treatment response as well as guidance on treatment initiation including medication management and therapy resources.  
    • We are defining an eConsult as a service that provides chart review and a scheduled telephone/Zoom discussion of the case at a scheduled time 
    • We are defining the Brief Consultation Model as an intermediary step between the outpatient pediatrics department and the psychiatry department that would provide three 1-hour sessions over the course of 3 months to provide more in-depth assessment and psychoeducation with medication recommendations provided to the treating pediatrician.  
  • The clinic would require a Child Psychiatry attending to staff the clinic and a clinic coordinator to arrange scheduling.  
  • The potential adverse effects are minimal. Patients are already waiting to get seen by mental health clinicians. However, like any other form of treatment, there are side effects to treatment that will need to get managed, but they are not unique to this model. As part of the clinic, proper consultation materials will be provided to the Pediatricians to mitigate this impact of side effects.  
  • While the clinic is the main intervention, there will need to be an effort to develop the connections between the Pediatrics and Psychiatry departments.  
    • This connection will be strengthened through a series of weekly lunch talks through the 6 different ambulatory pediatric clinics at UCSF throughout the year.  
    • Psychiatry will provide 8 lectures to each clinic for a total of 48 different lectures
    • The lecture topics will be determined by a series of focus groups at the beginning of the academic year to establish the 8 most valuable topics for outpatient pediatricians at the different sites.   
 
PROPOSED EHR MODIFICATIONSNote: EHR modifications are NOT required for a winning
proposal 
 
 
What are the clinical problems you are hoping to solve with APeX?
  • Scheduling of Adolescent Psychiatric eConsult
What APeX tools (patient lists, reports) or workflows (orders, documentation alerts) are you using now to achieve this goal? How would you want these modified?
  • Establishing a separate Collab ClinicTemplate
  • Creating a referral order
  • Uploading additional Psychiatric Metrics within MyChart that can be shared between providers and patients

•COST-Estimated baseline costs to the health system and projected savings from the
proposed project
  • Revenue Generation: Use of Psychiatric eConsult billing codes (2020 Medicare rates): 
  • Cost-Savings: 
    • In Wright et al, they examined the overall costs and cost-effectiveness of a Collaborative Care system for Adolescents with Depression in the Primary care setting and was published in 2016. Per this report, the mean net difference for total health plan costs of care over a 12-month period between the Collaborative care participants and the control was $591. 
      • Wright, D. R., Haaland, W. L., Ludman, E., McCauley, E., Lindenbaum, J., & Richardson, L. P. (2016). The Costs and Cost-effectiveness of Collaborative Care for Adolescents With Depression in Primary Care Settings: A Randomized Clinical Trial. JAMA pediatrics, 170(11), 1048–1054. https://doi-org.ucsf.idm.oclc.org/10.1001/jamapediatrics.2016.1721 
    • Adjusting for inflation, per FRED economic data, prices for medical care have increased 28.3% from Jan 2014- Jan 2023 resulting in a inflation-adjusted mean net cost difference to $758.  
    • In the Gap section, we estimated there are 7,796 youth with untreated depression within SF and Alameda County.
    • This clinic would be able to address a portion of this need in one year. Using available clinic slots, we estimate the total number of patients served per year:
      • Assumptions 
        • 3 fellows per week 
        • 48 weeks in a year 
        • 4 eConsult visits a week per fellow 
        • 1 Brief Consult Clinic visit a week per fellow 
        • 3 Brief Consult visits per patient per year 
        • 4 eConsults per patient per year 
      • Available clinic visits per year by model 
        • eConsults: 576 
        • Brief Consult: 144 
      • Patients served by model: 
        • eConsults: 144 
        • Brief Consult: 48 
      • Estimated total number of patients: 192 
    • Cost savings using estimated number of patients served: $145,536. 
    • Estimated total (Revenue + Cost-Savings): $266,800
SUSTAINABILITY-If successful, how will this intervention be sustained beyond the
funding year? Who are the key UCSF process owners?
 
  • The clinic would be able to generate revenue and thus become self-sustaining. 
  • The clinic would be housed within the Department of Psychiatry and Behavioral Sciences, in the Division of Child and Adolescent Psychiatry 
  • In 2024, the ACGME will be requiring an additional month of behavioral health training for Pediatrics residents.This clinic will be supported and potentially expanded by the increased need for training sites for Pediatricians.  
 
BUDGET-Line-item budget up to $50,000-Briefly identify key areas of the project that
will require funding, e.g., salaries, software, printing, etc
  • Salary Support for 0.10 FTE of Clinical Psychiatrist= $25,000 anticipating that it will take about one year for wRVUs generation to offset the cost of 0.1 FTE faculty clinical time 
  • Salary Support for 0.02 FTE Pediatrician: $5,000 
  • Focus Groups: $1,000 
  • Lunches for the 48 lectures: $12,000 
  • Printing of supplies and resources: $2,000 
  • Mirah Platform: $4,000 
  • RedCap: $1,000 
 
Supporting Documents: 
Image icon Collab Clinic Swimlane

Comments

Catherine Lau - April 20, 2023 - 12:51pm

Excellent proposal that addresses a very important, and growing issue. A few questions/comments below.

 

  • Please reach out to Dr. Ralph Gonzales to further discuss and verify your eConsult revenue calculations. Ralph was involved in the design and implementation of the existing eConsult framework at UCSF Health, and has contacts in Finance and Revenue that can further assist with your calculation.
  • What would be the long-term solution for funding this program once a potential Caring Wisely year is complete?
  • Your proposal is multi-pronged, and one of the interventions is the transition “stable patients’ back to community pediatricians. Do you know what % of existing UCSF child/adolescent psychiatry patients falls into this “stable” category and would qualify to transfer back to their PCP using this care model you propose?
  • Do we believe that community pediatricians would be receptive to getting treatment information from an eConsult team and managing the treatment plan? What evidence do you have for this (e.g. needs assessment, survey of community pediatricians, etc).

Dimitri Macris - April 27, 2023 - 12:11pm

Thanks so much for the kind words and interest in our proposal. Truly appreciated. Here are our responses to your questions/comments:

  • Please reach out to Dr. Ralph Gonzales to further discuss and verify your eConsult revenue calculations. Ralph was involved in the design and implementation of the existing eConsult framework at UCSF Health, and has contacts in Finance and Revenue that can further assist with your calculation. 
    • We spoke with Lisa DeAngelis with theeConsult program who provided information to four insurance providers and 2additional providers with incomplete information with coverage of 99446-99448 and 99451. Taking this information, we averaged the insurances evenly. Below are the updated billing codes reimbursements: 
      • “Consult with Discussion” (medical consultative discussion and written report):  
        • 99446: 5-10 minutes $80.51 
        • 99447: 11-20 minutes $138.99 
        • 99448: 21-30 minutes $199.22 
        • 99449: 31+ minutes $250.84 
      • “Consult without Discussion” (health record review and written report, no verbal discussion required):  
        • 99451: 5 or more minutes $175.55 
      • Using these updated numbers and a conservative estimation of seeing 2x 99448 appointments per hour, the hourly rate would be $398.44. 
      • This would change our estimated yearly revenue from $76,608 to $114,751. 
      • We did not have updated billing information for 90837, but we underestimated the eConsult billing reimbursement by 49.7% and if we increase our previous estimate by the same percentage, we’d estimate a yearly revenue of $66,826. 
      • This would increase our revenue estimate from $121,248 to $181,577. 
      • Increasing our estimated total (Revenue + Cost-Savings) from $266,800 to $327,113.  
  •  What would be the long-term solution for funding this program once a potential Caring Wisely year is complete? 
    • The full-time wRVU requirements for a UCSF CAP psychiatrist is3800 wRVU.  0.1 FTE is 380.
      • wRVUs for Collab Clinic Proposed Billing Codes 
        • 99446: 0.3 
        • 99447: 0.7 
        • 99448: 1.05 
        • 99449: 1.4 
        • 99451: 0.7 
        • 90837: 3.31 
    • Based on estimates of 4x 99448 and 1x 90837 per fellow per half-day, there would be a total of 7.51 wRVUs generated per fellow.  
    • With 3 fellows and 48 weeks, we’d estimate the half-day clinic generating 1,081 wRVUs which greatly exceeds the 0.1 FTE required and could support almost 3 participating attendings and as stated below, this clinic can expand to support more trainees.  
    • Currently, ACGME has commenced solicitation of comments regarding a proposal to require a new Pediatric resident rotation with mental health providers. Anne Glowinski is talking with Lee Atkinson-McEvoy, Chief Division of General Pediatrics, about the Collaborative Care Clinic being a training site for residents starting in 2024. 
    • The FPO, in principle, has committed to DPBS to give administrative support for high clinical productivity clinics. We will reach that threshold.  
  •  Your proposal is multi-pronged, and one of the interventions is the transition “stable patients’ back to community pediatricians. Do you know what % of existing UCSF child/adolescent psychiatry patients falls into this “stable” category and would qualify to transfer back to their PCP using this care model you propose? 
    •  Within the Division of Child and Adolescent Psychiatry (CAP), we don’t have a standardized practice of measurement-based care to track remission and so the definition of stable is often a physician-patient/family conversation. This project would be the first step inestablishing a clinic and culture ofobjective measures of stability.  Dr. Glowinski has started to engage the CAP faculty in examining retention habits, reevaluating them, and recontextualizing to the current mental health needs.This funding would accelerate the development of this practice. 
    • We don’t know the percentage of patients who would qualify to transfer back to their PCP. However, based on our own panels, we believe that it is a significant percentage and at least 25% who remain in-part because of a combination of pediatrician discomfort and Child Psychiatrists’ current practice patterns (we will address both).  
  •  Do we believe that community pediatricians would be receptive to getting treatment information from an eConsult team and managing the treatment plan? What evidence do you have for this (e.g. needs assessment, survey of community pediatricians, etc). 
    • We do believe that UCSF pediatricians would be receptive to getting treatment information from an eConsult team, especially with the option to escalate the eConsult to an in-person consultation if needed. This is based off of discussions with Dr. Rosales, who is a member of the UCSF Ambulatory Pediatrics team.Also, this is feedback from our experience with the CAPP portal.Both UCSF and Children’s Oakland’s 2022 CHNAs identified behavioral health as a specific target for needed improvement. While we have notconducted a specific survey or needs assessment, the proposal incorporates a series of focus groups and lectures to develop collaborative skills for trainees and potentially facultyand establish a stronger bridge between the two departments, which will allow for feedback and iterative improvement throughout the year via PDSA cycles.