DUVAL COUNTY HEALTH DEPARTMENTDUVAL COUNTY HEALTH DEPARTMENT Maternal & Child Health Division Maternal & Child Health Division

JACKSONVILLE, FLJACKSONVILLE, FL

Integrating Behavioral Health Into Primary CareIntegrating Behavioral Health Into Primary Care

Donna Buchanan, MSW, LCSWDonna Buchanan, MSW, LCSW

Behavioral Health ServicesBehavioral Health Services

OutlineOutline

Overview of Duval County Health DepartmentOverview of Duval County Health Department Community ProfileCommunity Profile Mental Illness in Jacksonville, FLMental Illness in Jacksonville, FL Duval County Behavioral Health ServicesDuval County Behavioral Health Services

Holistic Approach to Care ModelHolistic Approach to Care Model

Medicaid Reform ChallengesMedicaid Reform Challenges Study of Maternal DepressionStudy of Maternal Depression Future Program PlansFuture Program Plans

Overview of Duval County Overview of Duval County Health DepartmentHealth Department

DCHD mission-“To lead continuous improvement in the DCHD mission-“To lead continuous improvement in the health and environment of all people in Greater Jacksonville, health and environment of all people in Greater Jacksonville, Florida ”Florida ”

Largest public health clinical program in Florida. 4Largest public health clinical program in Florida. 4 thth largest largest metropolitan area in the state. metropolitan area in the state.

21 health centers and clinics, 15 community based sites21 health centers and clinics, 15 community based sites Adolescent healthAdolescent health Adult health Adult health Communicable DiseasesCommunicable Diseases Dentistry Dentistry Immunizations Immunizations Pediatrics Pediatrics Psychiatry Psychiatry Women’s HealthWomen’s Health

Florida state and National Healthy Start Initiative are funded Florida state and National Healthy Start Initiative are funded and implemented through Maternal and Child Health.and implemented through Maternal and Child Health.

Overview of Duval County Overview of Duval County Health DepartmentHealth Department

The focus is on addressing health disparities The focus is on addressing health disparities in communities that have higher rates of in communities that have higher rates of infant mortality, diabetes, heart disease and infant mortality, diabetes, heart disease and other issues.other issues.

DCHD serves culturally diverse families and DCHD serves culturally diverse families and individuals of all ages.individuals of all ages.

Overview of Duval County Overview of Duval County Health DepartmentHealth Department

As of 2007, the population of the greater As of 2007, the population of the greater Jacksonville area is over 1.2 million.Jacksonville area is over 1.2 million.

2005 Census Data:2005 Census Data: White populationWhite population 506,961506,961 Black populationBlack population 240,117240,117 Hispanic populationHispanic population 43,60443,604 Asian populationAsian population 28,64628,646 Persons of 2 or more races Persons of 2 or more races 12,68912,689 OtherOther 19,73919,739

Mental Illness in Mental Illness in Jacksonville, FloridaJacksonville, Florida

62,000 residents with severe mental illness such as 62,000 residents with severe mental illness such as SchizophreniaSchizophrenia

26% of children and adolescents in Duval County 26% of children and adolescents in Duval County experience the signs and symptoms of a mental health experience the signs and symptoms of a mental health disorderdisorder

1 in 4 adults suffer from diagnosable mental disorder1 in 4 adults suffer from diagnosable mental disorder

50% of all severe cases of mental illness manifest by age 14 50% of all severe cases of mental illness manifest by age 14 and another 25% by age 24and another 25% by age 24

11,000 Jacksonville adults with severe mental illness 11,000 Jacksonville adults with severe mental illness receive public assistancereceive public assistance

Mental Illness in Mental Illness in Jacksonville, FloridaJacksonville, Florida

Mental healthcare resources are scarce in Mental healthcare resources are scarce in Jacksonville as are providers.Jacksonville as are providers.

Psychiatrists, Psychologists, LCSW, LMHC, Psychiatrists, Psychologists, LCSW, LMHC, LMFT’sLMFT’s

The uninsured, the working uninsured and the poor The uninsured, the working uninsured and the poor find themselves unable to access mental health find themselves unable to access mental health services because of the inability to pay.services because of the inability to pay.

Holistic Approach to Care ModelHolistic Approach to Care ModelAs a result of the shortage of providers and services, Duval As a result of the shortage of providers and services, Duval

County Health Department Behavioral Health Services was County Health Department Behavioral Health Services was formed in 2004 to provide counseling services to Medicaid formed in 2004 to provide counseling services to Medicaid clients in our health delivery system. Staff is composed of:clients in our health delivery system. Staff is composed of:

An adult and child psychiatrist An adult and child psychiatrist 2 LCSW’s, 2 LCSW’s, 1 LMHC1 LMHC 2 MSW’s. 2 MSW’s. A licensed professional is available 24 hours a day, 7 days a week for A licensed professional is available 24 hours a day, 7 days a week for

emergency or urgent services.emergency or urgent services.

Prior to that time we were focused on providing services to Prior to that time we were focused on providing services to Healthy Start families especially in the area of postpartum Healthy Start families especially in the area of postpartum depression.depression.

Program goals are to empower individuals and families in Program goals are to empower individuals and families in our community to become self-sufficient and able to deal our community to become self-sufficient and able to deal with difficult life circumstances.with difficult life circumstances.

DCBHS provides services in 9 of the Health DCBHS provides services in 9 of the Health Departments area clinics. All are located in Departments area clinics. All are located in areas to serve high risk populations.areas to serve high risk populations.

Services are available to:Services are available to: Children 6 years old +Children 6 years old + Adolescents Adolescents AdultsAdults

Holistic Approach to Care ModelHolistic Approach to Care Model

Holistic Approach to Care ModelHolistic Approach to Care Model

Research indicates that 25 – 30% of clients that Research indicates that 25 – 30% of clients that come for medical appointments have underlying come for medical appointments have underlying behavioral health related disorders.behavioral health related disorders.

Holistic Approach to Care ModelHolistic Approach to Care ModelDCHD provided medical services to 28,764 DCHD provided medical services to 28,764

Medicaid recipients in 2005. Medicaid recipients in 2005.

DCBHS provided 963 client sessions and DCBHS provided 963 client sessions and generated $183,000 in revenue.generated $183,000 in revenue.

Referrals generated by DCHD providers to Referrals generated by DCHD providers to mental health licensed providers and mental health licensed providers and psychiatristspsychiatrists

One stop shopping:One stop shopping: increases access to mental health treatment increases access to mental health treatment reduces barriers to treatment as clients are seen in an reduces barriers to treatment as clients are seen in an

already familiar environment.already familiar environment.

Holistic Approach to Care ModelHolistic Approach to Care ModelDCHD provided Medicaid services in 2005 to:DCHD provided Medicaid services in 2005 to:

18,710 African Americans 18,710 African Americans 3,826 Caucasian3,826 Caucasian 2,303 identified minorities2,303 identified minorities

DCBHS has monthly behavioral health partners DCBHS has monthly behavioral health partners meetings to:meetings to:

Conduct peer reviewConduct peer review TrainingTraining Provide staff supportProvide staff support

The client’s prognosis for recovery and adherence The client’s prognosis for recovery and adherence to other medical treatment is increased by to other medical treatment is increased by integrating behavioral health into primary care integrating behavioral health into primary care with our team approach.with our team approach.

Monthly/Quarterly audits are conducted internally Monthly/Quarterly audits are conducted internally and externally.and externally.

Holistic Approach to Care ModelHolistic Approach to Care Model

Treatment Interventions:Treatment Interventions: individual, family and groupindividual, family and group brief solution focusedbrief solution focused Cognitive behavioralCognitive behavioral Reality/insightReality/insight Empowering young men and families to Empowering young men and families to

succeed; Child/parent rites of passage/skill succeed; Child/parent rites of passage/skill groupgroup

SPECIALTY SERVICESSPECIALTY SERVICESFoster care children at our Kids N’ Care Foster care children at our Kids N’ Care

program are seen by a Pediatric Psychiatrist, program are seen by a Pediatric Psychiatrist, licensed mental health counselor and a licensed mental health counselor and a master’s level social worker. master’s level social worker.

The goal of Kids ‘N Care is to be the premier The goal of Kids ‘N Care is to be the premier health system for children in foster care and health system for children in foster care and so far has provided care to over 5,000 children so far has provided care to over 5,000 children in Duval County.in Duval County.

Last year 3,937 teens were seen at The Bridge Last year 3,937 teens were seen at The Bridge Adolescent Health Center for Medical and Adolescent Health Center for Medical and Behavioral Health Services.Behavioral Health Services.

SPECIALTY SERVICESSPECIALTY SERVICES

Last year 1,399 HIV/AIDS clients and Last year 1,399 HIV/AIDS clients and their families were seen at our their families were seen at our Boulevard Comprehensive Care Clinic Boulevard Comprehensive Care Clinic (BCCC) for Medical and Behavioral (BCCC) for Medical and Behavioral Health services.Health services.

DCBHS links to services within the DCBHS links to services within the community that support the care and community that support the care and treatment of mentally ill people. treatment of mentally ill people.

SPECIALTY SERVICESSPECIALTY SERVICESBehavioral Health staff are involved with the local child Behavioral Health staff are involved with the local child

and adult mental health task force of N.E. Florida.and adult mental health task force of N.E. Florida. Assess community mental health needsAssess community mental health needs Make recommendationsMake recommendations Bring together stakeholdersBring together stakeholders

Community relations are also fostered with a local Community relations are also fostered with a local historical black college in a predominantly African historical black college in a predominantly African American community.American community.

Health fairsHealth fairs Mental health monthMental health month Collaboration with student counseling centerCollaboration with student counseling center Attending monthly professional support groupsAttending monthly professional support groups

BEHAVIORAL HEALTH PROGRAM BEHAVIORAL HEALTH PROGRAM OUTCOMESOUTCOMES

Mothers reunited with their children – no longer living in violent Mothers reunited with their children – no longer living in violent home environments = stabilized families.home environments = stabilized families.

Healthy pregnancy = positive development of early mother & Healthy pregnancy = positive development of early mother & child relationships. Improved depression and postpartum child relationships. Improved depression and postpartum depression scores; increased self-esteem.depression scores; increased self-esteem.

High school diplomas, GED and employment obtained. High school diplomas, GED and employment obtained.

Client satisfaction surveys and feedback from referral sources Client satisfaction surveys and feedback from referral sources indicate that individual mental health has improved which indicate that individual mental health has improved which indicates that the overall health of the community have improved.indicates that the overall health of the community have improved.

MEDICAID REFORM CHALLENGESMEDICAID REFORM CHALLENGES

Impact to clients:Impact to clients:

ConfusionConfusion

UncertaintyUncertainty

Provider/plan unknownProvider/plan unknown

Clients frequently move to a new residenceClients frequently move to a new residence

Often times mail is not received by the client because Often times mail is not received by the client because of failure to notify the postal service of their new of failure to notify the postal service of their new address.address.

MEDICAID REFORM CHALLENGESMEDICAID REFORM CHALLENGES

Financial Impact:Financial Impact:

delay in reimbursement from reform delay in reimbursement from reform health planshealth plans

delay in client services due to providers delay in client services due to providers needing notifications/authorization from needing notifications/authorization from managed care companies prior to providing managed care companies prior to providing services.services.

MEDICAID REFORM CHALLENGESMEDICAID REFORM CHALLENGES

Impact to provider:Impact to provider:

new requirements, guidelines and paperworknew requirements, guidelines and paperwork

obtain notification and pre-authorization upon obtain notification and pre-authorization upon admission to programadmission to program

reauthorization after 250 units of service every 6reauthorization after 250 units of service every 6

monthsmonths

quarterly auditsquarterly audits

Study of Maternal DepressionStudy of Maternal Depression In 2005, a candidate for Doctorate for Public Health in Community Health and In 2005, a candidate for Doctorate for Public Health in Community Health and

Prevention, at Drexel University in Philadelphia, chose DCHD for her internship Prevention, at Drexel University in Philadelphia, chose DCHD for her internship from the Bureau of Maternal and Child Health.from the Bureau of Maternal and Child Health.

Goals and Objectives of Internship = analyze and evaluate depression data on 195 Goals and Objectives of Internship = analyze and evaluate depression data on 195 pregnant and postpartum women enrolled in the Healthy Start program.pregnant and postpartum women enrolled in the Healthy Start program.

Screening Tools:Screening Tools: Are you in danger of post partum depression?Are you in danger of post partum depression?

- Assess women at risk for PPDAssess women at risk for PPD- Identifying support system or lack ofIdentifying support system or lack of- Stressful life eventsStressful life events- Lack of income Lack of income - Family HistoryFamily History

Edinburgh Postnatal Depression Scale:Edinburgh Postnatal Depression Scale: 10 item questionnaire which screens women 6-8 weeks postpartum, as to how they have 10 item questionnaire which screens women 6-8 weeks postpartum, as to how they have

felt over the previous 7 days.felt over the previous 7 days.- Range 0-30Range 0-30- Score of 9-13 may indicate depressionScore of 9-13 may indicate depression- Score of 14 and above is indicative of depression and the person should be followed by a clinical Score of 14 and above is indicative of depression and the person should be followed by a clinical

interviewinterview

FindingsFindings Race:Race:

African AmericanAfrican American 66%66% CaucasianCaucasian 32%32% Other (Indian and Latino)Other (Indian and Latino) 2% 2%

Depression:Depression: 113 women completed the Edinburgh 113 women completed the Edinburgh

- 38% of the women scored 13 or higher38% of the women scored 13 or higher- Average score was 14Average score was 14

Race and Depression:Race and Depression: Research indicates that African American women are more likely Research indicates that African American women are more likely

to have stressors in their lives which leads to depression but did to have stressors in their lives which leads to depression but did not indicate any significant findings.not indicate any significant findings.

Both groups scored higher than 13 indicating that both groups are Both groups scored higher than 13 indicating that both groups are depressed.depressed.

White women scored slightly higher on the Edinburgh.White women scored slightly higher on the Edinburgh.

FindingsFindings Age: average age was 22 (range 11-47 yrs of age)Age: average age was 22 (range 11-47 yrs of age) Education: Education:

45% did not graduate from high school45% did not graduate from high school 10% still in high school10% still in high school

Symptom Focus:Symptom Focus: DepressionDepression 16.8% 16.8% Sexual abuse historySexual abuse history 16% 16% Domestic violenceDomestic violence 5% 5%

History of depression (factor in PPD): 59%History of depression (factor in PPD): 59% Insurance:Insurance:

MedicaidMedicaid 67% 67% HMO (job, parent or spouse) 19%HMO (job, parent or spouse) 19%

FindingsFindings Prenatal Care:Prenatal Care:

92% received prenatal care92% received prenatal care 6% received late prenatal care6% received late prenatal care 2% did not received care2% did not received care

Birth Outcomes on 135 women:Birth Outcomes on 135 women: Birth weight ranged from 1 pound to 10.10 pounds with average weight of 6 Birth weight ranged from 1 pound to 10.10 pounds with average weight of 6

pounds)pounds) 14% premature births14% premature births 16% had very low to low-birth weights (under 2500 grams or 5 lb. 8 oz.)16% had very low to low-birth weights (under 2500 grams or 5 lb. 8 oz.) 8 women had twins (weight ranging from 3.12 to 7.30 lbs.)8 women had twins (weight ranging from 3.12 to 7.30 lbs.) 2% miscarried2% miscarried 5% infant deaths5% infant deaths

Treatment completion:Treatment completion: Average length of sessionsAverage length of sessions 33 Completed with symptom improvementCompleted with symptom improvement 40%40% Could not be contacted for follow upCould not be contacted for follow up 36%36% Referred for additional servicesReferred for additional services 12%12% Declined further servicesDeclined further services 10%10%

FindingsFindings Number of sessions and healthy birth outcomes. Number of sessions and healthy birth outcomes.

Advocate for more finances and staff to provide counseling Advocate for more finances and staff to provide counseling sessions before and after delivery to impact high infant sessions before and after delivery to impact high infant mortality rates.mortality rates.

Women who declined services at 16.5%, scored the highest Women who declined services at 16.5%, scored the highest on the Edinburgh test. Women who completed the sessions on the Edinburgh test. Women who completed the sessions at 13.29%, scored the lowest. Although this was not at 13.29%, scored the lowest. Although this was not statistically significant it was concluded that those who statistically significant it was concluded that those who declined services are more depressed.declined services are more depressed.

The majority of the women indicated that they cannot The majority of the women indicated that they cannot financially support themselves alone.financially support themselves alone.

Future Program PlansFuture Program Plans The program is in the process of setting up more program The program is in the process of setting up more program

evaluation with DCHD’s Health, Policy and Evaluation evaluation with DCHD’s Health, Policy and Evaluation Research Department.Research Department.

DCHD recently added on the Department of Institutional DCHD recently added on the Department of Institutional Medicine in 2006.Medicine in 2006.

Medical and Behavioral Health Services are provided to Medical and Behavioral Health Services are provided to inmates. inmates.

An additional need was identified to provide inmates and An additional need was identified to provide inmates and their families counseling to assist with the transition of their families counseling to assist with the transition of inmates back to the community. inmates back to the community.

An additional licensed mental health professional is being An additional licensed mental health professional is being hired to provide these services.hired to provide these services.