Capitol Associates

Moderator: Bill Finerfrock
July 14, 2009
1:00 pm CT

Operator:  Good day everyone and welcome to this Rural Healthcare Clinic teleconference.  Today’s call is being recorded. 

At this time for opening remarks and introductions, I’d like to turn things over to Mr. Bill Finerfrock; please go ahead, sir.

Bill Finerfrock:  Thank you very much, Operator and welcome to the Rural Health Clinic technical assistance call.  Today’s program is on the TeenScreen program identifying depression, mental health screening for adolescents.

I want to welcome everybody to today’s call.  I am the Executive Director of the National Association of Rural Health Clinics and I’ll be your moderator.

Our presenters today are individuals who have been involved in the TeenScreen program.  We have Leslie McGuire who is the Deputy Executive Director of the National Center for TeenScreen and joining here is Christina Carro who is the Program Coordinator for the TeenScreen Primary Care.

Today’s program is scheduled for 1 hour and the first 45 minutes will be devoted to our speaker’s presentation with 15 minutes for questions-and-answers.  This series is sponsored by the Health Resources and Services Administrations, Federal Office of Rural Health Policy in conjunction with the National Association of Rural Health Clinics.  The purpose of the series is to provide RHC staff with valuable technical assistance and RHC specific information.  Today’s call is the 31st in a series which began in 2004.  During that time over 6000 individuals have participated in the bimonthly teleconferences.  As I mentioned, we will take questions at the end and the operator will give the instructions for that.

As you all know, there is no charge to participate in this series and we encourage you to refer others who might benefit from this series to sign up and receive information.  To do so, they can visit the Federal Office of Rural Health Policies Web site.  They can go to www.ruralhealth.hrsa.gov/rhc.

I’d like to welcome our speakers today Leslie and Christina.  We look forward to your presentation.  The time is yours.

Leslie McGuire: Terrific.  Well, thank you, Bill and thank you to everyone else.  It’s great to have you with us today.  This is Leslie McGuire and I’m going to start our presentation and I just want to give you a quick overview first of what we’re going to cover today.  And what we’ll do is give some background information on the problems of mental illness and suicide in adolescents.  And then talk about ways that mental health screening can practically be implemented into rural health clinics, so that you can identify your adolescent patients who may be at risk for these conditions and proactively work to address these potential problems.

And at the end we’ll talk about some of the materials that we make available at the TeenScreen National Center for Mental Health Checkup that we provide free of charge to groups that are interested in implementing their own mental health screening initiatives or implementing mental health checkups with adolescent patients.

So the first thing I want to do is just give you a little bit more information about who we are and where we’re coming from.  So as I said we’re from the TeenScreen National Center for Mental Health Checkup.  We’re part of Columbia University.  And what we are is a national resource center that’s committed to the early identification of mental illness in adolescence and the prevention of teen suicide.

And the goal that we’re working towards is to ensure that every teen in America has access to a mental health checkup and the point there being to improve early detection of mental illness, just like any other condition, the earlier you identify it the better the prognosis for the teen.  And the way that we do this is to promote mental health checkups and provide our materials free to groups that want to implement this in healthcare settings and schools and other youth serving organizations and settings.  And we get this out through two initiatives, TeenScreen Primary Care which is what we’ll focus on today and TeenScreen Schools and Communities which is geared towards implementation primarily in schools, but other community settings as well.

So we are a private non-profit organization that’s housed in the Division of Child & Adolescent Psychiatry at Columbia University and we are funded by a private family foundation that very strongly believes in this notion of early detection and it’s through their generous support that we’re able to give our resources and our trainings and materials away for free to groups that want to implement their own mental health checkups.

So moving on to the next slide, this just gives you a little bit of a sense of the scope of TeenScreen nationally.  And this slide this map is a little bit out of date.  Currently, we’re actually close to 600 local TeenScreen sites across the country in 43 states.

So moving on, next I’ll give a bit of an overview on the problems of mental illness and suicide in youth making the case then for mental health checkups in this population.  So mental illness in adolescents.  This is a very significant problem.  Eleven percent of our children and adolescents suffer from a serious mental disorder that causes significant functional impairment for them either at home, at school or with their peers.  So 11% of our youth are having a serious mental illness that’s really interfering with their ability to succeed in the ways that you would expect a normal teenager to get through life.

Sadly most of these kids go undiagnosed and untreated.  Only 20% of adolescents and children with a mental disorder actually get identified and get the services that they need.  So clearly, a lot more needs to be done across the board to try to identify these conditions early.  We also know too that identifying it in these early years is so important because 50% of all mental disorders actually have an onset in the teen years.  So again, going back to that point of the earlier you diagnose and treat the better the prognosis.

We also know too that most people with a mental disorder are symptomatic for years.  In fact, it’s an average of 2 to 4 years that they’re symptomatic before the symptoms actually go to a full blown diagnostic level.  So again there’s really a lengthy window of opportunity for prevention.

Moving on to the next slide or the next page in the series.  Depression is a significant problem in this population specifically as well.  So if you look at this slide, this was from a survey that was conducted by SAMHSA and it shows you the rates of depression for 12 to 17-year-olds between the years 2004 and 2006.  And probably the most striking thing is that you can see how the rates really increase as the teens get older which is to be expected.  But, again, we’re talking about large numbers of teenagers.

And if you go to the next slide, it shows you that if you look across that entire age span of 12 to 17-year-olds, 8.2% of adolescents suffer from a major depressive episode in the past year.  And again, most of these kids 2/5 of them – only 2/5 were diagnosed and actually received some kind of treatment.  So again, a large group that we’re missing.

Moving on to the next slide, you can see that suicide is also a very significant problem for our adolescents.  It’s currently the third leading cause of death for 11 to 18-year-olds.  It’s been the third leading cause of death for quite some time.  A really significant thing in terms of prevention is that 90% of teens who die by suicide suffer from a diagnosable and treatable mental disorder at the time of their death.  Two-thirds of those teens had been symptomatic for a year or more prior to their deaths.  So again lots of time to identify, lots of time to treat, and hopefully time to prevent the suicide if we can identify these conditions in time.

We also know and I’m sure all you know this far better than Christina and I do but that mental health and suicide are especially significant issues in rural areas.  So first of all, if you look at which states have the highest suicide rates, particularly it’s Western and mountain states have the higher suicide rates, and those states obviously have higher proportions of rural communities.  We also know that rural communities have – many rural communities have a shortage of health professionals, but especially a shortage of mental health professionals.  And that these obviously can contribute to the higher suicide rates as well.

Moving on to the next slide, mental illness and primary care there’s much that we still can do within the primary care setting to address these issues.  So first of all we know that about a quarter of all pediatric primary care visits actually involve a mental health type concern or problem.  But again, most of these kids, two out of three, are not identified by their primary care provider, especially when it gets to depression two out of three are not identified as having depression by their primary care provider.

And we do a poor job in primary care as a well in identifying the anxiety symptoms.  We also know that even when conditions are identified for whatever reason referral out from the primary care setting to a mental health provider is poor.  And that only a minority of children who are identified do get a referral to a mental health provider.

So moving on, there are lots and lots of consequences of untreated mental illness in children and adolescents.  So we already talked about suicide being the third leading cause of death for this group and really being the result of untreated mental illness.  There are higher healthcare utilization costs.  So kids with mental illness tend to go to their primary care provider more often.  They tend to go to the emergency room more often.  They tend to have more medical tests and things like that.

These kids also have much greater difficulties in school.  And we know that 50% of students who drop out of high school have a mental disorder.  This is the single greatest contributing factor to dropping out of high school.  We also know that many of these kids get involved in the criminal justice system, which is really quite sad.  I was particularly surprised to see this statistic that 65% of boys and 75% of girls in juvenile detention have a mental disorder.  So certainly if we could identify those conditions and get them the help that they need they might not end up in jail.

And then there’s the long-term disability and suffering that is brought upon the teen and also their family and this is such a critical period of development and really years that can never be recaptured.  So when you get someone who in these years really gets so derailed by mental illness, it’s hard to really get back on track in terms of their development and their ability to reach their full potential as a person.

So moving on to the next slide, I just gave you probably what sounds like lots of doom and gloom.  There really is a significant problem.  But the good news is that there is something that can be done.  We have accurate and effective screening tools to identify the teens who are at risk for mental illness.  Mental illness is treatable.  So once you identify these kids there are some solutions that you can offer them.  Again, most of these kids are not all ready being helped.  So it’s not like your efforts are really going to duplicate and find kids who are already receiving services.

For the most part you’re going to find the kids who aren’t already known to others.  There’s a lot of time to intervene before symptoms reach the full level of diagnosis and before kids are so desperate that they turn to suicide.  And really, the most critical thing for me after having been doing this work now for 11 years and screening myself thousands of kids, the most compelling reason to me has been that no one else is asking them these questions.

And when you screen these teenagers and you find so many kids who are really, really in dire straits and it seems impossible that no one knows this, and you ask them and you say how is it that this is news that no one – you’re not getting help and that your mom doesn’t know and your dad and your teachers.  Every single kid has given me the exact same answer over all of these years and the answer is that no one ever asked me.  And what screening does is it gives a systematic way to ask everyone the same questions.

And even the kids – it’s been interesting to me even the kids who don’t have a mental health problem they really think screening is so important.  And they’re pleased and glad to see that adults care enough to ask them these important questions because they realize that no one else is asking them.  And even if they don’t have a problem they certainly know people who do.  And for the kids who do have a problem it’s remarkable to just see this relief come across their face.  Suddenly someone has helped put this together for them and it’s offering them some hope.

So moving on to the next slide, some other reasons to screen.  There’s really quite a bit of support for mental health screening particularly in primary care and the last year in particular there’s been some very exciting events that have happened the most exciting of which was the recent recommendations that came out from the U.S. Preventive Services Task Force.  And what they did was they – I’m sure you all are probably aware of them, but they’re an independent government supported panel of experts and primary care prevention and research.  And really their recommendations are considered the gold standard in clinical preventive care.

So they did a very thorough review recently of the benefits and harms of screening for depression among youth in primary care settings.  And after their careful review, they came out with a recommendation that all 12 to 18-year-olds should be screened annually for major depression by their primary care providers.

Moving to the next slide there’s some other support as well from other groups.  There was a report that came out just before the U.S. Preventive Services Task Force and that report came out by the Institute of Medicine and they came out also supporting mental health screening for youth and particularly highlighted primary care settings as an important location for screening.  The American Academy of Pediatrics has also put a great deal of emphasis on primary care screening and has supported that as well, as well as the Society for Adolescent Medicine and the American Academy of Family Physicians who also have come out in support of either early identification or mental health screening.  And these are also things that have been endorsed previously by a presidential mental health commission and also by a former Surgeon General.

So moving along what I’m going to talk about next and soon will pass over to my colleague is mental health checkups and really getting into more of you know what can you as providers in rural health clinics do to integrate mental health screening into your practices.

So what is a mental health checkup first of all?  So this is something that you can incorporate into a regular healthcare visit and I think most people are doing this typically during an annual well child exam but you know some people do this with other visits as well because adolescents start to show up less often in those years.  So this is something that’s really pretty time efficient and feasible that can be done in other visits as well if you want to just try and catch kids when you can.

And what this is is we’re able to provide you with some evidence based practices and instruments to help you routinely screen all of your adolescent patients for mental illness and suicide risk.  And the focus as I had said is on early identification of mental illness, the prevention of suicide and then linking those in need with mental health services.  And we certainly understand that for many of you there are no mental health services in your communities or there are very, very limited mental health resources in your communities.

So in many cases you’re not referring out, but that you would be managing these conditions on your own.  And we’re not going to get into the details on how to do that, but certainly if you’re interested in taking these things up we do have some materials to assist in that.

So moving on to the next slide TeenScreen Primary Care is what mostly what we’re going to talk about for the rest of the presentation.  And this is an initiative of our TeenScreen National Center that focuses specifically on implementing mental health checkups in primary care settings.  We are currently working with managed care companies, hospitals, health centers and providers in six states to demonstrate system-wide use of mental health checkups and primary care.  And we definitely have our particular model and materials that we’re able to give away for free.  But really the goal that we’re working towards is about widespread implementation of mental health checkups.  It’s not really about getting everyone to do TeenScreen.  It’s about everyone doing a mental health checkup with teens and that’s the goal that we’re working towards.

And a little bit later we’ll talk about the different tools that we’re able to offer for free to providers who want to integrate this into their practices.

So if you move on to the next slide that’s got a flow chart this gives you a sense of how does the mental health checkup actually work.  So first of all our materials are designed for use with 11 to 18-year-olds.  And the screening is something that as I said is really something you can do quite easily and efficiently.  You can administer it – basically it involves the administration of a screening questionnaire followed by more detailed follow up with the primary care provider if the teen scores positive.

So the screening questionnaire is something that you can administer in the waiting room, in the exam room, whatever works best for you.  It’s something that a nurse or a medical technician or other staff can administer and score and then slip into the medical charts for the primary care provider to review.  And if the kid – if the teen scores negative you can just have a very brief check in, let them know the results and see if they’ve got questions or anything else you may want to follow up on.  And if they score positive you can then really dive into the specific symptom areas that they endorsed on the questionnaire.

So with that, I’m going to pass it off to my colleague Christina Carro.

Christina Carro:  Thank you, Leslie.  I am Christina Carro and I am a Program Coordinator for TeenScreen Primary Care.  And for the remainder of the slides I’m going to focus on the logistics of implementing mental health checkups in a primary care setting.  And we’ll really talk about the process from start to finish to discuss the flow of how screening works and how it can easily be integrated into your current practices.

Much of the information that I will be reviewing is also provided in the materials that we offer which I’ll talk about towards the end of my slides and will also give you information about how you can request these materials as we’re happy to send them to you.

Before I get started I do want to stress that screening can really be a very quick and easy way to systematically address mental health with your adolescent patients.  And you know we will review some details but most of the points that I’ll be presenting are really general recommendations and considerations that are helpful to think through.

So with that being said, I’m going to dive right in to the implementation logistics.  As Leslie said mental health checkups can really be conducted during any routine office visit that you encounter with your adolescent patient so it could be well child exams, sports or health physicals, sick visits, or really any other routine office visit.

The screening questionnaire is completed by the patient during the office visit and can be scored a nurse, a medical technician, office staff or even the doctor depending on what works best for your practice.  We do recommend that patients are left alone in a private environment to complete the questionnaire.  And that they’re also informed of their rights to confidentiality just to ensure that they feel comfortable answering the questions and they’re not concerned if mom or dad are looking over their shoulder.  Even if it’s a little sectioned off place in the waiting room or somewhere they can sit by themselves for a couple of minutes to complete it.

After the questionnaire is scored the primary care provider then reviews the results and briefly evaluates patients that score positive.  And for youth who require a more complete evaluation or mental health services, they are either referred by the primary care provider to a mental health provider or in some cases can also be treated or managed by the primary care provider themselves.

So I’m going to move on to the next slide.  Actually, we can skip over two slides to this first screening questionnaire that I’ll talk about that we offer through our program which is the Pediatric Symptom Checklist for youth.  This is a 35 item youth self-report questionnaire.  It takes less than 5 minutes to complete and score.  It’s very easy to use.  And the PSC is really designed to be more of a broad mental health checkup, designed to detect behavioral and psychosocial problems in use.  And the questions on the PSC cover attention problems, internalizing problems and externalizing problems.

There are also two questions about suicide that are on this questionnaire.  And the PSC has been validated and is also widely used in primary care settings.  So we felt like this is a good choice to offer to primary care providers as a broad mental health checkup.

If you move to the next slide, you’ll see a very small version of the PSC that we offer and you can see that there are the 35 items.  The two items highlighted in yellow towards the bottom of the questionnaire are the suicide questions.  Each of the 35 items are ranked either 0, 1 or 2 for never, sometimes or often.  So after the patient finishes completing the questionnaire basically to score it that’s all you have to do is to add all of the item scores together and if it’s greater than or equal to 30 the total score that would constitute a positive screen.  The screen would also be positive if either of the suicide questions are endorsed.

One thing I wanted to point out is that as you can see the PSC is color coded based on problem area.  And this was done just to help the primary care provider as they’re reviewing the results see if any of the patient’s answers sort of cluster towards one problem area.  So for instance the pink is associated with attention problems.  The green are internalizing problems and the blue are externalizing problems.

The PSC is available in a number of different languages but through our program we have it in a brochure that we’ll show you a little bit later and we have those brochures available in both English and Spanish.  And also before we move on I wanted to mention that in the materials we offer we do have additional information about scoring the PSC and also interpreting the screening results.

Next slide.  We’ll move on to talk about the PHQA which is the second questionnaire that we offer through our program.  And this is the Patient Health Questionnaire for Adolescents and it’s a depression screen.  It is a nine-item self report questionnaire.  And it also has the two same suicide questions that were on the PSC.  Again, this questionnaire takes less than 5 minutes to complete and score.  It’s very easy to use.  And this questionnaire was one of the ones recommended by the U.S. Preventive Services Task Force for depression screening in adolescents.

So if you move on to the next slide, you’ll see a copy of the PHQA.  And the way that this questionnaire works is that if the patient answers yes to either of the first two questions, they go on to then answer questions 3 through 9.  If they answer no to the first two questions they then move down to the bottom to answer the two suicide questions.  So a positive score on the PHQA is if a patient answers yes to either of the first two questions, if they answer yes to five or more of questions 3 through 9, and also if they answer yes to either of those suicide questions.

And now I’m going to move on to the next slide where we talk about the post screening interview.  So after the questionnaire is scored,the provider is ready to discuss the results with the patient.  This is the part of the process that I’ll be talking about next.  And the post-screening interview is really just a discussion between the doctor and the patient to review the results of the screening.

So the first part of the post screening interview and these are just general recommendations that might be helpful for their provider is to look first to see if the patient’s answers cluster by problem area on the PSC if that’s the questionnaire that you’re using.  You know if a patient receives a positive score and they seem to be having a problem with one of the major problem areas that the PSC screens for it suggests the need to further assess the patient for disorders associated with that area.  If the patient scores positive on the PHQA then the provider would want to further assess the patient for problems with depression.

During this discussion it may helpful to explore any of the symptoms that were endorsed on the questionnaire and also to inquire about the level of impairment the patient may be having at school, at home or with their friends to get sense of how these symptoms are affecting their daily lives which can you a little bit more about the severity of the problem.

We do recommend that providers inquire about suicidal thoughts and behaviors for all patients that score positive on the questionnaire regardless of their answers to the suicide question just to ensure that these issues are being addressed in a systematic way and also to make sure that none of the teens are being missed or purposely didn’t answer or endorse those questions on the questionnaire.

For the vast majority of patients that score negative on the PSC we do recommend briefly reviewing the symptoms that they endorse as sometimes or often, but really this part of the process for them takes no longer than 2 to 3 minutes; just a quick check in and then that’s really it.

Moving down to the next slide, you’ll see that we do have a number or resources available to assist with the post screening interview.  We have a post screening interview checklist.  We also have information about conducting a suicide risk assessment.  And a bunch of sample questions by problem area that can be used to further assess patients for problems with depression or anxiety or any of the problems that they seem to be having.

Moving on to the next slide, we’ll talk about the referral process.  So after the post screening interview there will be some patients who require additional follow up either through a mental health referral or through follow up with the primary care provider.  So on the next slide I’m going to talk about some recommendations about making a referral but I first wanted to mention that we do understand that many times in rural areas there may be a lack of referral resources to send these teens and their families to.  And that in some cases the primary care provider may, in fact, be the ones who treat or even manage these patients.

So with that being said, there are a number of resources available to primary care providers that give some good information about different mental health issues, when and how to refer to a mental health professional and also how to manage these issues within a primary care setting.  Just to name a few there’s information on the American Academy of Child and Adolescent Psychiatry Web site, which is AACAP.org.  There’s also information on the American Academy of Pediatrics Web site which is AAP.org.  The National Alliance on Mental Illness or NAMI.org has some really good information as well.  So those are just a few to name but as Leslie said we can also provide you with some additional information about you know treating and managing these disorders in a primary care setting.

We do provide some recommendations about making a referral.  Part of the recommendation that we make is if you are able to, compile a list of referral resources to share with parents and families and we do have some resources that provide strategies for doing this.  And in cases where a referral is both necessary and feasible it may be helpful to work with the patient’s existing insurance benefit to determine what types of services are available to them and also if there are any mental health providers in their community.  And so this information is in the TeenScreen Primary Care Quick Start Guide that I’ll talk about in just a minute.

So moving on to the next slide about coding and reimbursement.  And this is another really important component of screening that is critical to really integrating screening into routine care.  And through or work what we’ve learned is that there really isn’t one consistent code being used to bill for mental health screening.  But we have identified a number of codes that are relevant to screening.  I’ll talk about a couple of these codes today but we do provide some additional coding information in the materials.

We do recommend that providers also consult with their offices coding and billing department to determine if these codes will work for you or if there are other codes that will work for mental health checkups and screening.

So moving to the next slide you’ll see two codes that were approved by the centers for Medicare and Medicaid services a couple of years ago that specifically related to developmental and behavioral screening in pediatrics.  For the purposes of this project and a broad mental health checkup the best code to use is really the 96110 code.  And as a matter of fact, the PSC is listed by the AAP as one of the questionnaires that can be used when screening under – or billing under 96110.  The 96111 code is really more for an in-depth developmental screening/testing.

There’s another code it’s not listed on this slide here but it’s the 99420 code that may also be used for the administration and interpretation of a health risk assessment questionnaire.  So that might be another code that can be used.

If you slide on down to the next slide you’ll see that we’ve provided a little snapshot of the information that’s available in our materials.  And in addition to listing out codes, we also provide information about different combinations of codes that might work well together.  So information about evaluation and management codes based on time, codes that are used for well child visit and how they may interact or work with the 96110 code that we just talked about.

The next slide, so there are as we’ve said a number of materials that are available through our program.  The first resource that we’ve developed is what we call our quick start guide.  And in the quick start guide we provide an overview of TeenScreen primary care.  We also provide a copy of the questionnaire, information about interpreting the screening results, how to score the questionnaire, making a referral and also all of the coding and reimbursement information that I just reviewed.  All of that is available in this one little packet.

In addition to the quick start guide – actually as an appendix to the quick start guide, we have a guide called preparing office staff to implement mental health checkups.  And really the purpose of this document is to just provide helpful tools and information about how to prepare office staff to implement screening.  We also list out some of the tasks associated with screening and how to divvy those up amongst staff members.

The next material that we have is the teen brochure.  And this is the brochure that contains an actual copy of the screening questionnaire inside of it.  So when you open it up on the inside is the questionnaire for the teen to complete.  And we have these available for both the PSC and the PHQA.

And we also have moving to the next slide a bunch of other supplemental materials available.  There is a CME training course that is available through Medscape through this link that is provided here on this slide.  We also have mental health checkup resource guide which is a more comprehensive guide to implementing screening.  It provides much more detail about the referral and reimbursement process and a bunch of different codes and different worksheets that have been developed.

We also have a guide to referral coding and reimbursement which is specific to making a referral and also reimbursement strategies.  We have the post screening interview resource which I talked about earlier which provides you know materials and resources to help with the post screening interview portion of the screening.  And we also have developed a PowerPoint presentation entitled tips for integrating mental health checkups into your practice.  And this takes you step by step through the screening process.  And really walking through each individual step to figure out how you can integrate screening into your practices and with all of the stuff that you have.

Finally, on the last slide, we have information about how you can sign up to receive these materials.  We have on our Web site TeenScreen.org/checkups-in-primary-care with the hyphens in between.  You will see that there is a place to sign up to receive the materials.  There’s a little form there available on our Web site.  And there’s also some information about the different materials that we offer.

You can also call this 800-number that’s available on here on this slide or e-mail us at this e-mail address to request the free materials.  And once we receive that information from you we’ll be happy to send you the hard copies and also electronic copies of the materials that we have available.

And I think that that takes us here to the end of this slide.  So I believe that we can go ahead now and open it up for questions.

Bill Finerfrock:  Great.  Thank you both.  That was – I found it extremely helpful and I think it’s a wonderful program and much needed program.  Operator, if you would give the instructions for folks to ask questions.

Operator:  Certainly; at this time if you do have a question, please signal us by pressing star 1 on your touch-tone telephone.  A voice prompt on your phone line will indicate once your line has been opened.  Once again, that is star 1 for questions.  We’ll pause for just a moment.

Bill Finerfrock:  And I would add when your line is opened up if you could identify yourself by your name and the state that you’re calling from just so we can get an idea of where our calls are coming from today would be greatly appreciated.

Before we take our first call, I had a couple of questions that I wanted to ask.  You made reference to doctors in terms of the follow up conversation with the patient.  All of our rural health clinics utilize physician assistants and nurse practitioners as part of the team.  I presume that these are things that the PAs and NPs could do as well?

Leslie McGuire: Certainly, the nurse practitioners.  I’m not as sure about the medical technicians given that …

Bill Finerfrock:  Physician assistant.

Leslie McGuire: Physician assistant.  I think so.  I mean it’s going to be more of something that it depends on their comfort level as well.  I mean you definitely can end up getting into some very detailed conversations and long conversations.  You know this can be concerning to parents.  It can be surprising to parents.  You know you’re sometimes letting them know that their child is suicidal and they weren’t aware of that information.

So you know it’s more of an issue of you know people feeling comfortable and prepared to have those talks but certainly that level of training is fine, yes.

Bill Finerfrock:  Now, with regard to Medicaid programs what’s been your experience with regard to Medicaid programs recognizing – because we’re dealing with adolescents we’re either going to be dealing with commercial insurance or a Medicaid population and many of our RHC’s have a significant percentage of patients are Medicaid.  What’s been your experience in dealing with Medicaid programs?

Leslie McGuire: Christina can probably address this a bit better than I can.  Generally in terms of the reimbursement if that’s what you’re getting at the 96110 code that Christina talked about is a Medicaid code.  And I believe that every state reimburses for that code.  There are definitely some tricks to be found though in terms of primary care providers being reimbursed for mental health assessment and treatment.

So there’s you know it’s a little bit more variable if you’re starting to get into also using E&M codes and things like that or modifier 25.  But it’s definitely worth a try.  And at least the 96110 reimbursement rate does exist within states.  It just depends you know do they allow at a well visit or not that type of thing.

Bill Finerfrock:  Rural health clinics are typically reimbursed on an all inclusive rate through Medicaid either some type of a cost based trade or what’s referred to as the perspective payment rate.  So in all likelihood this would be something that could probably be incorporated into an E&M coded visit or sick visit something that you would all ready be seeing that patient for and simply incorporating that into the visit.

Leslie McGuire: And we definitely you know do have other resources to give tips on coding and reimbursement.  There’s definitely you know to be up front there is no magic to this.  And states do vary quite drastically on it and so do health plans for that matter.

Bill Finerfrock:  I think what I’ve found most intriguing was the ability to incorporate this into a visit for another purpose.  So it’s something that you can do as part of something and even to your point about the school physicals.  Many of our RHC’s do school physicals for their adolescent patients.  And this is something that they could incorporate as part of the school physical, sports physical as well.

Leslie McGuire: Absolutely.

Bill Finerfrock:  OK, operator, do we have some calls lined up, some questions?

Operator:  Not at this time.  However, again, that is star 1 for any questions or comments at this time.  We’ll take our first …

Bill Finerfrock:  How long …

Operator:  I’m sorry.

Bill Finerfrock:  Go ahead.

Operator:  We’ll take our first question.

Bill Finerfrock:  Go ahead, caller.

(Connie Massey):  Hi, this is (Connie Massey).  I’m calling from California.  I’m a clinical social worker.  And I’m working in a rural clinic, obviously.  I have a question about if we obtain the screening materials are you doing any kind of follow up studies or do we have any reporting requirements?

Leslie McGuire: No.  There’s no research involved in this whatsoever.  We may contact you with a brief survey to find out are you using the materials, how are you using the materials, any feedback you may want to give us on how it’s working, what’s not working, things like that, but no there’s no reporting requirements.  There really are no strings attached.  We’re just happy to give it away and hopefully and get more kids this opportunity to get a mental health screening.

(Connie Massey):  Great.  Thank you.

Operator:  We’ll take our next question.

Bill Finerfrock:  Go ahead caller, your name and where you’re calling from.

(Shelly):  (Shelly) from South Dakota.

Bill Finerfrock:  Go ahead, (Shelly).

(Shelly):  I’m just wondering does South Dakota – are they part of this program at all because I’m not familiar with it.

Leslie McGuire: Our – we’re not doing anything at this point within primary care in South Dakota.  I don’t – Christina do you remember if we have anything in our school program?

Christina Carro:  I don’t – I actually don’t think we have anything in South Dakota.  I think that’s one of the states where we don’t have any.

Leslie McGuire: That’s right.  You’re right.  I’m looking at the map.  So no, you would be the first.

(Shelly):  OK.

Bill Finerfrock:  There you go, (Shelly).  Here’s the opportunity to be groundbreaking.

(Shelly):  Definitely.  So what is – what would be the proper channels, I guess, to try to get this implemented, say into the school or into our rural health clinic?

Leslie McGuire: Probably the simplest thing for you to do (Shelly) is the e-mail address that’s on that very last slide.

(Shelly):  OK.

Leslie McGuire: The mentalhealthcheckups@childpsych.columbia.edu if you send us an e-mail we would be happy to get that process started with you.

(Shelly):  OK, thank you.

Bill Finerfrock:  And I’ll bet because you’d be the first they’ll jump right at it because they want to get a foothold started.

(Shelly):  Yes, I’m sure.

Leslie McGuire: You will indeed get special attention.

Christina Carro:  Yes.

(Shelly):  Thank you.

Bill Finerfrock:  We’ll take our next caller.

Operator:  And there are no further questions on the phone at this time.

Bill Finerfrock:  OK.  Do you guys have any additional comments or things we don’t have to – if we end early, we can end early but do you have any additional comments or things you’d like to say?

Leslie McGuire: I don’t think so.  Christina do you have anything?

Christina Carro:  I don’t think so.

Bill Finerfrock:  Well, again, I want to really thank you for the presentation today.  And this is something that I’m going to continue to push within the RHC community to encourage folks.  I hope all of you who have listened in today will take a serious look at this and consider trying to incorporate this into your clinical processes there, your information gathering part of the history taking process for your patients.

I think that this is a very serious issue that’s going on not only in rural communities around the country and I think that to the extent that you can begin trying to engage in these kinds of conversations, eliciting this information, it will be all for the good that you have the opportunity to improve lives and save lives simply by asking some questions that does not take a whole lot of time and can really make a huge difference in somebody’s life.

So I hope all of you who are listening today or who are listening to the recording will take the opportunity to contact these folks.  The e-mail addresses you’ve been provided, to visit the TeenScreen.org Web site, call the 800-number to get more information and consider participating in this project.

I want to thank everyone for being with us today.  A recording of this call will be made available and a transcript will be available hopefully within a week to 10 days.  I would encourage you to have others participate in this series if you know folks who in your office particularly clinicians who were not able to be on the call today but you think would find this information helpful.  Encourage them to visit the Web site that I gave earlier www.ruralhealth.hrsa.gov/rhc and when the presentation is available that they listen to it and consider bringing this into the practice.

The next Rural Health Clinic technical assistance call is tentatively schedule for the second Tuesday in September and a notice of that topic and details will be sent out prior to that call.  I want to thank our speakers today both Leslie and Christina for the time that you’ve taken to be with us and I want to wish you all a good day and thank you for being here.

Leslie McGuire: Thanks every one.

Operator:  That does conclude today’s conference.  Have a pleasant day.

END

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