NC Pediatric Society Winter Open Forum 2011

North Carolina Pediatric Society Winter Open Forum

2/05/2011

Raleigh Renaissance Hotel

With much of the country groaning under historical snowfalls and low temperatures I suppose it would be poor form to whine about the endless gray rain that has fallen since I left Wilmington yesterday morning. Let's just say there have been worse days to spend in a cavernous hotel ballroom. And the company here is awesome! The grilled chicken wraps, well....

President Karen Breach welcomes us, and as always we pass round the microphone for introductions, with Executive Director Steve Shore doing the heavy lifting.

Business meeting

• Revising by-laws
• Minutes from these meetings will be on the website for everyone to comment and share their ideas, opinions
• Introduction of officers: John Rusher, Debbie Ainsworth, Scott St. Claire, etc.
• Please share any concerns or ideas with the officers.

John Rusher

Update On Legislation

• In addition to Steve Shore we have to outside lobbyists
• Big news is budget deficits, $3.7 billion this year. Lots of activity looking for places to cut.
• We have a lot of new legislators to educate about the value of what we do for children.
• Maintaining Health Choice, looks like we may have success.
• Maintaining Medicaid reimbursement rates. If they get cut,many physicians will stop serving those patients. We will need much help in explaining the importance of access to care for children.
• Health and Wellness Trust Fund is at grave risk, has been very effective at preventive services.
• Malpractice reform looks promising this year, notably statute of limitation provisions regarding pediatric patients.
• Scope of practice: different groups want to take on some of our work, detract from the Medical Home. Pharmacists may ask again for the right to vaccinate children under age 18.
• We need everyone's help this year. Email Steve Shore to get on our list server for pediatric issues. Do act! Get to know who your senators and representatives are. Build relationships with those people, offer your knowledge of pediatrics and medicine, act as a consultant.
• www.ncleg.net is the website to look up bills, find links to your representatives!
• Come to White Coat Wednesdays this Spring! You can find the dates on our website. You will hopefully get to meet your own representative.
• Come find John and he will help you with the process.
• Let John know if you have had problems with the loss of the Universal Vaccine program
• Please read emails from Steve Shore, especially if they say "legislative alert."
• Kathleen Lucas reports UHC is not covering Gardisil administration to males, wonders if that violates the Accountable Care Act.
• David Tayloe recommends reporting these denials to the Section On Practice Management of the AAP and we have mechanism to address it, even with the NC Department of Insurance.
• Brandon Rector states this child would fall under the state program for Gardisil, since he would be considered under-insured.
• Karen Breach mentions we will probably need more money this year for lobbying

Leslie Starsoneck, Director of Development

NCPS Foundation Report

• Hoping to decrease reliance on grants, which is heavy now' and increasing our reliance on endowment.
• Participation by members is critical, even if they just give a little
• We are hoping to get further grants from Healthy and Ready to Learn
• We may participate in the Foster Care Medical Home Initiative
• We need to have an endowment of about $1 million to be healthy. If every member contributed $50, it would get us $90,000 closer
• Glaxo, Wachovia, Wells Fargo have matching programs for employee donations.
• We're working on making the website more user-friendly
• Christoph Diasio recommends using Constant Contact to help drive traffic to the website for the Foundation

Jane Meschan Foy, MD, FAAP, District IV Vice Chair

AAP District IV News

• Discussion of the eight mega-trends that will affect the future of pediatric practice.
• Early Brain Development is a new priority. We are organizing a new group to address it.
• Foster care is going to become a permanent group within the academy
• There is a new workgroup on pediatric mental health, on which Jane Foy and Marian Earls will both serve.
• Media, epigenetics, partnering with families, are all rising issues within the Academy
• Affordable Care Act. The Academy is working to help us all implement these changes.
• There are five recommended actions steps for chapters
• We need to speak on impacts such as
• No exclusion for preexisting conditions
• No deductible for preventive care
• Extension of dependent care to age 26
• No lifetime limits on coverage
• This week the legislature will try to undermine the Affordable Care Act.
• John reminds us to have parents contact legislators as well if they have benefitted, especially those with special needs
• Jane suggests we organize these success stories by forwarding them to Steve Shore
• We need to monitor for child only plan problems
• Offer our expertise and participation in creating Accountable Care Organizations
• Per Steve Shore the NC Institute of Medicine has been tasked with designing our implementation of the ACA. He represents us on this organization.
• We are represented on seven of the eight commissions tasked with designing these solutions
• There is some concern that we won't really know how this all plays out until the Supreme Court decides on the constitutionality of the law.
• Remind people that unless ED's can turn people away therre already is an individual mandate, it's just under the table rather than explicit
• Healthcare is the 2nd largest item in the state budget, which means we are at grave risk for cuts in reimbursement.
• As accountable care organizations start to form, we will need to make sure physicians drive the nature of these organizations. Other groups, like hospitals, want to drive how these are formed and run.
• If we don't drive a pediatric component to these organizations and structurres, they will focus exclusively on adults, which is where the money is
• Community Care of NC has already demonstrated that we can do is and save tons of money
• Christoph reminds us that BCBS already pays large rewards for participating in their Medical Home project
• Jane Foy addresses the complaints pediatricians have and with Maintenance Of Ceritifcation with the American Board of Pediatrics, and the ABP has made substantive changes as a result of our input.
• Karen Breach encourages us to contact her with any concerns we have with the MOC process, which will be addressed at the Annual Leadership Forum in March
• Document specific problems as they arise, and report them.

Department Chairs

• Duke has a new cv surgeon, a new cardiac intensivist, a new neurologist, more NICU beds. Also building a new pediatric MRI.
• Carolinas/Levine is adding a sixth GI specialist, a new rheumatologist, a new adolescent medicine director. Their training program continues to grow. Quality improvement has grown and involves all residents and faculty. A new, free pediatric handbook will be available to us from them in spring.
• ECU/Brody mourns the passing of Morris Brody. In June they begin construction of a pediatric patient tower and pediatric ED. There is a new pees clinic and a new dental school. They have two new nephrologists, a new surgeon.
• Wake Forest has received a national award for palliative care. A new book from them will document the 2009 flu pandemic.
• UNC is expanding their NICU. They have new hematology staff, two doctors. The residency program is opening a new primary care tract, adding four additional residents.
• Mission Childrens has added a third GI doc, an orthopedist, an endocrinologist. Now they are the first baby friendly hospital in NC.

Brandon Rector, MSW, State Immunization Branch

• TDaP can be used now down to age 7 years
• We will follow the ACIP recommendations for meningococcal vaccine, memo coming out next week
• The HIb booster requirement for daycare has now been restored since vaccine supplies have recovered.
• We have had a few flu deaths in the state. Vaccine is still available from the state.
• Sanofi will stop making Tripedia, Trihibit. There are two other TDaP choices.
• The NCIR ha now enrolled 95% of providers, still does not include hospitals, which means the first HBV vaccine is still not registered, but there is a new vital records registry that will document this information, almost in place. Don't add the first dose to the NCIR at this point, it will be duplicated!
• Bidirectional interface may be operational in 2011, no promises, but high priority.
• If you find duplications email them to the Immunization Branch.
• Nurses are now required to visit half the providers in a given year. Expect a site visit every other year.
• Any office that employs a person on the list of excluded persons from federal programs cannot participate in Vaccines For Children
• Christoph points out that NC has done a great job of getting flu vaccines out in a timely fashion, much better than almost any other state!
• The immunization branch tracks religious exemptions, goes out into the high exemption counties to try to find out what's happening and counter the trends.
• Remember adolescents now need a meningococcal vaccine booster if they got the first dose before age 16.

Gerri Mattson, MD, MSPH, FAAP

Update On Public Health and Mental Health for NC Children and Youth

• Works for Title V for the state, maternal and child health
• Healthy People 2020 and Healthy NC 2020 just released, include mental health objectives
• Compared to national statistics we have more children with mental health diagnoses, fewer who have received mental health services.
• These children need case management, care coordination
• Care Coordination for Children is the new program for this purpose.
• CHIPRA developed quality of care measures for pediatrics, including ADHD follow up and mental health follow up. Community Care of NC will be involved in collecting these data.
• In 2009 to 2010 school nurses were aware of chronic health conditions in 19% of school children, up form 8% in 1998-1999.
• School nurses have limited training in identifying mental health problems
• Department of Pubic Instruction has sent out a survey to further identify the mental health nee in schools today.
• North Carolina has a commission on children with special health care needs. They work with the division of medical assistance to ensure these children get needed services.
• The NC Institute of Medicine must look at young child mental health according to legislation passed in 2010
• LAUNCH linking unmet needs in child health, assesses social emotional development in young children
• Increasing screening and service provision for at risk infants, children, and their families
• Includes supposed for home visits and parenting programs
• Early Childhood Comprehensive Systems Grant. Looks at early parent education, health, and family strengthening systems.
• Improving early childhood workforce capacity, data systems for accountability, and investment in early childhood.
• Evidence based programs for family strengthening. Home visiting for mothers, infants, and children. Project Connect: communities supporting young families. Offers support to pregnant women ages 13 to 24.
• Programs: IncredibleYears, Strengthening Families.
• Care Coordination for Children (CC4C). This is a care management program for at risk children. Include children with special needs, abuse, neglect, parental substance abuse or depression, foster care, exposure to violence. Medical home will make referrals. Will replace child service coordination program.

Jane Meschan Foy, MD, FAAP

Enhancing Mental Health Services In Pediatric Primary Care: Tools You Can Use

• How to use the AAP mental health tool kit
• Task force provided a supplement to the June, 2010 Pediatrics. This includes many of the tools in the kit, but the kit is more complete and easier to use.
• The tool includes downloadable updates, look to the left side of the home screen. Should update quarterly.
• You might start with a mental health practice readiness inventory, included in the tool kit. Let's you see how well your practice is already doing. Creates a report on strengths and weaknesses of your practice.
• There is a template for generating an inventory of community mental health services.
• Toolkit includes algorithms to guide the process of care for various mental health problems, including screening tools, coding, community resources
• You can also go straight into the clusters, the most common symptoms that present in primary care. Can look at depressions,anxiety, developmental issues, inattention/impulsivity, substance use and abuse. From there you get walked through an evidence based clinical approach.
• You can look at the tool for improving payment for mental health services you provide, very popular among users.
• Suggests appropriate E&M codes and guidance on how to document to use them. Remember consultation codes are sometimes appropriate, can result from referral from almost anyone as long as the request is documented.
• Remember you can bill based on time as the key factor so long as that time is documented and accounts for more than 50% of the visit.
• You can use tools to improve the mental health referral process. About half the children we refer for mental health services never get there.
• Mental health professionals often give us not feedback, exchange of information. This is an area to work on.
• There is a printable brochure to demystify the process for families. Families who are engaged in the process are more likely to actually show up to the referral.
• HELP: show hope, empathy, language/loyalty, permission/partnership/plan. Tis is an evidence based approach to behavioral change that works to help families meet goals.
• http://tinyurl.com/enhancingMentalHealth/
• Monitor functioning of children with mental health problems, includes functional assessment tools like the Strengths And Difficulties Questionnaire
• Ends with an example of a child with a specific problem (anxiety) and how you could use the tool kit to manage his illness.
• Ten percent of children are actually functioning normally but their parents are concerned they are not!
• The tool kit should help pediatricians become more comfortable with pharmacological approaches to treating mental health issues based on evidence based guidance.
• www.aap.org/mentalhealth
• aapcodinghotline@aap.org
• jfoy@aap.net
• There is a mental health coding webinar available at the aap or at teen screen
• North Carolina Center of Excellence for Integrated Care can provide direct assistance to your practice!

Mike Palanza, MA, PLA

• Starting SBIRT With Adolescents: screening, brief intervention, and referral for treatment of substance abuse
• The program at Wilmington Health Access for Teens has been in place about 2 1/2 years
• 19% of high school students have binge drunk in the last 30 days
• 1/5 have used marijuana in the last 30 days
• Implications are for poor academic performance, high risk behaviors of all types
• Primary care offices provide a unique opportunity to provide substance abuse screening and treatment
• We have a ago in care for youth who are just on the verge of getting in trouble with substance abuse.

Tim Evans, MSW, LCSW, same topic

• SBIRT can be implemented in primary care centers, emergency departments, trauma centers, and other community centers.
• Substance abuse requires a life long disease model approach. You can't just get them off drugs one then stop treating them.
• Brief intervention focuses on increasing insight and awareness, motivating behavioral change
• The goal is to link to treatment programs available in your community
• There is evidence that using SBIRT is effective at reducing hospital stays, ED visits, and other end points
• Starts with a brief screen like GAPS, then positive answers trigger a full screen.
• Provider then performs a brief intervention.
• Follow up questionnaire is CRAFFT
• CRAFFT: driven in a car, use drugs to relax, use drugs alone, forget things, friends and family tell you to quite, gotten into trouble?
• Only refer if teen is open to it
• WHAT brings in a mental health provider or SBIRT specialist into the room when possible for positive screens
• The specialist provides technical assistance and training to the providers
• The workflow can be customized for various settings.
• Start with open ended questions, reflect back and summarize the answers you get, put the actions and consequences back on the patient
• Brief interventions rely on behavior change models, motivational interviewing strategies
• Pre-contemplation: problem, what problem?
• Contemplation: I may have a problem. Maybe I should do something about it. Tomorrow.
• Preparation: I do have a problem. I think if I didn't it would be better.
• A brief intervention may simply involve providing brochures, picture or models of potential outcomes, offering information about potential behavior change
• Follow up with more questions: how are you going to do that? How do you think it will help you?
• Codes for brief intervention: 99408, 99409
• Referral scares a lot of people, has to be handled with reassurance
• So far screenings at Bakersville clinic have been only 6% positive, but is is a very small community where many patients may fear being honest, also they see lots of elderly patients
• WHAT CRAFFT given 1640 times, 221 had two positives, 140 had one positive
• 64% of referrals were kept

Presentation to Marian Earls for service to AAP

Hillary McClafferty, MD, FAAP

Physician Stressors: Update and New Management Strategies

Section on Complementary and Integrative Medicine

• Focus on how to promote physician wellness, look at emerging research and resources
• Goal is to capture a sense of well-being and vitality about our daily work
• Sixty percent of physicians report burnout symptoms
• If you are not well, you make more mistakes, get more lawsuits
• Physicians who are not well don't get as good outcomes for their patients
• First guidelines on physician mental health published 1973 by the AMA
• Our altruistic, compassion,competitiveness, resiliency, fear of failure are all risk factors when pushed go the extremes.
• Looking at a global concept of health: body, mind, spirit
• Wheel of life gives a visual model of how you are balancing the various aspects of your life
• As pediatricians we understand the importance of modeling desired behaviors
• Canada has a model policy for physician health and wellness: ephysicianhealth.com
• The AAP is working on our own website for this purpose

Remember our next Open Forum is Saturday, April 9th in Concord, NC. Please come and participate! I'll even lend you some mayonnaise for the grilled chicken wraps!