RECENT PERINATAL MENTAL HEALTH POLICY CHANGES: CLINICAL IMPLICATIONS IN PRIMARY CARE NANCY W SELIX, DNP , FNP-C, CNM UNIVERSITY OF SAN FRANCISCO SCHOOL OF NURSING AND HEALTH PROFESSIONS SAN FRANCISCO, CALIFORNIA
LEARNING OBJECTIVES • IDENTIFY CURRENT PERINATAL MENTAL HEALTH POLICY CHANGES FROM: • 2010 AMERICAN PEDIATRIC ASSOCIATION (APA) • 2014 MENTAL HEALTH ASSOCIATION OF AMERICA (MHA) • 2105 AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS (ACOG) • 2016 UNITED STATES PREVENTIVE SERVICES TASK FORCE (USPSTF) • COMPARE DIFFERENCES AND GAPS BETWEEN THESE POLICIES • DESCRIBE CLINICAL IMPLICATIONS OF THESE RECENT POLICY CHANGES AND HOW CARE CAN BE IMPROVED
AMERICAN PEDIATRIC ASSOCIATION (APA) • 2010 APA RELEASED BRIGHT FUTURES PROGRAM AND RECOMMENDATIONS TO SCREEN MOTHERS FOR DEPRESSION • RECOMMENDS SCREENING AT 1, 2, 4, 6 MONTH WELL-BABY VISITS • RECOMMENDS EPDS OR PHQ-2 • RECOMMENDS USING COMMUNITY RESOURCES FOR MATERNAL TREATMENT AND REFERRAL
Mental Health Association of America (MHA) • 2014 MHA RELEASED POSITION #49: PERINATAL MENTAL HEALTH • IDENTIFIED VALUE OF SCREENING, TREATMENT, AND REFERRAL OF PREGNANT AND POSTPARTUM WOMEN • INCLUDED SUGGESTIONS FOR TIMING OF SCREENING PRENATALLY, POSTPARTUM, DURING CHILD WELLNESS VISITS, AND AS A CONDITION FOR RETURN TO WORK FOR WORKING MOTHERS, AND IMPORTANCE OF COORDINATED PROGRAM OF FOLLOW UP FOR THOSE WHO SCREEN POSITIVE • RECOMMENDS CO-LOCATED MENTAL HEALTH PROFESSIONAL (IN PERSON OR BY TELEHEALTH) WHERE SCREENING IS DONE • PHQ-9 OR EPDS
American College of Obstetricians and Gynecologists (ACOG) • 2015 CREATED PERINATAL MENTAL HEALTH POLICY THAT REPLACED PREVIOUS POLICY • RECOMMENDS SCREENING TREATMENT AND REFERRAL • SCREEN ONCE IN PERINATAL PERIOD FOR DEPRESSION AND ANXIETY • MORE FREQUENTLY FOR THOSE WOMEN AT INCREASED RISK, WITH POSITIVE HISTORY, OR SYMPTOMATIC • TREAT OR REFER IF SCREENS POSITIVE • CREATE SYSTEM TO FOLLOW UP FOR THOSE WHO SCREEN POSITIVE OR ARE SYMPTOMATIC
United States Preventive Services Task Force (USPSTF) • 2016 INCLUDED PERINATAL MENTAL HEALTH FOR THE FIRST TIME AS A PREVENTABLE AND TREATABLE MENTAL HEALTH PROBLEM • LISTED PERINATAL MENTAL HEALTH ALONG WITH GENERALIZED DEPRESSION AS A CATEGORY B RECOMMENDATION FOR SCREENING TREATMENT AND REFERRAL • DESCRIBES PHQ-9, EPDS AS CHOICES FOR SCREENING • RECOMMENDS CBT OR NON-PHARM TREATMENT PRIOR TO USING PHARMACOLOGIC TREATMENT IN PREGNANT WOMEN • DOES NOT RECOMMEND SPECIFIC TIMES FOR SCREENING
MEDICAID • IN 2016, MEDICAID (MEDI-CAL) BEGAN REIMBURSEMENT TO ALL PROVIDERS WHO SCREEN AND REFER FOR PERINATAL MOOD DISORDERS • REIMBURSEMENT TIED TO EARLY PERIODIC SCREENING DIAGNOSIS AND TREATMENT (EPSDT) PROGRAM • MATERNAL SCREENING BY MATERNITY CARE PROVIDERS NOT COVERED
21 ST CENTURY CURES ACT • PROVIDES FUNDING TO STATES FOR CREATING PROGRAMS THAT SCREEN AND TREAT WOMEN WITH PERINATAL MENTAL HEALTH PROBLEMS • MAY BE TREATED WITH OR WITHOUT CO-OCCURRING SUBSTANCE USE DISORDER • SOME STATES HAVE ALREADY RECEIVED FUNDING FOR SUCH PROGRAMS • EXCELLENT OPPORTUNITY FOR GRANT WRITING TO CREATE NEW PROGRAMS AND COORDINATE EXISTING CARE
COMPARISON OF POLICIES POLICY SCREENING FREQUENCY SCREENING TOOLS TREATMENT APA AT WELL CHILD VISITS: PHQ-2 USE COMMUNITY 1, 2, 4, 6 MONTH VISITS EPDS RESOURCES FOR TREATMENT MHA DURING PREGANANCY, PHQ-9 CO-LOCATION OF MENTAL POSTPARTUM, AT WELL CHILD EPDS HEALTH SERVICES IN PRIMARY VISITS, ER VISITS, WIC VISITS, CARE, TELE-MENTAL HEALTH BEFORE RETURN TO WORK ACOG AT LEAST ONCE IN PERINATAL PHQ-9 PROMPT TREATMENT OR PERIOD, MORE FREQUENT IF EPDS REFERRAL SYMPTOMATIC OTHERS USPSTF NO SPECIFIC FREQUENCY, PHQ-9 RECOMMENDS CBT, OTHER MUST HAVE ADEQUATE SYSTEMS EPDS NON-PHRAM TREATMENT FOR TREATMENT IN PLACE PRIOR TO MEDS IN PREGANANCY
CLINICAL IMPLEMENTATION Tool Screening Frequency Location for Screening EPDS, PHQ-9 Prenatal visits – at least once Maternal care providers Postpartum period WIC service providers Emergency or urgent care providers if pregnant or postpartum 12 moths of less Well child visits – 1,2, 4, 6 months Pediatric care providers EPDS, PHQ-2 WIC service providers EPDS, PHQ-9 As condition for return to work Maternal care provider or Occupational health provider
GAPS IN IMPLEMENTATION IN CLINICAL CARE ACCORDING TO THESE PUBLISHED POLICIES, GAPS IN SCREENING EXIST • ROUTINE PERINATAL SCREENING AT SPECIFIED TIMES DURING ANTENATAL AND POSTPARTUM PERIODS NOT CLEARLY DEFINED • SCREENING NOT SPECIFICALLY DEFINED AFTER 6 MONTH WELL CHILD VISIT • PROVIDERS MUST USE INDIVIDUAL JUDGMENT TO DETERMINE WHICH WOMEN NEED ADDITIONAL SCREENING AT TIMES NOT LISTED IN POLICIES BASED UPON RISK FACTORS AND CLINICAL PRESENTATION
WHERE DO WE GO FROM HERE? • CREATE A LIST OF PERINATAL MENTAL HEALTH RESOURCES IN YOUR COMMUNITY • PROVIDE TRAINING FOR STAFF MEMBERS AND PROFESSIONALS (CNM, NP , MD, LACTATION SPECIALISTS, WIC NUTRITIONISTS) WHO IMPLEMENT SCREENING AND REFERRAL • INCLUDE MORE THAN JUST DIRECTIONS FOR SCREEN ADMINISTRATION- • DE-STIGMATIZATION AND NORMALIZATION OF SCREENING • VALUE OF A COORDINATED PROCESS FOR TREATMENT AND REFERRAL FOR THOSE WHO SCREEN ABOVE THE CUT OFF SCORE • TYPES OF TREATMENT THAT ARE PHARMACOLOGIC AND NON PHARMACOLOGIC • EMOTIONAL SUPPORT AS WOMEN TRANSITION FROM PCP TO MENTAL HEALTH PROVIDERS (COORDINATION OF THAT CARE AND WARM HAND OFF WHEN POSSIBLE)
THANK YOU • NANCY SELIX DNP , FNP-C, CNM • NWSELIX@USFCA.EDU
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