Implementing Postpartum Depression Screening in Infant Well Child Checks

– Hello Welcome to our webinar on Implementing Postpartum Depression Screening During Infant Well Child Checks

We will be talking about options and resources for addressing logistical barriers to screening during child and teen checkup visits My name is Tessa Wetjen, and I am part of the Maternal and Child Health section of the Minnesota Department of Health, and I'll be leading our webinar today I am the coordinator of our Postpartum Depression Quality Improvement Project, and with us later on our call will be Dr Brian Lynch, a pediatrician with the Mayo Clinic, and Dr Shannon Neale, a family practice physician with the Park Nicollet Clinic

These two have implemented postpartum depression screening in well child checks, and they'll be sharing about their experiences Today we will talk a little bit–well, we're going to talk a lot about the postpartum depression screening and how to implement it If you and your practice are interested in further work on that, we will have a learning collaborative that will be starting in summer of 2016, and we are still signing providers up for that project So if you are interested in working in a learning collaborative to implement the screening process, please do contact Tessa Wetjen at the contact information provided here So today we'll be talking a little bit about why we should implement universal postpartum depression screening and why do it in the well child check

We'll be talking about how to plan for referrals We will be discussing logistics that may come up and possible ways to overcome barriers, and we will hear from both Dr Lynch and Dr Neale about their experiences, and then we'll be taking questions and comments So why should we screen for maternal depression in the well child check? Well, a number of reasons clearly, but first and foremost that maternal depression has significant impacts on both mom and baby health outcomes

It is very much, the maternal or the primary caregiver's mental health has a significant impact on child health, and that's why looking for it within the context of a child well child check is appropriate The symptoms of maternal depression and symptoms of depression– it doesn't self-resolve Often people think we're referring to what's commonly referred to as baby blues, which is kind of deep emotions, high– can feel like depression and anxiety that comes up really within those first two weeks after a baby's birth and does self-resolve, and that's not what we're talking about So screening for maternal depression is done because it is something that is not likely to resolve itself quickly and because treatment and support exists It is something that we can help a mom and her family figure out how to deal with

And because we know our prevalence is significant, and it has health equity implications The prevalence in our state is probably similar to nationwide, which is between 10% and 15%, but our information tells us that those numbers are much higher for moms of different cultural and community groups So what are the effects of maternal depression on the child? Untreated or existing maternal depression The impacts on the women, on the mothers: the mom, is less likely to breast-feed, might exhibit poor self-care and inability to follow health care recommendations, and we have the increased risk of negative behavior such as substance abuse, suicide, and the negatives–increased risk for future depression On the children that that mom is raising, we have evidence of the impact of sleep problems, developmental delays, specifically difficulty with language development and attachment issues

We have an increased risk of mental health issues for the child and an increased risk of failure to thrive Minnesota has what's called the Pregnancy Risk Assessment Monitoring System This is nationwide Not all states participate in it, but a number do, and Minnesota is one of those This survey asks a couple of questions to help us identify issues around maternal depression in our state

It does not say– the question is not, "Do you have postpartum depression?" But it's a little more specific to asking mom what– has she been told by her provider that she has postpartum depression? Has she experienced some of these symptoms, and has it impacted her life? And so looking at those percentages, we see statewide actually a little bit lower number than we'd expect at 92%, but we see in our black population and in our American Indian population statistically higher percentages We have 144% and 20% among American Indian We also see a statistically higher percentage in those who did not complete high school, at 16%, and so we do know that we have particular populations within our state that are experiencing postpartum depression at a higher rate than the average population

Another interesting information that we know is from our billing data, so the Department of Human Services does collect billing data from women who are enrolled in the Medicaid program in– so for the past– for three years– for 2011, '12, and '13– we were able to identify how many mothers had a coding–or had prescriptions, or were using a couple of different things– had some way of us understanding that they had a diagnosis for depression So we have it around 18% of our MA population for Minnesota, and we pushed a little further to ask next of those moms who have a diagnosis that indicates postpartum depression or depression within the year after birth, how many of those moms had a code for mental health treatment, at least one? And on that, we– it looks like our numbers are actually going down So we had 63% in 2011 down to close to 50% in 2013 So what we're talking about here is, you know, if you average those out, around 50% of moms who have a diagnosis were receiving any treatment Now, we certainly know that we are likely to have a large group of moms who do not have a diagnosis and are also therefore not receiving treatment

So the best practice here is, instead of trying to sort of guess or identify which moms might be the ones who need treatment or need a diagnosis or a next step on maternal depression, is to just go ahead and universally screen all moms So that's what we're asking you to do, is to universally screen all moms in well child checks for maternal depression And we do–we are asking you to use a tool There are actually three tools that are available within Minnesota–within MA– for the PHQ-9, or the patient health questionnaire The Edinburgh Postnatal Depression Scale, which is usually referred to as the Edinburgh, or the EPDS

Also I should mention the Beck is a tool that is eligible for billing However, the Beck is a tool you have to pay for, and so we are not going to talk about it today We're talking about the ones that are free You are also welcome to use a pre-screener tool, which is the PHQ-2, instead of the PHQ-9 It is appropriate within the pediatric visit

It is not billable, so we won't spend a lot of time talking about that It's a–basically it's two of the PHQ-9 questions The screens are most effective around three weeks after birth, according to a lot of the research, but we know we don't always see moms three weeks after birth and that we also have moms who aren't willing to talk about depressive symptoms until they either manifest more or they just become tired of dealing with them or not talking about them, and so we are recommending a screen at all of the well child checks up to 6 months and up to 12 months, if you're able to put it into your system at your clinic We're going to talk more in depth about the different types of referrals, but we do recommend that everyone plan for the referrals that you may make as a result of doing this training For those moms who have low to no concern indicated on the screening tool, we are going to show you the Maternal Wellbeing Plan, which is a tool that you can really use for a conversation with mom about how to promote and maintain positive wellbeing

We also have a fact sheet regarding postpartum depression and anxiety, and these are just tools that can be shared with any mom, regardless of how she scores, or a family, regardless of how they score on the tool, in order to help sort of increase the education families are receiving about postpartum depression and about maternal mental health For those moms who–those who indicate a moderate concern on the screening tool, we do recommend that you work with the mom to make a detailed plan for the next steps and that you do follow up within one week And I want to make a–or I should have said this earlier We're not exclusively talking about moms The postpartum– or the postpartum depression screening, we really want to think about doing it with the primary caregiver who's bringing mom to the visit

Some people, in the past, may not have recognized that it doesn't have to be the birth mom If there's an adoptive mom, adoptive moms can also experience postpartum depression, and so we want to be screening those as well, and if it is in a case where the father or grandmother or aunt or someone else is a primary caregiver, we can certainly be screening them as well It's, the mental health and the wellbeing of the primary caregiver is really what we're getting at Just to make it easier and because most often that's mom, that's why we're going to use mom as our target for this presentation Okay, so getting back to the referral techniques, if you–if there is a moderate concern, we do want to create a referral plan with the mom and designate a staff– or a process for which your clinic will follow up with mom within a week, and if there is a crisis situation, we do expect an appropriate crisis-level response, you know, in a unique situation with a mom with small children, and sort of there are some good questions that we'd like you to ask in that crisis situation and as you create your plan for that

So thinking about what those referrals might be within your–for a mom with a moderate concern, there are some things to consider What are the easy or most rational referrals within your own network? Are there–if the provider who's working with the child is a family practice provider, are they– like, can they see the mom themselves? Is there mental or behavioral health options available within the clinic or within the network? Would those be the first response? We are going to– we're going to stress that you want to talk about who mom is willing to see, so maybe mom is more willing to see their own doctor If not, maybe mom would be willing to talk to a family home visitor or to a therapist or a support group There are nonmedical supports, things like family home visiting, nonmedical or non-health system support groups that might exist in the community, and if mom isn't willing to go to a provider, she might be willing to go to one of those, and so it's helpful to figure out what those are in your community And really just talking to mom about what she is willing to do and take it from there

You know, we thought, "Well, of course the referral is back to the primary care physician" Well, sure, but if the mom has this great relationship with her OB or her midwife who she's just been seeing for nine months, then maybe she should–and she'd be willing to go to them, maybe she should talk to them You know, it is really a conversation with mom about who is the provider that she is most willing to see And really thinking about treatment in terms of three different areas of support There are peer and community support programs

There is psychotherapy There is cognitive behavioral therapy, and there are therapists who are really well-trained in how to understand using those treatments for mom to experience in postpartum depression And there is medication It's important, in this context of serving the child, as the child's provider, that I think it's helpful to be aware that moms are concerned– there are some moms that are concerned about taking medication when they are breast-feeding, and it is not an irrational concern And so having–if you are going to be serving mom and seeing mom and discussing medication with her, then that's a risk conversation that you'll have to have

It also–we have found in some of our clinics who were doing referrals that moms were told that they were not allowed to continue breast-feeding on medication, and so that's a conversation that if it's possible and appropriate to have with mom about the different risks, then that's something to talk about It–there are those that take the stance that the little– that the unknown and yet– it's an unknown risk in that it– that in weighing the risk factors, there are moms who do breast-feed on medication with an understanding of the risks and that it's worse for the infant or the baby to have a mom with untreated maternal depression than not and that the benefits of breast-feeding outweigh the possible risks So there are certainly larger conversations than you may want to have in the pediatric well child check, but it's a good–it's information to be aware of and to be able to have those conversations, if that's what mom wants to talk about And there are sources for your referrals and for your questions When we think about crisis, if it is a crisis and your clinic is not prepared to handle the crisis, then we may need to call 911

You may need to call the crisis connection or the suicide prevention line These are also numbers that are available on those– the information tools regarding depression and anxiety that moms can take home, in case of a crisis later, but we do want you to think ahead of time about what your crisis plan would be And we have some referral opport–or some places to go for questions about other referrals United Way First Call for Help can certainly help identify options An interesting option for providers and for families is the Mother-Baby HopeLine at the HCMC Center, or at Hennepin County Medical Center

This is a warm line, not a hotline, so you'll expect a call back within two days, and they actually can provide support for providers, as well as for moms and families So if a provider is interested in supporting a mom and pursuing medication for mental illness or for depression while on– while breast-feeding, this is a place the provider can ask some questions about the best medications to use for that or any other questions providers can have about best practices and treatments The Mother-Baby HopeLine is prepared to help answer those More of a regional and community support is what the Pregnancy Postpartum Support Minnesota Resource List can help you with They can help identify support groups in the area, trainings for providers, other sort of regional activities

And they've actually recently started a new service, which they've had their help line Their help line has been a warm line as opposed to a hotline, so you may receive a call back instead of immediately talking to someone, but they have also recently added a texting service, which is just, I think, a great option for some moms So this a help line for moms or for families The information'll be provided by peer volunteers, or the response is provided by peers, and a mom can email, call, or text to the information there So going back to some of the other resources, the Maternal Wellbeing Plan is a way to talk to mom about what it means to promote maternal wellbeing or positive mental health for mom

So this is a modified depression action plan, and it is a tool that's been used to help people deal with depression So this is the– what we tried to do is modify it a little bit, because it had some expectations around how– sleep and other things that are just hard to do with new babies And so what we did is took it and put it into what we think can help support wellbeing for a mom, and it does talk about rest, sleep, connection with other people, healthy food, movement, of support And it also provides mom with an opportunity to think about, "How will I know if I'm not healthy, "if I'm not feeling well mentally? And who would I talk to about that?" And it asks some of those questions We also have–and we have that in seven languages– Amharic, English, Hmong, Karen, Russian, Somali, and Spanish

Also in those seven languages is our basic information sheet about postpartum anxiety and depression And those tools–just to highlight a little bit more about how to make that selection between the PHQ-9 or the Edinburgh– the PHQ-9, nine questions Neither the PHQ-9 or the Edinburgh are validated in a lot of the– in some of the languages that we have here in Minnesota, but some of them are available as translations as an un-validated tool And so we have this little, nice grid for you Some questions to ask is just– and what this is, is a tool to help you, in your practice, decide which of these screeners might be the best for you

The PHQ-9 is not specifically designed for pregnant or postpartum women; the Edinburgh is The PHQ-9 is widely used It is used, oh, I wouldn't say exclusively, but very widely used in the behavioral health/ mental health community; the Edinburgh is not Some people will not know what the Edinburgh is The reason why that might be helpful is, if you are referring a mom with suspected depression to a mental health provider, it may be helpful to say, "And her PHQ-9 score was a 12

" If you say the EPDS score, they may not know what you're talking about All three of these are billable within the well child check, and the PHQ-9 and the Edinburgh are both free and easily accessible And when you do look at those tools, kind of think about which tools are used in our system most often, which tools are available in the languages we need, and maybe that one or both of the tools are already available within your electronic health record or your SMART sets, and that's something else to consider Another question we get a lot of: "Well, which of these visits should we screen at?" And certainly we recommend, if you can figure out a way to get it into your schedule, to just go ahead and screen at all the visits This is certainly– it seems the most appropriate especially for clinics where families or children are not coming in exactly on the dot for each of the visits

They may visit–they may come in at three months or five months or seven months instead of at the two and the four and the six And so if you're doing it at all the visits, then you don't have to worry about which visit it fits If you're only going to pick one or two to do it at, we certainly would hope for the two or the four month or the two and the four month Now, this also relates a little bit to, "Is this provider also the one seeing the mom for her postpartum visit?" which is at the six weeks One of the reasons for doing it in the infant well child check is that a depressed mom may not be attending her postpartum visit

If you know that they are and it's the same person seeing it, then that might be a reason to do four months If you're not–if your moms are not consistently attending their postpartum check, which nationally I think it's about a 66% that are, then doing the two-month check is a really good idea We don't want to only do the one-week visit, and it's questionable as to whether or not you would do it at the one- to two-week visit anyway, just because mom is really just coming out of that newborn daze, and it's not really the best time to assess But another really big problem, or big question, that people face is where to document, so where to document the score and the follow-up The, um

There are many actions for this In order to bill for it, it needs to be documented in the child's encounter that a screening tool was used to screen for maternal depression That's what you need in order to bill, so you don't even have to list–you certainly don't need to list the score that was–the score on the screen in order to bill for it

However, now that you've screened the mom, you have a score, and you may have some follow-up to do, and so that probably needs to be documented somewhere, and determining where is really up to you and your system to determine Some people have chosen to just–some people do document everything within the child's health record Some document within the mom's health record If mom is not a patient within the system in– or if many of the moms are not a patient in the system, then most likely you're going to have to figure out a different way to do that And so there are a couple of different ways people have done it

Oop, sorry I'm going to go back So in addition to putting it in mom's record, another option people have used is developing a separate file, and so, you know, like a folder on a shared drive or a folder in a protected spot in which the screens are scanned into and remain there, and if you ever needed to follow up on it, you could find them there And the follow-up and referral is tracked there, but it isn't tracked in the child's health record And that can be another way to protect the separation of that information

If mom's–another note that we want to add is, if mom's score is positive, it's important to think about how to ensure that the baby is screened for social/emotional development concerns at the next visits for at least the next few years So if you are not already doing those screens at each of those well child checks, then it might mean new flags that you need to put into the child's medical record in some way This is a lot of information about how to bill for it with the CPT code This information is found in the Minnesota Health Care Program Provider Manual, so I'm not going to spend a lot of time on it Just a little– a few notes on how to differentiate between baby blues and postpartum depression, baby blues is pretty common

It's up to 80% of new moms It kind of is that emotional instability, crying spells It's–it is– it looks like sadness and irritability and anxiety, but it does not interfere with the care for the infant It occurs very quickly after birth, in the first month, and the symptoms do resolve With postpartum depression, as we said again, we think is somewhere between 10% to 15% nationally

Research shows that in high-stress populations or communities experiencing a lot of stress that can be closer to 30% to 35% of moms Some similar signs: irritability, but also feeling the deep sadness, and symptoms really very similar to major depressive disorder and can include thoughts of harming herself or her child It can occur any time within the first 12 months after birth, and the symptoms will persist and do require treatment And we want to encourage you not to forget the partners About 10% of partners– so not the mom or the main caregiver, but the other partner– will also experience symptoms

You can ask the partner about their feelings You can normalize and validate that it is a stressful time for partners, and partners can experience depression, along with mom's experience of it Some considerations when you make those referrals are, does mom have a primary care provider who she wants to see? And really, again, getting back to that idea that a warm handoff is the time– is a handoff that is done quickly and that we're aware of the time but we've also talked to mom about who the right person is to make the handoff to If that referral handoff time can be made while the mom is there in the office, even better That is– that would be ideal

So want to encourage you again that if you're interested in this quality improvement project to help your practice implement this, we do have openings in the quality improvement project that we'll be starting in the summer of 2016 So now we're going to go ahead and hear from some of our providers who've had experience in implementing maternal depression screening So we want to thank Dr Lynch for being here He's calling us from the Mayo Clinic and is going to share about his experiences

Dr Lynch, go ahead – Perfect Okay I'm a general pediatrician

I work at Mayo Clinic in Rochester, Minnesota, and we've been doing maternal depression screening since 2009, and it's been overall an outstanding experience for us We've used the PHQ-9, mainly from convenience We already had it in our electronic medical record When we started this process and as we've been continuing it since then, we've always documented the results of the screen in the child's medical record That's being reevaluated at this point, but until this point, we've done that

We had our legal team here review that We've–we had some advantages at our clinic One is that we had– that most clinics don't have We had depression care coordinators on-site at our clinics where we initiated this, so as a pediatrician, if concerns were identified in the PHQ-9, I could immediately refer a parent to someone on-site who could then further assess them and set up follow-up, so that was nice, and that's something a lot of clinics don't have Another advantage we have is that most of the children I take care of in my clinic, their parents are also taken care of at Mayo Clinic, so we had access to that maternal record and those contacts

So overall, the experience has been very good We've had very few problems Families have been very accepting Again, there's been a few cases where a mother has had care outside of Mayo Clinic, and we've had to sign authorization then to communicate with their provider or follow up with the mother about how they're doing and if they've had follow-ups, but just a few rare cases like that But most of the time, again, the follow-up would be coordinated by these depression care coordinators that we have assigned at our clinic, and that's worked very smoothly

So right now, we're reevaluating this process for kind of all the Mayo Health System, and I think with the idea of now patients having portal access to their records and then some of the lessons learned from Tessa's project– the idea of actually putting the actual score and follow-up plan in the child's record– is being questioned right now No final decision's been made, but I get the sense that maybe our legal team will argue that we just put "screen completed" in the record, and then we put the results of the screen in mom's medical record, so that's kind of where we're currently at – Thank you so much, Dr Lynch That was great

Next we're going to hear from Dr Neale She is a family physician at the Park Nicollet Clinic – Okay Yeah, so like Tessa said, I'm a family physician at Park Nicollet, and we started–we rolled out postpartum depression screening throughout all of the clinics, family medicine, pediatrics, and MedPeds, as well as OB in the fall of 2012

Prior to that, we had rolled out developmental and autism screening throughout all of Park Nicollet in 2010, so for us, this was just– it was kind of an easy add to get people to just do another screen, but I'll talk a little bit about how we–some of the challenges we had initially getting people to screen at all in 2010 when– and one of those was because we're so big, we had people doing lots of different things at all different sites, a lot of times using them incorrectly They weren't approved screens Some people weren't screening at all, so what we did was, we actually chose the screens purposely that we told people that they needed to do As far as the postpartum depression screening, we chose the Edinburgh because it does have a couple of questions that specifically address anxiety, and so we wanted to make sure we were capturing that So we told people which screens to do, and then we did a lot of education

We did WebExs where we talked about why we were doing this We went out to each of the individual sites and taught nursing staff and clinicians how to score them and talked about some of the barriers that they might have Because every site is different, we understood that people might be having to distribute the screens differently, and so we said that that was okay as long as they used some of the methods that we recommended, such as some sites hand them out at the front desk; some, the nursing gives the patients the screen in the room; some mail screens ahead of time; some people have people arrive early to do it In any case, the goal was that they actually just handed them out, and then we developed some cuing sheets so people remembered what they were supposed to do at each site, because once you start screening, there are a lot of different types of screens, and people get confused That's normal

We currently are screening for postpartum depression prenatally and at postpartum visits at six weeks, as well as at the one-month, two-month, and four-month postpartum– or well child visits We–one of the things we found was that a follow-up plan, if there is a positive screen, is really important to have in place That's one of the barriers that people don't want to do screening, is, they're worried if they have a positive, what do they do? So one thing–our mental health department here, we've been really fortunate; they've been very supportive They started a few years ago having all of the Edinburgh screens, whether they were positive or negative, sent to a central area in mental health after they were done, and then the positives are all called by somebody in mental health and–to make sure that people are being followed up with quickly That doesn't mean that people aren't being followed up with at the office immediately either

It's just sort of a safety net for us and also for the providers as well As far as documentation goes, we– [laughs] Our legal department was very uncomfortable with us putting scores in the baby's chart, so we came up with a system where, if the mother was not a Park Nicollet patient, that the screen for the baby would go into this shadow file that we would just keep indefinitely, so if at some point it was needed to be referred to, for whatever reason, it could be accessed If the mom is a Park Nicollet patient, that baby screen is just sent to the mom's chart And then obviously if it's the mom being screened, then that's the easy one, but the hard one is always the babies And so we also came up with some wording that if there was a positive screen that we could at least know for the next visit that there was an issue, so if something like the Edinburgh was completed and a referral was made, versus if it was normal, Edinburgh was completed, and there were no concerns that arose

So this actually is being looked at again, though Apparently our legal department is having a change of heart and thinking that maybe we actually can put some more documentation in the baby's chart, so I think we're going the opposite way that Mayo is right now But so–but, again, I don't know what's going to come with that Usually these things take a year or so to get all hashed out, but currently that process I just said is what we're doing – Thank you so much

Now we're going to go to our questions We have some that have come in Dr Lynch from the Mayo Clinic, can you clarify for us who is performing the screening? – Yeah, so here's Dr Lynch

And here, the care coordinators are registered nurses, but I think, after having experience with care coordinators over the past ten years, they wouldn't have to be, for a lot of these They could be social workers You know, there could be different staff with different training who could successfully sort of do this follow-up and work, but here, we've used registered nurses who then got special training with depression management – Thank you Dr

Lynch, can you clarify for us who is doing the follow-up? – So the tool is actually handed out by our front desk, and then it's completed by the families The nursing staff makes sure it's completed before I, as a provider, come into the room, and then I'd be the one who does the initial scoring and deciding what the plan would be Again, if it's passed and there are significant concerns, you know, we would discuss that there, and there wouldn't be any follow-up If they did not pass the screen, that's when we would talk about the follow-up plan, and, again, in most cases at Mayo, that mother is cared for at Mayo, and so either they're getting depression therapy right now, or I refer them to these RN depression care coordinators, who then come in, take some time to assess the situation, try to make sure, you know, "Does a referral need to be made today, or does any more action need to be done?" And then there's a minority of cases where the mother was not cared for at Mayo where I could not involve those depression care coordinators, and then I would be making that plan with the mothers – Great

Thank you Another question that I would love to have both Dr Neale and Dr Lynch answer is if you would talk to us a little bit about how much time this added to your visits and, I guess, overall, what you would say the benefits are of incorporating these screenings into all of your visits, sort of in relation to the costs of time and energy, or things like that So what would you say to other providers about that? – Sure

Overall, you know, the biggest time crunch of doing screening is actually having people do the screens, so as far as what it adds to my face time with the patient, as long as I have the screens done when I go in, it makes my visit so much better, and I think universally people– providers would say that, because it gets all of the concerns out there at the beginning– probably–maybe not all, but 95% of them, so it decreases the "Oh, by the ways" and, you know, you think everything's great and then, you know, they drop something at the end So–but the challenge is figuring out how to get the screens done before you actually go in the room, so we ask people to come in 15 minutes early Again, like I said, every site does it different Some sites send out the screens ahead of time We're waiting for the day that we can have them in my chart and people can do them, but there's a lot of problems with some of the screens with licensing, not so much for sure with the PHQ-9 and the Edinburgh, but we're just not there yet

So that's really the biggest barrier, but we have so many different sites with different capabilities of people being able to turn them in Like, the site that I work at, we probably get– if we were to mail these out, we'd probably only get 40% of them back just because of the patient population And then there's other sites that they get 100% of them back, so I think you have to look at who you see in your clinic, as far as when– how you decide how you're going to distribute them – I echo that experience at Mayo Clinic I think it helps the efficiency in my business to actually have the screen

I think before we had the screen, I spent time trying to ask some of these questions I didn't do it in an organized way and hadn't always remembered to do that And now I come in, and 95% of the time, our standard screen is completely completed I can review it If there's minor concerns, the discussion point's right there, and we can add onto

Maybe the mother's very tired, which is not unexpected, and we can talk about that, so I find the tool to be very helpful In the few cases where it is not done, usually it can be completed quick enough, maybe during my exam of the infant or other times And I also don't think it affects the flow, so I think overall it's been time even We've actually done studies at Mayo Clinic, not with this screen but with the developmental screen and social/emotional screens, and we found, too, that overall, you know, it's been very minor, the amount of increase in time, just, you know, a couple minutes at most, overall, and that instead of reviewing these questions, you have them done by the family before the visit Obviously, every clinic has to assess how to do it, and I think with a lot of the new technology, they can maybe be done by portals prior to the visit, but then there's a lot of issues with that

What about the timing? What if a mother completes this and they're suicidal and they complete it two weeks before the visit? And you have that and, you know, didn't act on it, you know, so there's new questions that come up that'll come with that also, but I think every clinic just has to assess it individually based upon the technology they have and the patient population that they have – Thank you so much Now we're going to go ahead and try to answer some of the questions that have come in from our participants So the first question is, "Do the health plans pay for screenings?" Sort of, is our answer, so they definitely should be paying for the maternal depression screen in a well child check for– a well child check for a baby under 12 months old for a mom who is enrolled in Medicaid It is not consistent yet with private pay health insurance plans

So for example, one of our clinics was screening all their moms, and they did have a couple of moms receive a bill for it Those actually ended up all being people who were employees of the clinic, so it was people who were on a private pay health insurance that was owned by the clinic system Anyway, they're working on it, so the private pay should be covering it Whether or not they're set up to cover it yet is not– it depends on your area and where you are, and so I would say that that is one of the reasons why it isn't consistently being billed for Sort of more information on that is that when we look at our billing data, we're only seeing it in, I think, less than 3% of our–of the well child checks that are billed under 12 months, and we think that the screening is happening more than that, but we just don't have people billing for it consistently yet

So it should be paid for Whether or not it is, I– it would really depend on the system that–the health plans in your community The next question is, "We are an independent pediatric practice "If we need to make a referral for mom, "do we need to automatically refer her back "to the prenatal provider or her primary care physician?" No, this, again, will–this will depend a lot on the mom and also on mom's insurance So some insurance plans– I mean, the majority of them, actually, will allow mom to go directly to a therapist or to the–to mental or behavioral health without a referral

Some will want her to have a referral There's actually–the majority of plans have a phone number that the mom can call to ask what the mental health referral should be, but really when we think about giving the referral to mom, we should really focus on what mom is most likely to follow through with And so if that is her own prenatal provider or primary care physician, then absolutely If it is someone else, then someone else, but that referral that– you're going to be calling and helping to make it a warm handoff referral, but it is what the mom is choosing, and so that–so, no, it doesn't have to automatically be back to her primary care physician And our last question that's come in is, "Can we explain the rationale "for postpartum depression screening "at a well child check versus at their six-week postpartum visit?" I can answer that

We are not saying do it at the well child check instead of their postpartum visit We are certainly recommending also doing a postpartum depression screen at the six-week postpartum visit We are adding it in the well child checks because of a couple of things that we've mentioned: because moms with depression may be less likely to actually attend their postpartum visit; because in general, we have a much better turnout for the well child check than we do for the postpartum visit; and because moms have generally been shown to have a different rate– to have a– there's a wide variety in the rate of when mom is willing to start talking about her feelings of depression or anxiety So there–actually, Dr Lynch was part of a study that looked at returns on a two-month screen versus the four-month screen

There are moms who will screen positive at four months who would not screen positive at two months because they weren't willing to talk about it yet or the symptoms itself weren't– hadn't become to such a case that they really felt like it was interrupting their life or their ability to care well for themselves and their child And so there are moms who won't talk about that until later on in the experience with postpartum depression, and so that's why we're recommending doing it at the well child checks And then really getting back to the fact that this is an issue for well child, for baby health outcomes, is the status of mom's mental health And so that's why we're recommending it at those visits and not– it isn't–and that it isn't an "or" question Which one? It's a "do it at both," the six-week postpartum visit and the well child checks

We want to thank everybody for your time in listening to our webinar and participating in our webinar today We'd like to especially thank Dr Lynch and Dr Neale for all their time on this work, both in their own practices and spreading this within their systems, but also in supporting other providers across our state in implementing universal postpartum depression screening for mom for–within those well child checks, so thank you so much Thank you for your time

If you do have any questions or if you would like information about the postpartum depression implementation learning collaborative or any other materials, we certainly have a lot of things online, and we also welcome your contacts and emails You see on the screen my email and contact and our website And then also if you have any questions related to child and teen checkups, please feel free to email or call them as well Thank you so much for your time, and good luck with implementing universal postpartum depression screening

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