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Problem:
In rural Northern New England, access to medical care is limited by distance, road conditions, and inclement weather. Population centers are small and isolated. School systems are often without adequate professional staff to identify problems in children. Health care resources and facilities are limited--especially in the area of psychiatric and developmental services for children.The role of the primary care pediatrician in the early recognition and effective management of developmental and behavioral issues is particularly critical. Collegial professional relationships and access to CME opportunities for pediatricians may be difficult to maintain.
Historically pediatricians have had limited ability to recognize and manage behavioral and developmental problems in the course of a well child visit. This study group will provide training for pediatricians to identify dysfunction in the course of office practice, before it presents in the school setting or within the legal system. It will also emphasize practical approaches to common problems in pediatric practice: school dysfunction, family dysfunction, difficult behavior, problems in development, signs of emotional disorders, adjustment to chronic disease, and other problems. The goals and objectives for the COR group reflect the special needs of the rural communities in which we practice and teach.
Goals and Objectives:
This collaborative project will help pediatricians develop knowledge, skills, and attitudes listed in the following objectives:
1. Greater understanding of and sensitivity to psychological and developmental issues.
2. Enhanced skills in discriminating between transient disturbances and more serious psychiatric disorders, such as childhood depression, autism, and schizophrenia.
3. Enhanced skills in managing developmental crises such as separation, discipline, school achievement, sexuality, body image, adolescent autonomy, divorce, and family dysfunction;
4. Greater understanding of psychosocial issues in chronic illness and disability: family dynamics, developmental effects, behavior problems, school issues, and service limitation.
5. Greater understanding of family dynamics, including abuse, through a family system.
6. Enhanced skills in interviewing and counseling techniques;
7. Increased ability to recognize serious psychopathology and to better understand the scope of the pediatrician's competency in matters requiring intervention;
8. Increased awareness of the impact of such factors as personal bias and values on the pediatrician's relationship with children and families;
9. Development of productive collegial relationships between pediatrics and psychiatry.
10. Increased awareness of, utilization of, and collaboration with community mental health resources for children on a local, regional, and state-supported level;
11. Facilitation of a more comprehensive approach to children's health supervision, such as is proposed in Bright Futures.
12. Understanding of the utility of the DSM-PC codes for practicing pediatricians.
13. Development of collaborative "spinoff" projects which impact screening and access.
14. Consider and discuss possible avenues for growth of our group in the education
of health professionals in behavioral and developmental health especially in our region
15. Continue and evaluate a model of collaboration through a distance-teleconference site.
Methodology:
The collaborative study group will consist of 18 primary care pediatricians,approximately half of whom are members of the full-time general pediatrics or developmental pediatrics faculty at the Children's Hospital at Dartmouth, and half of whom are practicing pediatricians from surrounding rural communities in NH and VT. An additional pediatrician serves as the Pediatric Moderator of the group, and another as the Alternate. Two faculty child psychiatrists serve as Child Psychiatry Moderator and Alternate. Group sessions also include the Pediatric Chief Resident, the Child Psychiatry Fellows, and 1-2 pediatric residents. The group meets twice monthly for 90 minutes to discuss in depth a case presented by a group pediatrician.
The case presented is a current case from the presenter's practice which brings a developmental or emotional concern to the pediatrician. Led by the presenter, the pediatrician moderator, and the child psychiatry moderator, the group then discusses the case from multiple perspectives, including data gathering, assessment instruments, DSM-IV diagnosis, DSM-PC coding, individual psychodynamics, family and cultural factors, and possible interventions by the pediatrician or consultant.
Coordination:
This project relies greatly on the strength of the Medical Home environments represented by those participating in the Study Groups. As such, relationships with existing networks such as Early Intervention, family support agencies in both Vermont and New Hampshire, mental health agencies, religious and volunteer organizations, among others, will be enhanced through COR participants' increased understanding and appreciation of the need to access these services through the peer training, updates, and case-based discussion.
Evaluation:
Both moderators will be responsible for monitoring the sessions for content and objectives. Year-end self-assessments and qualitative feedback to moderators will be used to assess the utility of the group process in meeting these objectives. In addition, the moderators will attend the annual meetings of all the COR group representatives in Washington, designed to evaluate the programs as a whole.As part of our proposal to create more collegial relationships with our local mental health professionals (MHP) and to establish ongoing conferences of Pediatric Primary Care Providers with MHPs in our area, we propose to do a pre- and post-conference survey of conference participants to determine the following outcomes measures:
• Satisfaction of the pediatrician in the delivery of behavioral health care in the community.
• Satisfaction of the pediatrician in the referral of pediatric patients to area MHPs.
• Satisfaction of the MHP in the process of receiving referrals from pediatricians.
• Barriers to collaboration between MHPs and pediatricians;
• Perceived direct and indirect costs of providing comprehensive pediatric care in the office.
• How pediatricians ideally want to work with MHPs, and visa versa.
Experience to Date:
We have strengthened our program through four essential achievements. These include, a) Recruiting and retaining new committed members of the Study Group who represent a balance in training, skills, and current practice methods that fully complements the group; b) The successful design and launching of a videoconference-linkage with a northern rural site at Weeks Medical Center, Lancaster New Hampshire, bringing colleagues with limited access to the COR format into this project on the second of the two monthly sessions; c) The Devlopment of a new program assessment tool which, for the first time, allows us to monitor and quantitate participants interests, experiences, and attitudes in Collaborative Office Rounds; designed in collaboration with CECS; d) Refining and expanding the scope of case-based discussions to include situations in which developmental/educational disability contributed to the evolution of significant psychopathology in children attending school.
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