Evaluation and Process Improvement

By assessing the service data, the clinics gained a clearer understanding of patient needs.

They found that of the two clinics, the clinic that offered more brief treatments (16- to 32-minute sessions) had better appointment attendance the other clinic, which offered more brief interventions (5- to 15-minute sessions). Based on this data, the program will use the brief treatment model moving forward. This activity is also billable, while brief interventions are not.

The MCN Okmulgee Clinic
The MCN Okmulgee Clinic
Head Start office set up for play therapy
Head Start office set up for play therapy

Expansion to Head Start Program

As a result of the BH2I data collected, the program was able to expand its services to the tribal Head Start programs, using the same model of care applied in the pediatrics clinics.

Through the process of quality improvement assessment, the program recognized the importance of finding ways to treat children outside of the primary care setting. Partnership with the Head Start program provided a strong solution for this need.

The program gathered data on the total number of Head Start students, the number of insured students, issues identified through observation, and reported teacher concerns. Currently, the program is piloting a half-time Behavioral Health Clinician in one Head Start location to test the processes and procedures before expanding to additional facilities, with the goal of gathering enough revenue to sustain a full-time therapist position.

A Wide Range of Screenings

Many integrated care programs only offer 3 to 4 types of behavioral health screenings. The MCN Pediatrics Clinics provide up to 18 diverse screenings to identify symptoms that are treatable within an integrated care setting.

Screenings are chosen based on age appropriateness and the domains that the team believes would be helpful in identifying potential issues. Screening domains include:

  • Developmental
  • Behavioral
  • Environmental
  • Physical
  • Emotional
  • Cultural/Spiritual

Some of the screening tools include:

  • Survey of Well-Being of Young Children all-in-one screenings for children 0 to 4 years old, which screens for behavioral health symptoms, signs of autism, and some social determinants of health in a family context. Domains: Behavioral, Environmental, and Developmental
  • Pediatric Symptom Checklist for children ages 6 to 10, which screens for an array of internalized and externalized symptoms. Domains: Developmental, Behavioral, Emotional, and Physical.
  • Generalized Anxiety Disorder (or GAD7); Patient Health Questionnaire—Adolescents (or PHQ-A); Subjective Units of Distress Scale; Short Mood and Feelings Questionnaire; Pediatric Symptom Checklist Youth Report; and Columbia Suicide Severity Rating Scale (or SSRS) for Primary Care, all of which assess behavioral health in adolescents. Domains: Emotional, Behavioral, and Physical
  • Edinburgh screening for all new mothers.

The program chose the Adverse Childhood Experience Questionnaire as its annual screening and the CRAFFT tool to screen for substance use risks.

The MCN Koweta Clinic
The MCN Koweta Clinic
MCN Behavioral Health Team
MCN Behavioral Health Team

Crisis Assessment and Planning

The program implemented crisis screening and assessment for patients ages 11 and older based on PHQ-A scores of 8 or higher or for patients who have lower scores but significant risks. If a patient screens positive on the Columbia SSRS for Primary Care suicide screening, a suicide assessment is completed.

For patients who had recent thoughts of self-harm or suicide, the team helps create a safety plan and provides intensive care coordination and monitoring that involves the entire care team, including parents and other external supports. As needed, the program provides funds for the emergency hospitalization due to patient suicide risk. Analysis of treatment data revealed that using brief therapies in conjunction with primary care, psychiatry, and specialty care when needed was effective for these patients.

The program convened a team of five to six clinical staff members who travel to the local emergency departments and tribal programs when certain crises arise, such as suicides, homicides, disasters, and student deaths. The team responds to these crises by providing debriefing, supports, care coordination, and postvention to those directly impacted by the crisis.

Education and Outreach

Education also plays a key role in treating patients. The Koweta Clinic Pediatric Behavioral Health Consultant engages in outreach to share educational materials with patients.

Outreach is also conducted for patients’ parents. Data showed that almost half of the program’s pediatric patients were eligible for Medicaid and had no insurance, so education was provided to those families to help those children become insured. That coverage, in turn, made it possible for the program to bill for services and support the addition of a sustained clinical position in pediatrics.

The Koweta Indian Health Clinic Behavioral Health Consultant staffing a booth to share educational materials
The Koweta Indian Health Clinic Behavioral Health Consultant staffing a booth to share educational materials