Columbia University Mailman School of Public Health

Louisiana

(return to PRiSM homepage)

Strategies

Maternal Depression and Risk Factor Screening and Referral: Louisiana Mental Health Perinatal Partnership (LAMHPP)

Louisiana Mental Health Perinatal Partnership (LAMHPP) provides mental health consultation to pediatricians, family physicians, OB-GYNs, and other healthcare professionals caring for pregnant and post-partum women and their families. Begun in 2019, consultation services are now offered statewide to support clinicians as they address the needs of pregnant and parenting women related to perinatal depression, anxiety, substance use disorders, as well as other risk factors such as housing instability and food insecurity. While LAMHPP consultations focus mainly on the mental health needs of pregnant or parenting women, they also provide consultation to child-focused clinicians about the impacts of parent mental health and related conditions on parenting and infant well-being.

LAMHPP operates with a team that includes psychiatrists, psychologists, clinical mental health professionals, and a perinatal resource specialist. A team member will respond immediately to callers by providing resource and referral information and assistance, and will connect them with a LAMHPP psychiatrist, who is available for 24 hours a week, about clinical support, treatment options, and follow-up support. Healthcare providers can also schedule consultations. In addition to state-wide telehealth consultations, on-site consultations are available in some regions of the state: New Orleans (provided by a perinatal psychiatrist), the Lafayette region (provided by a licensed mental health clinician), and the Monroe region (provided by a licensed mental health clinician). Because the licensed mental health clinicians vary in the extent of their background in infant mental health, they participate in an online training on this topic that is approximately 30 hours, biweekly case conferences about consultation activities and clinical supervision with a psychologist trained in infant-early childhood mental health.

LAMHPP promotes perinatal healthcare providers’ use of screening tools by providing a wide range of tools online, clinical handouts about screening and response, and web-based and in-person training on screening. Consultations are also used to help providers interpret and respond to results of screening. Tools available online include validated screeners for maternal depression, anxiety, and substance abuse. A care guide on depression offers guidance about medications, with consideration of those most compatible with breastfeeding, and adult treatment options, while also including interventions focused on the quality of parent-infant interactions (e.g., dyadic treatment, parent education, and home-visiting).

LAMHPP consultations and resources also encourage providers to identify and address risk factors that contribute to perinatal mental health conditions, parenting stress, and infant mental health conditions. The website highlights several tools that screen for social determinants of health (SDOH). The Social Needs Screening Tool helps identify risks related to SDOH, including housing instability, food insecurity, transportation needs, child care concerns, and threats to personal safety. This tool, which is also available in a short version, was developed by the American Academy of Family Physicians, along with a guide on conducting SDOH screening and responding to identified needs. The Social Needs Screening Tool provides a place for documenting resources and plans to address individual risks. The LAMHPP website also has tools that specifically screen for domestic violence, alcohol use, and substance abuse.

When needs are identified in screening, LAMHPP resource specialists and healthcare providers using LAMHPP can use online resources to find treatment and other services for families. The site’s maps allow users to find regionally-based treatment and supports for maternal and infant mental health problems, substance abuse, basic needs, and more. The maps also help users find resource guides for expecting and new parents that identify additional services, including Part C early intervention.

At this still early stage in the program, LAMPHPP has provided up to nine consultations a week, most conducted in-person. LAMHPP aims to eventually deliver 20 consults a week. Consultations have focused on screening or clinical questions. In consultations about screening, concerns about maternal depression, substance abuse, and anxiety have frequently been addressed, as well as transportation issues and access to food. As appropriate, consultants have encouraged providers to screen for these concerns and use LAMHPP resources to help connect families to local resources. Providers in rural areas have shown a particular need for consultation when caring for mothers with serious conditions, including schizophrenia and depression. With few resources available in rural settings, consultations aim to help OB-GYN and family medicine providers support women with conditions that are beyond the scope of their training.

Outreach to inform providers about LAMHPP has included visits to practices in the regions where LAMHPP has a physical presence, emails to providers, and communication with professional organizations. For example, The American Academy of Pediatrics included information on LAMHPP in its most recent newsletter. Ongoing efforts include regular visits to medical practices and reaching out to professional organizations such as the American College of Obstetricians and Gynecologists and American Academy of Pediatrics.

Funding

LAMHPP funding comes from a five-year 21st Century Cures Act grant from the federal Health Resources and Services Administration (HRSA) within the US Department of Health and Human Services through the Louisiana Office of Public Health, Bureau of Family Health. Proposals to extend funding beyond this five-year grant period are currently underway. There is no cost to healthcare providers or patients.

Monitoring and Evaluation

Extensive data are routinely collected on each consultation, including: demographic information on the patient; some patient health information, especially related to perinatal concerns; whether any screening has been done, what kind, and the results; information about recommended screening and referrals is also recorded. These data are used for quality improvement, as well as HRSA reporting.

IECMH in Home Visiting

Through an Infant-Early Childhood Mental Health (IECMH) consultation program, Louisiana provides consultation to home visitors and treatment services to families participating in the state’s two home visiting programs. Louisiana’s home visiting program is provided by 19 teams that deliver services through either Nurse-Family Partnership (available statewide) or Parents as Teachers (available in particular regions). Families must be eligible for Medicaid, WIC, SNAP, TANF or SSI to be eligible for home-visiting. In state fiscal year 2018, 3,817 families were served and 39,017 visits were conducted.

The IECMH services delivered within the home visiting program are a mix of consultation to home visitors and direct services to families. Currently, consultants spend approximately 75 percent of their time consulting with home visitors and 25 percent on delivering services to families. Consultation consists of education, individualized support and guidance, joint visits with families, and assistance identifying resources for families and making referrals. Consultants offer monthly in-service trainings to home visitors, with topics primarily related to trauma- and diversity-informed care, parent-child relationships, and mental health issues, such as maternal depression. Home visitors also participate in monthly individual consultations and can receive more frequent consultations, as needed. Home visitors can request consultations for any concerns they have and consultation requests are automatically made when parents screen positive for depression or anxiety, or are known to have experienced trauma. Consultants can also conduct visits jointly with home visitors to assess mental health concerns, provide psychoeducation, and help address family mental health needs.

Currently, each team has an embedded consultant at half-time equivalency. From 2016-2018, 6,334 consultations that focused on 1,273 clients were conducted, along with 169 joint home visitor and consultant visits and consultant participation in 625 case conferences.

IECMH consultants provide direct services to families by delivering Child-Parent Psychotherapy (CPP), an evidence-based dyadic therapeutic model designed to address trauma (see research summary on dyadic treatment). Exposure to trauma is the predominant criterion used to determine whether to offer CPP services, but the decision to offer CPP to a family is made following consultation with the home visitor and a joint visit to the family. During the joint visit, if the consultant feels that CPP may be a good option for the family, she may approach the family to see if they are interested in being assessed for participation in CPP.

Consultants are licensed mental health professionals with additional training in infant mental health. In-person training for consultants is provided by Tulane University’s Institute for Infant and Early Childhood Mental Health and consists of 15 days over a five-month period. Consultants begin providing services to home visitors before their infant mental health training is complete. However, new consultants with limited prior infant mental health experience receive weekly individual supervision. All consultants have individual clinical and reflective supervision at least one to two times a month. There are also monthly half-day statewide IECMH Team meetings that includes a case presentation, as well as monthly consultation with an adult and child psychiatrist. Consultants can also access a statewide consultation program, the Louisiana Mental Health Perinatal Partnership which helps health and mental health care providers identify and address a range of conditions including maternal depression, anxiety, and substance abuse.

With the incorporation of CPP training into the consultation model, the current group of consultants is now receiving training, free of charge, through the National Child Traumatic Stress Network’s Learning Collaborative model. During the CPP training period (which is approximately 18 months), all consultants have twice-monthly supervision plus consultation calls with the CPP trainer two times a month.

In regions of the state that lack consultants, services are provided by a consultant who lives in another region. In these cases, the consultants travel to the site at least once monthly and provide consultation by telephone or video-conference when they are not on-site.

Financing

Currently, the Title V Maternal and Child Health Services Block Grant provides funding for the infant mental health consultants’ delivery of both consulting and direct services. Previously, a HRSA Targeted Innovation Award supported the IECMH consultation; the grant’s aim was to develop and retain a highly-skilled home visiting workforce, with special attention to mental health needs. In addition, the state provides funding through the Title V Maternal and Child Health Services Block Grant for consultants to participate in training in IECMH at Tulane University and for transportation to CPP training.

Monitoring and Evaluation

On-going monitoring of consultation services is incorporated into the model. Data are collected on the number, duration, content, and frequency of consultations, as well as on the amount of direct services provided by consultants. Data on home visitors’ knowledge from and satisfaction with services are also collected, as well as an annual measure of provider self-efficacy. Home visitors who work with consultants showed significant increases in ratings of professional self-efficacy, as well as in self-reported content knowledge and knowledge about community mental health services. They also report feeling supported by their consultants. However, data on client outcomes are not collected with respect to consultation.

IECMH in Part C Early Intervention Program and Pediatric Care

Louisiana has developed IECMH consultation services for pediatric and family medicine providers and early intervention programs. The model focuses on expanding the capacity of the providers to identify children with mental health needs and risk factors and to implement interventions within the scope of their practice. The models promote the use of validated screening tools for child social-emotional problems and family risk factors (including maternal depression) and effective referrals and follow-up. These services are located in two parts of the state: New Orleans and the Lafayette area.

Consultation services in New Orleans are offered to pediatric primary care providers and are provided by the Tulane Early Childhood Collaborative (TECC), an initiative housed in an academic setting that employs part-time infant mental health clinical faculty in pediatrics and psychology to serve as the consultants. The TECC team also includes trainees in pediatrics, psychiatry, psychology, and public health. The consultants are available to provide onsite consultation at pediatric settings. TECC has developed online resources for providers, including validated screening tools and screening recommendations and guidelines. Consultations can be delivered via phone, e-mail, or secure video. Onsite consultation can include presentations, informal case discussions, and face-to-face consultations with children and their families to answer the pediatric primary care clinician’s consultation questions.

In the Lafayette area, the program consists of a single team serving pediatric primary care providers and early intervention programs. The team includes a child psychiatrist and two Master’s level IECMH specialists, with one focusing on pediatric primary care and the other on early intervention. The entire team participates in case conferences together. The pediatric primary care IECMH specialist is available full-time to provide on-site consultation in pediatric and family medicine practices. The pediatrician/child psychiatrist provides telehealth (with video-connection), in-person, phone, and email consultation. Telehealth and in-person consultations are provided by the child psychiatrist after discussion with the IECMH specialist. Early intervention programs have access to the IECMH specialist who provides in-person and in-home consultation with families, as well as additional consultation with the child psychiatrist (which can include phone and email consultation).

Consultation programs in both New Orleans and Lafayette offer treatment to a limited number of families involved in consultation. These families receive Parent Child Interaction Therapy, a dyadic treatment model designed to address externalizing behavior problems for children from two to seven years old (see research summary on dyadic treatment).

A number of strategies have been employed to reach out to and recruit pediatric providers to enroll in the consultation program. Initially, outreach was conducted through professional organizations such as the American Academy of Pediatrics and the American Academy of Family Physicians, as well as directly to larger practices. Ongoing efforts are focused on partnerships with federally qualified health centers and pediatric hospitals. Additional efforts include offering introductory webinars and grand rounds to pediatric providers.

Early intervention providers are recruited into the program through regular, quarterly in-service trainings and staff meetings where they receive information about the consultation services offered. New early intervention providers receive emails with information about the consultation program.

Financing

Original funding for consultation in the Lafayette region was from the Substance Abuse and Mental Health Administration’s Project LAUNCH. The salaries for clinical mental health consultants in primary care and early intervention as well as eight hours a week of psychiatric consultation services have been sustained by the Louisiana Office of Public Health, Bureau of Family Health through Maternal and Child Health Block Grant funding.

In New Orleans, funding comes from a mixture of state and philanthropic funds, with work being undertaken with the state to develop systemic approaches to funding. Initial funding came from a two-year grant from the Baptist Community Ministry, with matching funds from the Louisiana Office of Public Health, Bureau of Family Health. Since that time, funding has been from philanthropic funds. The budget for the project, which includes extensive training across medical disciplines, is about $100,000 annually. Efforts to create a system for billing billable services are underway.

Monitoring and Evaluation

In primary care, outcomes have included changes in providers’ self-reported ability to identify mental health needs, overall increase in use of recommended early childhood clinical skills, including promoting use of screens to identify and track disruptive behavior problems, anxiety, and for trauma and adversity exposure (including maternal depression), and a trend towards identifying mood and anxiety problems. A QI project that has been a component of the New Orleans program demonstrated an improvement in referral success using direct contact with and support to the families.

For early intervention, annual provider surveys show improvements in provider perceptions of their ability to identify and meet young children’s mental health needs, access intensive mental health services for young children, and access case management services. Other outcomes have included increased self-reported focus on parent-child and parent-professional relationships

Special thanks to Sarah Hinshaw-Fuselier, Assistant Professor of Psychiatry, Tulane University School of Medicine, and Mary Margaret Gleason, Professor of Psychiatry, Tulane University School of Medicine, for providing information for and reviewing this profile.