Columbia University Mailman School of Public Health

Massachusetts

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Massachusetts Strategies

Maternal Depression Screening and Response

Since 2014, the Massachusetts Child Psychiatry Access Project for Moms (MCPAP for Moms) program has supported health care providers, including obstetric, pediatric, adult psychiatric and primary care providers, in addressing the mental health and substance abuse concerns of their perinatal patients. The aim of the program is to build the capacity of health care providers to offer evidence-based treatment for maternal depression. MCPAP for Moms offers three core resources to health care providers: trainings and toolkits, psychiatric consultation and referral, and linkages to community resources. Providers call a hotline to speak with a resource and referral specialist who assesses their needs. These can then be addressed with a telephone psychiatric consultation, which is sometimes followed by a one-time face-to-face consultation with the patient, and with assistance connecting with community providers and resources.

The MCPAP for Moms toolkit, which is sent out to enrolled practices, includes the Edinburgh Postnatal Depression Scale and a guide to help the health care provider interpret screening results and consider treatment options. For mothers at all levels of depression – from mild to severe – the treatment options address the needs of both the parent and the infant or young children; those especially focused on the child include dyadic (mother-child) therapy and support for parenting a child with feeding, sleeping, and other self-regulation problems. MCPAP for Moms is also developing resource lists for health care providers to use with individual patients. The lists include a tailored directory of mental health providers near the patient that accept the patient’s insurance.

The obstetric practices covering approximately 85% of the 72,000 deliveries in the state are enrolled, though enrollment is not required for providers to use MCPAP for Moms services. Over 95% of pediatric practices are enrolled in the MCPAP program, which provides consultation on child mental health concerns; the MCPAP program includes information on MCPAP for Moms in the toolkits it sends to pediatric providers. Approximately five percent of calls to MCPAP for Moms are from pediatric practices. MCPAP also urges pediatricians to use the SWYC screening tool for children under one year, which has the Edinburgh Postnatal Depression Scale (EPDS) included.

Practices’ use of the services varies and has changed over time. As doctors have become more aware of the issue of maternal depression, they have become more comfortable following their patients longer through the treatment process. There has also been an increase in one-time face-to-face MCPAP for Moms psychiatric consultations with obstetricians.

Outreach to providers helps engage practices. MCPAP for Moms program staff conduct site visits with newly enrolled practices to explain the program and the importance of maternal depression screening and treatment. MCPAP for Moms also reaches out to enrolled practices that have not been calling the hotline. Quarterly webinars conducted by MCPAP for Moms are available online and generate interest in site visits among practices. When the program began, MCPAP for Moms conducted many site visits during the initial period of enrolling practices, and is now planning to increase site visits and outreach to enrolled practices.

Financing

Funding for MCPAP for Moms comes from the Massachusetts state Department of Mental Health, with approximately 50 percent of funding coming from a surcharge on commercial insurers based on the proportion of commercial clients who use MCPAP for Moms. MCPAP for Moms is free to all pregnant and postpartum women and the providers caring for them. The program’s operating costs were $8.38 per woman per year.

Monitoring and Evaluation

MCPAP for Moms tracks data on each provider encounter and provides information in annual reports to the state. On average, MCPAP for Moms receives 230 calls per quarter. Among enrolled providers there has been a 17 percent increase in reported screenings on the EPDS and a 50 percent increase on the PHQ-9.

A 2010 state law on postpartum depression requires the state department of health to produce an annual report on its activities related to screening for postpartum depression. The state also requires certain providers (OB-GYNs, family medicine practitioners, advanced practice nurses including nurse midwifes and nurse practitioners, and physician assistants) and insurers to report annually on screening for postpartum depression. Anecdotally it appears that most practices are screening, although they may not report screening to the state.

Providers can submit their screening data to the state through a data reporting form or through claims codes. The most recent state report, for calendar year 2016, presents results for both the data reporting form and claim code data. For calendar year 2016, data reporting submitted by seven providers found that 85 percent of patients were screened for postpartum depression. Of the 1,400 patients screened, 86 screened positive (6.1 percent). An analysis of claim code data for 89,289 deliveries from January 2014 through June 2015 found 5,852 mothers were screened (6.5 percent) and 297 had a positive screen.

There is currently research being conducted on how MCPAP for Moms is being used by providers. Nancy Byatt, Associate Professor of Psychiatry, Ob/Gyn, and Quantitative Health Sciences at the University of Massachusetts Medical School and Medical Director of MCPAP for Moms, is leading research efforts. An earlier journal article presented findings on the development, implementation, and utilization outcomes of the first 18 months of MCPAP for Moms.

IECMH Workforce Development in Part C Early Intervention Program: Parents Interacting With Infants (PIWI)

Massachusetts’ Part C Early Intervention Program is using Parents Interacting With Infants (PIWI), a training component within the Pyramid Model designed to support positive parent-child relationships and infant-toddler social-emotional outcomes. The Pyramid Model is a framework for promoting evidence-based practices that support children’s social-emotional development and address challenging behavior. Early Intervention specialists who receive PIWI training learn a wide range of strategies for working with parents to support social-emotional development through mutual enjoyment in parent-child interactions and responsive parent-child relationships.

To prepare for state-wide implementation, the Massachusetts Part C lead agency (the Department of Public Health (DPH)) conducted train-the-trainer sessions on PIWI so that current and future Early Intervention providers could receive training from a cadre of PIWI trainers. These master trainers included professionals that had Early Intervention, training delivery, and leadership experience. All master trainers were given extensive training on the foundations of Early Intervention and the PIWI approach and strategies. DPH consulted with one of the PIWI creators, as well as with local state partners involved with the national Pyramid Model center, to develop these sessions and the statewide rollout.

During the initial statewide PIWI rollout, beginning in June 2016, the state’s 60 Early Intervention programs were divided into three training cohorts. Prior to in-person PIWI training, all Early Intervention providers completed the Pyramid Model Framework Overview Training, an introductory online module that reviews the fundamentals of infant and early childhood social-emotional development as well as the Pyramid approach. Each cohort then participated in a one-day PIWI training led the master trainers.

Following the in-person training, each Early Intervention program designated one or more staff to serve as PIWI Champions who would be responsible for ensuring the successful implementation of PIWI at the local program. PIWI Champions develop implementation plans and provide continuing supports to PIWI-trained Early Intervention providers. The PIWI Champions first worked with a master trainer to develop a program action plan that laid out steps to support program-wide PIWI implementation based on an analysis of the program’s strengths and challenges. Plans differed depending on how programs chose to implement PIWI. Some programs took an approach emphasizing individual supervision and feedback for Early Intervention providers, while others created cohorts, providing training and support for a few staff at a time on a rolling basis. Still others offered professional development on using PIWI strategies widely to Early Intervention providers in the local program. Most programs developed their ongoing action plan over 3-5 face-to-face visits with their PIWI master trainer.

The PIWI Champions then received individualized, ongoing coaching from the master trainers to implement the action plan. This support occurred during three to five visits over a three-month period. The PIWI Champions’ responsibilities also include documenting the Early Intervention providers’ work with families and conducting program-level data collection. After this implementation period, if additional supports are needed, Early Intervention programs can reach out to their DPH Regional Specialist for individualized technical assistance.

Currently, new Part C providers receive PIWI training from master trainers on the second day of their state-mandated Early Intervention orientation. All Early Intervention providers who work 20 or more hours and/or act as service coordinators are required to attend this orientation and PIWI training. Prior to the in-person PIWI training, all new Early Intervention providers must also complete the Pyramid Model Framework Overview Training. As of April 2019, 2,020 Early Intervention providers had completed PIWI training. These providers then receive the ongoing supports provided through their program’s implementation plan.

The state offers a four-day PIWI institute to Early Intervention supervisors and PIWI Champions to help support PIWI implementation. Currently, 19 participants from 14 different EI programs have completed the institute training. The PIWI institute is an intensive offering that focuses on the brain science underlying social-emotional development; components of social-emotional development; conditions affecting the parent, child, and the parent-child dyad; and using PIWI strategies and the Individualized Family Service Plan (IFSP) to support children’s social-emotional growth.

Early Intervention programs use additional online PIWI training courses and modules available through the Massachusetts DPH to strengthen Early Intervention providers’ knowledge and skills. Data are collected on the providers who access the modules and the Early Intervention programs where they work. Early Intervention programs have used these online modules in staff meetings, clinical team meetings, and supervision, and also offered them to individual Early Intervention providers.

The state recently developed and implemented a pilot reflective supervision training for Early Intervention supervisors (15 participants) to further help them support Early Intervention providers in implementing PIWI. The pilot consisted of monthly trainings for supervisors over the course of three months. One facilitator of the pilot training includes a staff member at the state Part C lead agency who will be able to repeat the training for other supervisors.

Funding

PIWI training and supports, as well as the supervisory training pilot, have been financed with Part C federal funds to the state.

Monitoring and Evaluation

The evaluation of PIWI in Massachusetts was conducted with each cohort of Early Intervention programs in the six months following the initial PIWI training. Prior to taking the Pyramid Model Framework Overview Training, Early Intervention providers completed a self-assessment that covered their use of strategies to help parents engage in responsive, nurturing interactions during everyday routines, which provided a baseline on the use of PIWI strategies in home visits. The self-assessment was administered again following PIWI training. As of February 2019, 4,146 pre-test assessments and 315 post-test assessments had been completed. Findings from the self-assessments suggest modest to moderate improvement in the consistent use of PIWI strategies.

A second component of the evaluation is based on observations of EI providers’ use of PIWI strategies during home visits. PIWI Champions observed at least two providers per program, with 2-3 observations of that provider with the same family conducted at least one month apart. Overall, across all three cohorts, results showed that EI Providers have been increasing their use of less directive strategies (e.g., Affirming Parenting Competence) and decreasing their use of more directive strategies (e.g., Suggest, Model). The changes in the use of these strategies are consistent with PIWI’s guidance to use the most directive strategies less often and the less directive strategies more often in order to build parents’ initiative and responsiveness in interactions with their child. The PIWI training curriculum has been closely monitored, and changes have been made based on evaluation data. For example, DPH has added video examples of supporting parents’ use of PIWI strategies and a section on navigating barriers to the use of these strategies.

An evaluation of the pilot reflective supervision training is examining Early Intervention providers’ PIWI practices using checklists the provider completes. Data collection, which begins in May 2020, will finish by November 2020, and the report should be published in early 2021.

Special thanks to the following individuals for providing information for and reviewing this profile: Beth McGinn, Massachusetts Child Psychiatry Access Program Manager; Patti Fougere, Director, Early Intervention, Massachusetts Bureau of Family Health & Nutrition; and Emily Webb, Coordinator of General Supervision, Massachusetts Department of Public Health.