More than 11% of US children and adolescents suffer from a serious mental disorder causing significant impairment, but sadly, most mentally ill youth are not identified and do not receive mental health services3. On average, the symptoms of mental illness present two to four years before onset of full-blown disease. This suggests a lengthy window of opportunity for prevention in many cases5.

 According to the National Center for Children in Poverty, low-income children, youth, and their families are disproportionately affected by mental health challenges, impairing the ability of children and youth to succeed in school and placing them at risk of involvement with child welfare and juvenile justice agencies.

In Colorado, suicide remains the second leading cause of death for adolescents between 11-18 years of age7. With surveys showing that more that 70% of adolescents see a primary care physician at least once a year, the pediatric office is the logical setting to offer routine depression screening8.

Colorado Medicaid and CHP+ cover depression screening for adolescents aged 11-20 years, using a standardized, validated depression screening tool at the adolescent periodic visit. 

 
Why don’t these children get the mental health services they need?    
One of the reason teens aren’t getting mental health services is that no one is asking about whether they are depressed.  PCPs are on the front lines and can ask and help identify those teens who are depressed.  Primary care providers are very much needed to address this gap.

What services help to identify depression in adolescents?
The AAP recommends depression screening in adolescents to help identify, manage, and treat adolescent depression.

How Screening Works Screening involves administering a simple, evidence-based questionnaire that is completed by the adolescent privately and can be quickly scored by the clinician or the staff.  

Resources Are Available Resources provided through the TeenScreen National Center for Mental Health Checkups can help streamline the process of implementing depression screening for both clinicians and their patients. Affiliated with the Columbia University Division of Child and Adolescent Psychiatry, TeenScreen’s Primary Care program offers support to physicians by providing screening questionnaires, instructional materials for staff training, and REFERRAL INFORMATION free of charge.

TeenScreen offers three evidence-based screening questionnaires, developed and standardized at Harvard and Columbia Universities. These questionnaires come in a Screening Questionnaire Starter Kit (including the PHQ-9) that offers practice implementation resources, information on administering and scoring the questionnaires, and guidelines around the referral process. Click HERE to learn about the PHQ-9 and other resources that TeenScreen offers!

How do Colorado Medicaid and CHP+ reimburse primary health care providers?
Colorado Medicaid and CHP+ will reimburse primary care medical providers to screen, diagnose and treat (or refer) depression for adolescents aged 11 – 20 annually, at the adolescent’s periodic visit. (Note: Colorado Medicaid recommends the use of PHQ-9, but other validated, standardized depression screening tools are also acceptable.)

The PHQ-9 can be administered in a short amount of time by a medical assistant, and the primary care provider can review and incorporate into routine dialogue. Again, the entire process – for most adolescents – will take only a small amount of time. The supplies needed to do this are available at no cost to your practice, and the reimbursement is very fair.  

How can providers and staff be trained to provide this benefit?
Training is available on the TeenScreen website: http://www.teenscreen.org/resources/providers/#tools.

How should primary care providers code and bill for these services?
Medical personnel who may bill directly for these services include MDs, DOs, PAs and nurse practitioners. CLICK HERE FOR BILLING CODES AND GUIDELINES.

What if the primary health care provider identifies behavioral health needs requiring a referral? If a behavioral health need is identified, the primary care clinician must offer to either:
          1.    Provide the necessary services or
          2.    Refer the patient to a specialist

Primary care providers who choose to refer a client to a specialist must assist with the referral process. For more information on which BHO to refer pediatric clients, visit the BHO WEB SITE or see the HCPF TOOL KIT FOR PRIMARY CARE PROVIDERS.

What do providers get paid for these services?
Reimbursement is $10.08 (effective 8/1/2011). See the JULY 2011 HCPF PROVIDER BULLETIN for more details.

Please seriously consider adding these services in your practice! Questions?

 Angie Goodger
720-346-4903
angela@cchap.org

Christina Newport, Program Manager (Denver-based employee)
TeenScreen Primary Care
(800) 673-7714
Newport@nyspi.columbia.edu

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ANNOUNCEMENTS FOR PROVIDERS

Post-partum Mood Disorder Survey
Please complete this very brief on-line survey on Post-partum Mood Disorder: it will help design a free “on-site” training program for providers and staff.

Untreated Perinatal Mood Disorders can have major effects on gestational outcomes as well as infant cognitive, emotional, and language development. The majority of women in Colorado with these conditions continue to go unidentified and untreated.
 
A recent state-wide collaboration between the University of Colorado Depression Center’s Program for Perinatal Mental Health Systems Integration, Children’s Hospital Colorado’s Healthy Expectations Perinatal Mental Health Program, the Colorado Department of Public Health’s Women’s Health Unit, Access Behavioral Care and Behavioral Health, Inc  was formed to improve identification, education, and access to appropriate perinatal mental health services for women with public, private, and no insurance.

Through this collaboration, free on-site trainings on how to identify, educate, and refer women to experienced perinatal mental health professionals will be available.

Please complete the following online survey to help us assess current attitudes, knowledge, and skill in identifying, treating, and referring women with these concerns and to register for free training.  

The survey link is: http://www.zoomerang.com/Survey/WEB22DQ64N6LAU


Upcoming Asthma Course Offerings:
Improving Pediatric Asthma Care Training (IMPACT) –
Click here for brochure
April 11, 2012 Children’s Hospital Colorado

Reach the Peak Asthma Seminar and Asthma Educator-Certified Prep Course –
Click here for brochure
April 12–13, 2012 Children’s Hospital Colorado

• 91% stopped sharing utensils and other items
• 86% brushed and flossed more regularly 
• 77% stopped putting sweet liquids in the baby bottle 
• 67% saw a dentist and talked to others about the importance of dental health 
• 49% took their infant to a dentist

By increasing awareness of these simple behavior changes, your practice can empower new and expecting parents to prevent dental disease. Our campaign's bilingual education materials are available free of charge to help you share this important information with your patients.

These materials are supported throughout metro Denver by a bilingual advertising campaign during January and February. To date, hundreds of our partners have requested over 500,000 cards for their patients. Make sure your practice is part of this important effort!


Visit www.HealthyTeethHappyBabies.com to order free, bilingual education materials and access other oral health resources

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ACCOUNTABLE CARE COLLABORATIVE CORNER

 
Important Message to Communicate to Your Patients
Some ACC enrolled patients are getting confused when they call HealthColorado and they inadvertently request enrollment on the “old” Medicaid Primary Care Physician Program (PCPP) where a patient chooses a PCP. Many providers no longer accept patients on this plan and so, in this case, the patient will be enrolled on Regular Medicaid. If you are a contracted ACC provider, please advise your patients to tell HealthColorado that they want your practice to be their “PCMP”, or that they want to be enrolled with the ACC and with a certain provider. Please contact kevin.heckman@childrenscolorado.org or anita.rich@childrenscolorado.org if you need further help or clarification. Here are the current Medicaid Health Plan choices for patients:

Regular Medicaid – fee for service plan; patient can see any contracted Medicaid provider.
Primary Care Physician Program – patient may only see their PCP. The PCP must be open and accepting for the patient to be enrolled with the provider.
Managed Care – Denver Health Medicaid Choice and Rocky Mountain Health Plans are the two managed care organizations in Colorado. Patients may only see providers that are a part of those plans.
Accountable Care Collaborative – fee for service plan; patients must select a Primary Care Medical Provider (PCMP) to be their “medical home”. Any Medicaid contracted provider can see these patients but only ACC contracted providers are eligible for a Per Member Per Month (PMPM) payment in addition to the fee for service payment. CCHAP affiliated providers receive the Medical Home for Children enhanced reimbursement for well child care and do not qualify for PMPM payments on children.

Accountable Care Collaborative Referral Requirement Update
Primary Care Medical Providers (PCMPs) in the Accountable Care Collaborative (ACC) are expected to provide a referral for their clients to see specialists and other primary care providers. There is currently a grace period in effect for referrals. During this grace period, PCMPs are expected to provide referrals for their clients; however, specialist and other primary care provider claims without a referral will be paid. The grace period will remain in effect until the policy is fully re-evaluated with our stakeholders. ACC Referral Process: Click here

PCMP Fax Enrollment Form
Here is a fax enrollment form that ACC patients can use to choose your office as their Primary Care Medical Provider (PCMP):
Click here



RCCO Expansion Populations

• Foster Children  - HCPF is accelerating enrollment of foster children into the ACC program effective February 1, 2012
• Adults Without Dependent Children (AwDC) – HCPF will be enrolling these patients into the ACC program in April or May 2012

Treo Solutions (Statewide data Analytics Contractor) Dashboard Training

• To be scheduled for PCMPs in February or March
• SDAC dashboard data will include patient lists by practice with patient level information on:
  o    Clinical Risk Group Scores (CRG)
  o    Potentially preventable ER Visits, hospital admissions, medical complications and medical services
  o    Other medical and or risk indicator
• “Save the Date” notice for PCMP training will come out in early February.

Regional Care Collaboration Organizations Contact List click here.

Medicaid ACC website: Click here

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PRACTICE MANAGER CORNER

 
CCHAP Practice Manager Meeting January 24th 2012
Presentations by Maximus and CORHIO, handouts, links, contact information and a recording of the meeting - Click here



EHR Incentive Program Update – February 1, 2012
Click here


ATTENTION: THIS IS AN IMPORTANT CHANGE!
CHP+ Pre-HMO Period Will Remain In Effect
Contrary to previous communications, the pre-HMO period for the CHP+ program will not be changing. In its January meeting, the Medical Services Board unanimously approved a measure to keep in place the current pre-HMO period for children in the CHP+ program. If you would like additional information or have questions please contact Alan Kislowitz at 303-866-3646.

CHP+ Enrollment Fee Cost-Sharing Changes In Effect on January 1
The new enrollment fee for certain CHP+ clients went into effect on January 1, 2012. This fee does not apply to all CHP+ clients, only those in certain income categories. Anyone under 205% FPL will have the same fee as before. Changes to copayment amounts will not be in place until July 1, 2012.

Colorado Medical Assistance Program Prior Authorization Request (PAR) Submission as of February 1, 2012
Effective February 1, 2012, PARs may no longer be sent through the Colorado Medical Assistance Program Web Portal. Click here to access the Special PAR Bulletin from Medicaid.

Medicaid PAR Training
The ColoradoPAR Program is the new Utilization Management Program for the Colorado Medical Assistance Program.  CareWebQI is being launched by the Colorado Department of Healthcare Policy and Financing and the ColoradoPAR Program to ease the administrative burden for PAR submission.  CareWebQI is a web portal with enhanced functionality allowing electronic submission of PARs with expedited and often real time decisions to PARs. This is only for procedures that require prior authorizations for Medicaid RCCO or fee-for-service.
 
The ColoradoPAR Program will be conducting training via the web twice a day, Monday through Friday from November 28th – December 16th.  Web trainings will continue twice a week following the introductory three weeks. Click on this link http://coloradopar.com/provider-training to view times and dates, register for trainings and obtain your training materials.  You will need to obtain a username and password by filling out the form located on the CareWebQI tab on the ColoradoPAR website following training.
 
The ColoradoPAR program looks forward to bringing you CareWebQI.  If you have questions or need assistance call 1-888-454-7686 or visit www.ColoradoPar.com for more information.

ADD-A-BABY Training
(This session is near or at capacity – a March session will be announced)
Shawna Moreno at Medicaid will be holding training for providers and anyone else that reports or helps report the birth of a newborn.  Add-A-Baby process training will be offered via WebEx, on Wednesday, February 22, 2012 from 1-3 p.m.  The training will cover the following:

• an overview of  the process,
• submission of  the various forms (typed, handwritten, and online),
• who to contact for follow up requests, emergent requests, and 
• common errors when submitting the forms.  

This training is for providers, Community Based Organizations, Certified Application Assistance Sites, Medical Assistance sites and others who assist Medicaid or CHP+ Prenatal eligible mothers report the birth of their newborns.

Register Here: http://hcpftraining.gosignmeup.com/  -a minimum of 7 days advanced registration is required!

Medical Transportation Service (NEMT) Update
Effective January 1, 2012 First Transit became the new contractor for Non-Emergent Medical Transportation (NEMT) for Medicaid clients residing in Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer, and Weld counties. NEMT service plays a key role in helping eligible Medicaid clients get to and from their medical appointments.
In the first two weeks of service, call volumes were more than double last year’s levels and clients experienced long wait times. First Transit responded by doubling the number of incoming phone lines into their call center, brought in additional staff and extended service hours to improve their level of client service. Since then, wait times have dropped substantially.
For more information about eligibility, phone numbers, frequently asked questions or to let Medicaid know about your experience with First Transit visit the HCPF NEMT Web page or call Chris Acker at 303-866-3920.

Adults without Dependent Children Update
Changes have been made to the implementation plan for the Adults without Dependent Children (AwDC) program. Instead of the first-come first-serve approach, a randomized member selection process will be used to determine enrollment for eligible applicants. Here is the proposed approach for the new enrollment process:

• Applications will be accepted and processed between April 1 and mid-May 2012.
• All AwDC expansion clients who are receiving benefits will be enrolled in the Accountable Care Collaborative (ACC) Program through one of the program’s Regional Care Coordination Organizations (RCCOs) for their area based on the applicant’s address on file. 
• Those whose numbers are within the number of allocations in that region will be enrolled into AwDC and provided Medicaid benefits. For these clients, benefits will begin on May 1, 2012. 
• All other eligible applicants, including those who apply after the mid-May date 2012, will be placed on a statewide waitlist.

The program will still be capped at 10,000 clients and be limited to those under 10% of the federal poverty limit. The implementation plan is currently with the Centers for Medicare and Medicaid Services for review.

Google Translate for your practice website
Google translate has a free web page translator that practices may use for their patients who speak a language other than English. For more information and important considerations: http://translate.google.com/about/intl/en_ALL/

  Google Translate potential uses:

• Add translation to your website by adding a simple block of code. Allow visitors to your website to translate a webpage into their own language with the click of a button. Here is an example of a pediatric practice website that uses the “en Espanol” button for translation into Spanish: http://www.comprehensivepediatriccare.com/
  Go here for more information on this function: translate.google.com/translate_tools
• Translate a webpage into another language while navigating at the click of a button with Google Translate button on the Google Toolbar. The Google Toolbar must be downloaded and the translate feature must be enabled. toolbar.google.com
• Translate a block of text or full document on the Google Translate website. Copy and paste any block of text. Or choose a file to upload. Select the original language and the desired translated language. translate.google.com

  Google Translate potential concerns:

• Not all full documents will translate. Best solution is to stick with word processor files types such as Word.
• Does not work with all websites.
• Does not always translate medical language and terminology accurately. Be aware of this if you choose to use this tool.

THE HELEN M. MCLORAINE SCHOLARSHIP FOR FOSTER CARE
& EMANCIPATING YOUTH
The Helen M. McLoraine Scholarship Program for Foster Care and Emancipating Youth was created to provide educational scholarships for foster care youth who are emancipated or are in the process of preparing to emancipate from the foster care system in Colorado. Awards can be used toward part-time or full-time undergraduate study at any accredited U.S. post-secondary school (including trade, vocational, community college or four-year school). – Click here for the application form and more information.

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How Culture Affects Oral Health Beliefs and Behavior

by Marcia Carteret M.Ed.

Each February, the American Dental Association (ADA) sponsors National Children's Dental Health Month to raise awareness about the importance of oral health. Developing good habits at an early age and scheduling regular dental visits helps children get a good start on a lifetime of healthy teeth and gums. Good oral health contributes significantly to overall good health during a person's lifetime.

Studies indicate that children from low-income and minority families, children with special needs, and children raised in rural areas of the U.S. shoulder a disproportionate burden of oral disease, adding to the list of health disparities among some disadvantaged populations. Contributing factors may include lack of community water fluoridation, dental workforce shortages, and the high cost of care and limited access to dental insurance. Cultural beliefs, values, and practices are also often implicated as causes of oral health disparities, yet little can be found in the dental literature that isn't epidemiological in nature. In other words, the literature demonstrates disparities in oral health rather than identifying specific oral beliefs and practices among different cultural groups. 1

Indeed, cultural influences overlap with dental health literacy, socioeconomic status, and personal experience in complicated ways, but it is possible to identify some common beliefs and care-seeking practices around oral health that are culturally-based and significantly different from the western dental medicine model. This article will suggest four domains that shape people's cultural beliefs and practices related to oral health: 1.) help-seeking and preventive care, 2.) oral hygiene practices, 3.)  beliefs about teeth and the oral cavity, 4.) the use of folk remedies. Additionally, a list of interesting and useful culturally-related oral health facts are presented.

Help-Seeking and Preventive Care: Many cultural groups don't have a strong preventive orientation when it comes to their health care, and this is definitely true when it comes to oral health. People often seek care only when there is a problem. An individual might go to the dentist for a painful tooth after suffering with it for a while, and then simply expect to have the bad tooth extracted. Advanced interventions to save a bad tooth, such as root canals and crowns, may be common in the U.S. and other western countries, but are often the privilege of only wealthy people in other cultures.

Oral Hygiene Practices: In many cultures there is little understanding of gum disease. Brushing the teeth may be done to remove left over food from the mouth, but the concept of removing plaque and tartar is less well-understood. It follows that the use of dental floss, mouth rinse, and tongue cleaners may be virtually unheard of and might be viewed with skepticism. Americans are known around the world for being obsessive about perfectly straight bleached white teeth. Hollywood movies and American TV promote the importance of pearly white American smiles.

Beliefs About Teeth and the Oral Cavity: In many cultures the esthetic appearance of teeth may be important, but having "healthy" teeth and gums is not connected to appearance in a direct way. Red or swollen gums, bleeding gums, painful chewing, loose teeth, receding gums, all these symptoms of gum disease may be ignored as long as the visible teeth "look good". An interesting example comes from China where the appearance of teeth is psychosocially important. Having nice looking teeth can influence social interaction. However, a person with carious or discolored front teeth...is considered to have low intellectual competence.2

Use of Folk Remedies: In some traditional cultures there is a preference for using traditional remedies and cures either in place of western medicine or in conjunction with it. Use of herbs or healing methods like acupuncture and moxibustion are common. Pain in any area of the body, including oral pain, is treated using culturally-accepted remedies passed down through generations. For example, in some African American families the use of cotton balls soaked in aspirin solution, alcohol or salt water is a well-known home remedy for pain and swelling.3

Additional Culturally-Related Oral Health Facts

1. In some cultures there is a belief that treatment for primary teeth in children is unnecessary as those teeth are going to fall out anyway. This makes it harder to gain the cooperation of parents in brushing young children's teeth and reducing the frequent use of bottles with juice, soda, or other sweetened drinks at bed-time. Breaking this "soothing sweet" habit may cause sleep and familial disruptions, so giving a child a pacifier dipped in honey, for example, is an accepted tradition. In one study a mother was quoted as saying, "Those are anyway their first teeth, so even if they get decay it's not the end of the world sort of thing, it doesn't go down to the roots or anything." 4
2. Although the purpose of brushing is understood in most cultures, the role of fluoride in protecting teeth might be completely unknown.
3. It is not uncommon for people to believe that oral health is hereditary, making preventive care unimportant. Use of fluoride toothpaste, brushing and flossing, reducing the intake of sweets won't matter if a child's parents and grandparents all have terrible teeth.
4. In one study, 70% of African-American respondents believed that pain in the oral cavity was an early symptom of oral cancer. 5
5.  In one California study, Mexican immigrants referenced a belief that fever and diarrhea are common when a child's teeth erupt 6, 7
6. Traditional healers in Somalia treat infants for diarrhea using various oral procedures including cutting into and the lower gums and extracting the cuspids. In one case involving a 7 year-old boy, a hot nail was pressed into the gums in the area of the lower cuspids as treatment of an episode of gastroenteritis. 8
7. In China and other Asian countries influenced by TCM (traditional Chinese medicine), tooth health is believed to depend upon the condition of the kidneys.
8. In some cultures gum disease is believed to be related to the hot/cold syndrome; mixing the wrong combinations of hot and cold foods will lead to unhealthy mouths.
9. In China giving, birth to a child with teeth is considered bad luck and if parents have teeth into their advanced old age it is considered bad luck for their children. It is considered natural to lose ones teeth as one ages.

The Crucial Link Between Primary Care Providers and Oral Health Care.
Since dental decay can start as soon as teeth erupt, to be effective, preventive oral health strategies need to target children early when transmission of oral bacteria from mother to infant commences and eating habits are established. Since infants and children are seen by their primary care providers (medical) frequently during the first two years of life, there is an opportunity for these practitioners to promote oral health and refer children for dental care. However, primary care providers receive limited training in prevention of oral diseases, while general dentists care for young children, but their small numbers nationwide made such services unavailable to most children. High-risk children usually have dental insurance through medicaid, but the percentage of dentists participating in Medicaid is low. Only one in five children covered by Medicaid actually receives preventive dental care.

Cavity Free at Three. One promising program in Colorado  that seeks to tackle the challenge of preventive dental care for high-risk children is Cavity Free at Three. This three-year, statewide effort was developed to help prevent oral disease in young children. The effort aims to engage dentists, physicians, nurses, dental hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant women, infants and toddlers. Risk assessment, patient and family education, and fluoride varnish application done in primary care offices are key components of this program. Read more at http://www.cavityfreeatthree.org/GetInformation or contact Angie Goodger of CCHAP at angela@cchap.org.

Conclusion: Health care is a cultural construct arising from beliefs about the nature of disease and the human body, and it follows that cultural issues are central to the delivery of effective preventive care and illness intervention- both medical and dental. As the link between primary care providers and oral health care for children becomes more and more important in reducing overall health disparities, it is important to consider the cultural aspects of oral health - treatment seeking-behaviors, hygiene practices, and beliefs about the relationship between teeth and the health of the entire body.

Copyright 2011. All rights reserved.

 
Resources

1, 2, 3, 7  Yogita Butani*, Jane A Weintraub and Judith C Barker "Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature" BMC Oral Health 2008 This article is available from: http://www.biomedcentral.com/1472-6831/8/26 © 2008 Butani et al; licensee BioMed Central Ltd.

4 Henderson L, Millett C, Thorogood N: Perceptions of childhood
immunization in a minority community: qualitative study. J Emerg Nurs 2008, 21(6):569-70.

5 Yellowitz JA, Goodman HS, Farooq NS: Knowledge, opinions, and practices related to oral cancer: results of three elderly racial groups. Spec Care Dentist 1997, 17(3) 100-104.

6  Mendoza FS: The health of Latino children in the United States. Future Child 1994, 4(43–72)

7 Mikhail BI: Hispanic mothers' beliefs and practices regarding selected children's health problems.  West J Nurs Res 1994, 16(6):623-638

8  Peter K Domoto, Mark A Egbert,  Elinor A Graham. Dental injuries due to African traditional therapies for diarrhea. West J Med 2000;173:135-137

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CCHAP IS RECRUITING PRACTICES TO PILOT “BEST PRACTICE” GUIDELINES

Over the last several months we interviewed and surveyed practices that have already implemented Cavity Free at Three, and have now outlined what we believe to be efficient and tested processes that work best for implementing the program into the primary care setting.
 
CCHAP is currently recruiting practices to pilot these “best practice” processes!
 
Contact us today and …

• Learn “what works best” from other Colorado practices
• Learn tips and tricks for improved program efficiency and staff compliance
• Receive free assistance with practice training and preparation
• Receive sample flow sheets, step-by-step directions, educational materials, and more!

Whether you are new to Cavity Free at Three, have struggled getting the program embedded into your office flow, or would just like to learn ways to improve the program within your practice, these guidelines are for you!
 
Please seriously consider piloting our business model best practice guidelines for Cavity Free at Three! For more information, or to enroll, please contact Angie Goodger @ 720-346-4903 or angela@cchap.org

Resources …
Cavity Free at Three has free downloadable patient and family educational brochures. Download them today @ http://www.cavityfreeatthree.org/GetMaterials/ProviderMaterials.