On Monday, December 18, 2017, Annalee Gulley, Director of Government Affairs and Public Policy at Mental Health America of Greater Houston, provided the Texas Health and Human Services Commission feedback on the proposed draft policy language for Texas Health Steps (THSteps) Preventive Care Medical Checkups:
Postpartum Depression Screening and Referral Services.
December 18, 2017
Texas Health and Human Services Commission
Attn: Medicaid/CHIP Office of Policy
4900 North Lamar Blvd
Austin, Texas 78751
Re: Written Comments on Draft Policy for House Bill 2466 Postpartum Depression Screening
To Whom It May Concern,
Mental Health America of Greater Houston thanks you for the opportunity to submit comments on the draft policy for House Bill 2466 regarding the ability of an infant’s provider to conduct and bill for postpartum depression (PPD) screening for the infant’s mother in Medicaid and CHIP. We believe the following recommendations will assist in the successful implementation of this Medicaid benefit.
In early 2017, the American Academy of Pediatrics (AAP) recommended PPD screening at one, two, four and six months postpartum.[i] Line 1 of the draft policy states the Academy’s recommendation of screenings at the infant’s pediatric well-child visits but does not include the suggested intervals. We recommend adding language to line 1 about the appropriate integration of screenings at the 1-, 2-, 4- and 6-month visits.
HHSC’s draft policy (line 22) limits screening to once per provider in the year postpartum. We understand the need to implement this benefit within existing funds. That said, we recommend the agency consider the feasibility of screening according to national recommendations, as indicated by the American Academy of Pediatrics. This will result in multiple screens reimbursed per provider, and the language should be changed appropriately.
Mental Health America of Greater Houston participates in the Regional Maternal Mortality Task Force, where we examine the leading causes of maternal deaths in Houston. This task force is acutely aware of “white coat” syndrome, in which individuals are likely to lessen the severity of a condition when speaking to a doctor to disclose physical and behavioral health issues. Significantly more positive screens result in studies in which the screen was performed by a licensed clinical social worker, rather than a medical doctor. Line 7 states that screening tools may include the Edinburgh Postnatal Depression Scale (7.2), Postpartum Depression Screening Scale (7.3) and the Patient Health Questionnaire 9 (7.4). To ensure the successful roll-out of this new benefit and accurate screenings, it is important all THStep providers – including physician assistants, nurses and licensed social workers – are trained on the screening tools and the risk factors for postpartum depression.
The three tools listed above are all validated and routinely used for postpartum depression and identify a range of severity or level of need, which help guide clinician-patient decision making regarding necessary supports. The Edinburgh is most routinely used and available in more than 20 languages. While these screening tools are effective, they may not capture positive screens for women facing other maternal mental health disorders, including anxiety and obsessive-compulsive disorder present during the postpartum period. We recommend adding to the list of validated tools (line 7) so THSteps providers may screen moms using validated tools identifying a range of postpartum mood and anxiety disorders, such as the Generalized Anxiety Disorder-7 (GAD-7) tool, among others. No-cost screening tools should be prioritized to increase access to THSteps providers.
We appreciate HHSC recognizing that screening alone does not improve clinical outcomes for moms and infants, but more guidance is needed to ensure successful referrals and improved outcomes. Specifically, pediatric providers need to know the appropriate and available supports for mothers. While some pediatric providers may already screen mothers, most are not familiar with the mental health providers serving parents. We recommend HHSC should provide a menu of resources with which provider can refer when a mother screens positive for postpartum depression or other perinatal mood disorder. At a minimum, HHSC should provide THStep providers a menu of referral options in each region that serve women enrolled in or eligible for Medicaid, Healthy Texas Women or the Family Planning Program, as well as city or county indigent care programs. Also, at a minimum, this should include clear guidance to THSteps providers on how to refer women, in consultation with any existing primary care physician to the Local Mental Health Authority (LMHA). The Office of Mental Health Coordination offers a list of mental health and substance use professionals, including LMHAs and other mental health clinicians across the state. Including a list of postpartum depression treatment providers on this list would be a good resource for pediatric providers screening for perinatal mood disorders. Some moms may need more intensive therapy or medication; others may need a lower level of supports or services. It’s important that a menu of referral options is available so THStep providers, in consultation with existing primary care providers, can help refer women to services that meet her needs.
Mental Health America of Greater Houston also asks you to consider the efficacy of the existing referral process for postpartum mental health treatment. New mothers who are not eligible for Medicaid are automatically enrolled in Healthy Texas Women sixty days following delivery when their CHIP perinatal benefits expire. Healthy Texas Women’s coverage of postpartum depression treatment is minimal at best. Many women with the most complicated postpartum mood disorders cannot receive adequate treatment within the confines of the Healthy Texas Women reimbursement model. Should mothers require more intensive medication or hospitalization, they are typically referred out to another facility, frequently an emergency room, where they do not have coverage for services. We need to ensure that doctors have a safe place with the appropriate supports to send mothers who screen positively for postpartum mood disorders; otherwise, doctors will not feel comfortable making referrals and women won’t get the treatment they need. We recommend HHSC shall communicate clearly to state health programs and community mental health providers, including LMHAs, that women with postpartum depression fall under priority diagnosis of major depressive disorder and assist them to prepare for increased referrals of women with postpartum depression.
Lastly, the results of the screenings used are not digital – leaving a paper form to record the results of a postpartum screen. Mothers are sent from the pediatrician’s office with the paper medical record and information can be lost in the process. With digital records, a “warm handoff” can be more secure knowing that all information is transmitted to the next provider. We recommend the agency consider the feasibility of digital records to ensure successful referrals and improved clinical outcomes.
Again, we sincerely thank you for the opportunity to provide input on the draft policy for HB 2466. We look forward to continued partnership with the Texas Health and Human Services Commission to ensure families have access to needed mental health supports. For any questions or concerns, please contact Annalee Gulley at firstname.lastname@example.org or (210) 823-5818.
Director of Public Policy and Government Affairs
Mental Health America of Greater Houston
[i] American Academy of Pediatrics (Bright Futures). (2017). Recommendations for Preventive Pediatric Health Care. Retrieved from: https://www.aap.org/enus/Documents/periodicity_schedule.pdf