A pregnant woman is being examined by a doctor.

RI Moms PRN and Pedi PRN teleconsultation network empowers primary care providers – Richard Asinof

by Richard Asinof, ConvergenceRI, contributing reporter on health

It is no secret that the demand for mental health services has accelerated in response to the continuing trauma, loss and isolation caused by the COVID pandemic, stressing out the already limited networks of providers, making it difficult for patients to access care.

In turn, the inability to access care has often resulted in patients seeking to self-medicate as a way of dealing with feelings of anxiety and depression, leading to increased substance use, including alcohol and marijuana and opioids.

One of the most vulnerable groups for mental health problems are pregnant women and women who have recently given birth. “The first 12 months after delivery is really high risk time for any woman to come down with a mood or anxiety disorder,” said Margaret Howard, Ph.D., director of Women’s Behavioral Health at Women & Infants Hospital. “There are so many downstream consequences of untreated maternal mental health and pediatric mental health conditions.”

In response, two programs – the RI Moms Psychiatry Resource Network, and the Pedi Psychiatry Resources Network – have created a teleconsultation service that provide guidance and support for primary care providers who are treating pregnant women, new moms, children and adolescents.

Margaret Howard, Ph.D., director of the Women’s Behavioral Health Center at Women & Infants Hospital, who is working in partnership with the R.I. Department of Health with two psychiatric resource networks, one targeted for pregnant and post-partum moms and the other for pediatric patients.

The two programs are a working partnership between the R.I. Department of Health and the Center for Women’s Behavioral Health at Women & Infants Hospital and Bradley Hospital. They are funded through federal grants from the Health Resources and Services Administration. The goal is to support provider-to-provider teleconsulation that offers real-time guidance to meet the behavioral health needs of a vulnerable population.

“We have such a dearth of providers, given the demand, which has only multiplied because of COVID,” Howard said. “There are just not enough providers to go around.” By creating the teleconsultation networks, Howard continued, “It really empowers providers, for those who are comfortable, to take the first step at initiating treatment and medication.”

Together, the two programs, RI Moms PRN and Pedi PRN, have fielded more than 3,000 calls from 670 providers across 252 practices, as of Jan. 31, 2022.

Here is the ConvergenceRI interview with Margaret Howard, Ph.D., director of Women’s Behavioral Health at Women & Infants Hospital, and Professor of Psychiatry and Human Behavior and Medicine at the Warren Alpert Medical School of Brown University, talking about how the provider-to-provider teleconsultation network has empowered providers to seek mental health care for their patients.

ConvergenceRI: When we spoke in April of 2020, two years ago, you talked about how we are human, battling an inhumane disease. Now, two years later, with nearly 1 million dead, how do you view the changed landscape? What do you think is needed, from a provider’s perspective, to help providers and patients cope with the trauma and loss they face – and where they can find support and resolve to keep moving forward?
HOWARD: I think that there has been a shift. Two years ago, everyone was hearing the call to arms, if you will, and there was real sense of esprit de corps – we have to gather together and tackle this. I think there was fear and uncertainty, because we had this enemy, but we didn’t know what it was.

Now, two years later, I would say clearly we know so much more about the virus and its impact, but I think we are in kind of a new chapter. We hear about long COVID – but there are also people suffering from long COVID-coping, the exhaustion of the chronicity of this virus, and the way that it has upended life. It continues to take a toll, and I think many, many people are suffering and many people, just like before, are suffering in silence.

I love your question, but I think we are supposed to be talking about the psychiatry resource network.

ConvergenceRI: Yes, we are. But I asked that question because I thought it might help to frame the discussion. Tell me what you want to talk about in terms of the psychiatry resource network.

HOWARD: The R.I. Department of Health and the Center for Women’s Behavioral Health at Women & Infants Hospital are the primary partners in this HRSA-funded grant. The intent is to offer a teleconsultation line for any provider who comes in contact with pregnant or post-partum women who may be struggling with mental health or substance use issues.

The grant was primarily written by the R.I. Department of Health. It is very similar to another program that launched in 2016, the Pedi PRN; we called ours the RI Moms PRN. PRN stands for Psychiatry Resource Network.

The model is basically a telephone consultation line for those providers who come into contact, either with perinatal women or with pediatric patients, who have mental health needs. The goal is to have same-day medication consultation with either a perinatal psychiatrist, in the case of RI Moms PRN, or a child psychiatrist, in the case of Pedi PRN. Both programs also offer same-day referral for non-medication needs – such as looking for a support group, or someone looking for an individual therapist, or a Spanish-speaking group, or marital or family counseling.

On the RI Moms PRN side, we have created a very large database of all the different resources available to perinatal women who mental health or substance use needs.

I have to say, it has really been a wonderful partnership with the Department of Health. This is my first opportunity in working closely with them, and they have just been amazing partners and have helped us so much with the data collection.

We were one of only seven states nationwide to be awarded this grant. I think in large part we were attractive to the HRSA funders because we already had such a robust program here in Rhode Island for pregnant and post-partum moms in terms of meeting their mental health needs.

The RI Moms PRN has really expanded on that; it reaches all corners of the state. Am I talking too much?

ConvergenceRI: No.
HOWARD: It really empowers providers, for those who are comfortable to do so, to take the first step at initiating medication. As you know, we have such a dearth of providers, given the demand, which has only multiplied because of COVID, because there are just not enough providers to go around. You have these long wait lists. These programs are an attempt to provide care in a much more timely manner.

ConvergenceRI: What has been the response? Have you been able to measure, from an outcomes perspective, how successful the program has been? What are the metrics that you are using?
HOWARD: Well, we count and we do have metrics. For RI Moms PRN, our program launch was in September of 2019. Since then, we have fielded more than 1,000 calls from 430 providers at 153 practices.

ConvergenceRI: In terms of other metrics, beyond tallying the calls, how do you measure “success?”
HOWARD: One of the metrics that we use is whether or not [the providers] were connected with resources. I don’t have the complete numbers, but I would say a very high percentage of those folks who are calling do get connected with some sort of resource. That is the good news.

ConvergenceRI: Is there a “bad news” component?
HOWARD: We are trying to think about ways that these programs can be sustainable, because they have been so successful in terms of the screening and contact.

What I can say is when you have a program like this, let’s say an obstetrician or a pediatrician know that  there is a resource at their hands, they are much less hesitant to ask the important question [to their patient] about mood, about functioning, about anxiety, depression, I think they are much less reluctant to ask those questions, because they know they will not be left holding the bag, because they have a resource, a number to call, to say, “Hey I have patient who is telling me she is so depressed that she can’t get out of bed, I am worried about her, what can you do to help me?”

And, on RI Moms PRN side, our resource and referral specialists will ask them a lot of questions: questions about insurance, where she lives, does she have a preference for treatment, and for you as a provider, what are your thoughts. Does she need to start an anti-depressant? They can ask the questions and get the ball rolling.

Obstetrical providers are not trained to be mental health providers, nor are pediatricians. The provider groups that tend to be most comfortable with doing this kind of screening, in my experience, have been midwives and family practice doctors, because they have a fair amount of psych training as part of their training in residency.

These conversations are so important, because we can no longer ignore mental health needs. If anything, that is one thing that COVID has brought to the forefront. It cannot be ignored or swept under the rug.

ConvergenceRI: About the sustainability of the programs, is the funding for these programs scheduled to sunset? Can it be renewed?
HOWARD: The funding is coming from HRSA. The grant funding for both of our programs ends in September of 2023.

ConvergenceRI: Is there any way that the state can pick this up? Or, do you need the federal funding?
HOWARD: We will take it from wherever we can get it. I think what I would like to see, because I think of Rhode Island as a leader in the recognition and treatment of perinatal mood disorders and of child psychiatric disorders, I would love for us to be able to find some way to sustain the funding at the state level. We are eager to have those conversations. There are folks in the General Assembly who are really tuned into the importance of mental health care, not only for the individual or the family but also as a public health issue, because there are so many downstream consequences of untreated maternal mental health and pediatric mental health conditions.

ConvergenceRI: I have been reporting on the problems with the low Medicaid reimbursement rates behavioral health and mental health providers…
HOWARD: That is a very real problem. And I think that it cuts across all specialties, not just mental health. But I think we feel it most acutely in mental health.

What I can say is that the majority of the perinatal and pediatric patients who have been helped by our teleconsultation networks are covered by Medicaid. In fact, 55.7 percent of our patients that our providers are calling about are covered by Medicaid.

ConvergenceRI: In terms of substance use disorders, are you seeing an increase?
HOWARD: I think we are seeing what everyone else is seeing. There has been a national trend for increased substance use disorders. I think there is some recent data that just came out in terms of alcohol-related deaths, and they link it to this up tick during the pandemic.

And we also have the ongoing opioid crisis. One of the things that we are noticing is an up tick in the reporting of marijuana use, and we don’t know if that is a function more women are using marijuana or that more women are simply reporting their marijuana use, because of the loosening strictures around marijuana use, given the fact we are surrounded by states who have now legalized recreational use and it looks like Rhode Island is on the same path.

Does that mean they are actually using it more, or reporting it more? I think we have to do the research and find out.


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Richard Asinof

Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.

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