Estereotipos de maternidad y paternidad transnacional

This section examines stakeholder circumstances and perspectives which may impact the implementation of SBIRT for adolescents in KPNC pediatric primary care. The

stakeholders discussed here represent an attempt to include all groups directly relevant to adolescent SBIRT implementation within KPNC. Other stakeholders will almost certainly have indirect impacts on, or be impacted by, SBIRT implementation within KPNC. Moreover, in other settings, other stakeholders will be relevant to implementation (e.g., payers in fee-for-service delivery settings). Examination of these stakeholders merits further examination, but is beyond the scope of this dissertation.

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Table 2. Stakeholders

Stakeholders Issues/Concerns Potential

Impact on Teen SBIRT Implementation Facilitator (+) Barrier (-) Unclear (~) Patients _

Many youth are in distress, have co-occurring mental health, substance and/or

medical problems, are under pressure, and may face multiple stressors (family, school, social, cultural, sometimes legal).

+

 Teens often do not want to reveal substance use or other risk behaviors to parents and are ambivalent about both substance use and the need for intervention, and may prefer that screening and assessment not occur at all.

-

 Many teens are fearful or uncertain about specialty behavioral health care, especially chemical dependency treatment, and may feel more comfortable having these issues addressed in the relatively familiar and non-stigmatized milieu of Pediatric primary care.

+

 Adolescent-pediatrician rapport and trust about confidentiality of patient-provider conversations is a (some would say the) key element of effective adolescent health care,80,193,209,210 and implementation efforts must take special care to preserve

confidentiality and faith in confidentiality on the part of teen patients. Concerns about confidentiality could facilitate implementation by supporting need for additional resources for substance abuse for PCPs in Pediatrics, and/or could act as a barrier, as pediatricians prefer not to identify/address problems at all.

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Parents/

Families  Parents are deeply concerned about their children and worried about their emotional _{distress, stress and risky behaviors and the impact of all of these on their children’s} health.

+

 Some parents are in denial of children’s use or ambivalent about knowing about kids’

problems and may not welcome increased attention to behavioral health problems. -  Similarly, many may use substances themselves, either socially or problematically

(especially alcohol and marijuana), and may have ambivalence (and potentially, guilt) about their children’s use and need for intervention.

-

 Parents may also be wary of specialty treatment, especially chemical dependency

treatment, which they may see as the place where “bad” or delinquent kids go. -  Taboos about revealing personal/family information about mental health/substance

abuse problems and/or mistrust of behavioral health treatment systems may be especially strong among certain ethnic groups, including African-Americans and Latinos.190,192,211

-

 Conversely, parents from groups wary of specialty mental health or chemical

dependency treatment may welcome resources for behavioral health within Pediatrics, and associated with a trusted medical professional.212-215

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 For some subsets of Kaiser parents, opportunities for behavioral health treatment integrated into pediatric primary care may be welcome because such a delivery mechanism could effectively circumvent specific systemic barriers. These include parents whose insurance coverage imposes cost sharing mechanisms (co-pays, co- insurance, deductibles) which may function as barriers to specialty treatment, and parents of children who are Medicaid Managed Care beneficiaries and for whom specialty mental health and substance abuse treatment services must be obtained outside of the health system, through county systems.216

+

 Many parents of adolescents are also concerned about the confidentiality protections afforded adolescent patients and many would prefer to be more involved in all health care discussions involving their adolescent children; some of these parents may object to confidential behavioral health screening, assessment and intervention.217-221

- Pediatric Primary Care Providers (PCPs)

 Pediatric primary care providers are extremely stressed in the current health care environment, both within and outside of integrated systems like Kaiser. They want to provide best care to adolescent patients, while coping with time pressures199 (across the organization, with a few exceptions, pediatric PCPs generally have 15 minutes for Adolescent Well Visits), competing priorities (multiple, simultaneous initiatives occurring simultaneously, e.g., childhood obesity, asthma control, HPV vaccination, teen dating violence, ADHD treatment, etc.) and multiple, simultaneous leadership directives. This could inhibit implementation of physician-delivered SBIRT because of lack of time.

-

 Conversely, such pressure could make PCPs more amenable to an embedded

behavioral health clinician model which could free up their time for other preventive activities.

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 Many generalist pediatricians report discomfort with alcohol and drug use and mental health issues, have had little training in behavioral health assessment and

intervention,133 and low self-efficacy about handling behavioral health problems (e.g., screening, identification, assessment and intervention).

-

 Relationships with, and knowledge of the services provided by, specialty behavioral

health providers are less than optimal.222,223 ~

Adolescent Medicine Specialists

 Adolescent Medicine Specialists are advocates for optimal adolescent health policies and practices. They are typically more sensitized to and knowledgeable about the main adolescent health threats and their management, including substance abuse, than are their generalist pediatrician colleagues. They often have more time allotted for teen well visits than generalists. Very sensitive to confidentiality concerns of

adolescents, particularly with regard to sexual health and contraception, but in terms of behavioral health as well. Typically very adept at structuring workflows in a way that preserves confidentiality. They help to shape teen preventive services policy, but have may encounter difficulty getting generalist pediatrician colleagues to change practices. They are likely to be advocates of more integrated models of adolescent behavioral health care.

+ Other Pediatrics Department Staff: Medical Assistants,

 If pediatricians cannot deliver behavioral health services for logistical reasons, non- physician clinicians or staff may be tapped to deliver components of SBIRT. This could open up opportunities for non-physician staff to work “at the top of their job scope.”

+

 Conversely, non-physician staff may feel put-upon by new demands, may be stressed

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Nurses, Clinical Health Educators

 In a few locations within the KPNC system, there are already embedded behavioral health clinicians, although their hours are usually limited and they deal with

behavioral problems across the age spectrum. These “pioneers” could help to lay the groundwork for regional SBIRT implementation.

+ Child & Family Psychiatry (Psych) clinicians and Adolescent Chemical Dependency (CD) clinicians

 Committed to adolescent behavioral health. Significant expertise in adolescent

behavioral health care. +

 Concerns about out-stationing into Pediatrics, losing ground with current models of siloed specialty care, losing “specialist” roles, losing resources. May be threatened by models of care which move focus to non-specialty care settings (e.g., Pediatrics). May be wary of pediatric health staff involvement in behavioral health care provision.

-

 Behavioral Health clinicians currently have a relatively tense, contentious relationship

with management, regional leadership. -

Regional Pediatrics

Leaders

 Have established priorities, pressure from health system leadership to meet performance measures (e.g. % asthma control, adolescent depression screening), increase efficiencies.

~

 Committed to improving quality of care. +

 New leadership may be interested in more integrated models of care, in response to environmental changes. + Regional Mental Health Leaders

 Concerned about adolescent behavioral health care quality. +

 Under pressure for access, quality of adult care, teens may be a lower priority. -  Organizing to meet HEDIS adolescent depression screening performance measures.

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 Conversely, the focus on response to HEDIS adolescent depression screening performance measures and development of workflows which focus solely on depression screening while ignoring significant co-occurrence of depression and substance use, may inhibit SBIRT implementation.

-

 Regional leaders’ commitment to home-grown, un-validated instruments and protocols, outcomes monitoring agendas, may impede evidence-based SBIRT implementation.