Columbia University Mailman School of Public Health

Oregon

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Oregon Strategies

Dyadic Treatment and Workforce Development

Over the past 10 years, Oregon has greatly increased families’ access to dyadic treatment (see Dyadic Treatment research summary here). This expansion has been achieved through: 1) Medicaid coverage for dyadic treatment, 2) policies that help ensure identification of parents and children who could benefit from dyadic treatment, and 3) investment in clinician training. In dyadic treatment, a clinician works with both the parent and young child to promote positive interactions that strengthen the parent-child relationship and parenting skills. Children under age seven and caregivers are referred to Parent-Child Interaction Therapy (PCIT) for a variety of reasons, including infant-toddler or preschooler anxiety, trauma or behavioral difficulties; parent depression, which may interfere with responsive, nurturing parenting; and adverse family events, such as loss of a family member, that increase the child’s risk of mental health problems.

In 2004, the Oregon Commission on Children and Families awarded a grant to a county mental health agency that allowed two therapists to deliver Parent-Child Interaction Treatment (PCIT). The Commission had a state membership composed of Governor appointees and a local membership appointed by the Board of County Commissioners. This entity worked in partnership with other state agencies and under a legislative charge to support local comprehensive planning for all children and families and provide leadership for local and state efforts focused on early childhood. The Commission expanded PCIT to four additional county mental health departments in 2009. In 2013, the legislature allocated general funds (called “New Investment Funds”) for projects designed to improve health care for Oregon families eligible for Medicaid. These funds allowed expansion of PCIT to all parts of the state.

Currently, providers who offer the PCIT dyadic treatment model can be found in 19 of Oregon’s 36 counties and in 45 physical locations. In 2017, 1,617 children received PCIT treatment with their caregivers. A new competitive funding opportunity will further expand PCIT in Oregon and strengthen supports for quality in the period 2018-2021. In the next round of funding, both new and established sites can apply, although there will be a special focus on expansion in unserved parts of the state. In addition, funding will support training for PCIT clinicians to deliver treatment outside of clinic sites, including in home, child care, and other community settings. The goal is to bring PCIT to where families spend time. The funding also establishes new requirements for participation in fidelity and data collection activities to ensure high quality as the model is expanded.

Workforce Development

With support of New Investment Funds, an Oregon PCIT Training Center was established in Jackson County in 2015 to address the on-going training and consultation needs of PCIT clinicians across the state. This Center has provided training, supervision, and consultation to 49 therapists since its inception. Also in 2015, Oregon hired a full-time professional, Laurie Theodorie, to oversee dyadic treatment expansion in the state.

The PCIT Training Center employs three clinicians who are certified as trainers through PCIT International. The lead trainer, who is bilingual, is considered a Level II, or regional, trainer. The Center’s training team is contracted to start one or more training cohorts per year that offer twice a month consultation via phone, teleconferencing, and live visits for trainees for a year or until certification requirements of the trainees are met. The trainers also provide ongoing monthly consultation to certified PCIT therapists and arrange the PCIT national expert calls for the Oregon PCIT Consortium (described below). In collaboration with the Oregon Health Authority PCIT contract administrator, the trainers participate in site reviews which help ensure that PCIT services are being provided in accordance with the model’s protocols to maintain fidelity and achieve desired outcomes. As part of a statewide PCIT leadership group, the trainers help arrange the Annual Oregon PCIT Conference.

Oregon also has one other Level II regional trainer and approximately six additional Level I trainers authorized to provide regional and within-agency training. These trainers reduce the need for travel to a training site and improve sustainability for agencies when there is staff turnover.

Clinicians may be trained at any number of training sites in the world. PCIT International is the authorized organization for training in the evidence-based PCIT protocol and for certification. (See www.pcit.org for more information on how to find PCIT trainers.) The Oregon Health Authority also recognizes PCIT certification from the UC Davis PCIT Training Center for therapists and within-agency trainers.

Providers who deliver PCIT receive ongoing support through participation in Oregon’s PCIT Consortium. This group currently has approximately 130 members, including clinicians who have been fully trained or are in the process of PCIT training, and anyone supporting a PCIT program such as supervisors and skills trainers. PCIT providers can become members of the Consortium at no charge. Members are invited to join state-wide conference calls six times per year with National PCIT experts who present on various topics, such as “helping anxious parents in PCIT,” “providing PCIT in the home setting,” and “cultural considerations in PCIT implementation.” Members also learn about other training opportunities such as PCIT-Toddler Advanced training and regional PCIT Conferences.

Financing

Dyadic treatment is covered by Medicaid as long as the clinician’s agency is enrolled as an Oregon Health Plan Behavioral Health provider. The parent and/or child must have a mental health diagnosis that falls above the line on the state’s prioritized list of conditions for which treatment can be reimbursed, and the provider must use Parent-Child Interaction Treatment (PCIT) to address that diagnosis. Examples of such diagnoses are: “F43.8 - Other severe Reactions to Stress” or “Z62.820 Parent-Child Relational Problem.” Therapists must be independently licensed mental health service providers or working under the supervision of a licensed mental health service provider. Clinicians who have documentation that they have met the PCIT training and skills requirements, or are actively in training with a PCIT trainer, may provide PCIT. The following code is often used for billing: Family therapy (with the client present) - 90847.

Providers can bill for social emotional/behavioral screenings under a general screening billing code. Both a child social-emotional screen and a parent depression screen can be performed on the same day and covered by Medicaid. However, due to concern about providers’ understanding of this policy, the Health Evidence Review Commission is working on guidance for providers. Oregon’s use of “risk” codes means that children do not need to have traditional individual behavioral diagnoses to qualify for dyadic treatment. Risk codes reflect conditions that place the child at high risk of experiencing a mental health disorder. In addition to diagnoses for Parent-Child Relational Disorder and Severe Reactions to Stress, other risk codes reflect the child’s history of experience of physical, sexual, or psychological abuse and neglect.

Monitoring and Evaluation

The Oregon Health Authority has actively shared data on PCIT impacts on children and parents as a strategy for increasing stakeholder support for referring families to this treatment and expanding PCIT in the state. A report to the Children’s System of Care Advisory Committee states that 85 percent of Oregon families who participate in four or more PCIT therapy sessions demonstrate meaningful improvement in child behavior, positive communication, and positive parenting skills.

Special thanks to Laurie Theodorou, PCIT-I Implementation Specialist and Early Childhood Mental Health Policy Analyst, Health Systems Division, Oregon Child and Family Behavioral Health, for providing information for and reviewing this profile.