Barry Sarvet

Improving mental health services in primary care: Reducing administrative and financial barriers to access and collaboration

INTRODUCTION “Mental Health: A Report of the Surgeon General”1 documents the high prevalence of mental health needs of America’s youth. Although almost 1 in 5 children in the United States suffers from a diagnosable mental disorder, only 20% to 25% of affected children receive treatment. This is a troubling statistic, especially when considering that treatment of many mental disorders has been deemed highly effective. The Surgeon General’s report highlights the challenges of gaining access to mental health services in a complex and often fragmented system of health care. Without intervention, child and adolescent psychiatric disorders frequently continue into adulthood. For example, research shows that when children with coexisting depression and conduct disorders become adults, they tend to use more health care services and have higher health care costs than other adults. If the system does not appropriately screen and treat them early, these childhood disorders may persist and lead to a downward spiral of school failure, poor employment opportunities, and poverty in adulthood. No other illnesses damage so many children so seriously.2 On the other hand, early identification and treatment of children with mental health problems has the potential to reduce the burden of mental illness and its many consequences. Furthermore, data from a number of sources have demonstrated that enhanced access to outpatient mental health services is cost-effective.3 The American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry (AACAP) have created this joint position paper to ensure the mental health and wellness of our children and adolescents. With the implementation of the federal mental health parity law, many more children may be seeking mental health treatment.* Shortages of children’s mental health professionals will make the coordination of care between pediatricians and child and adolescent psychiatrists even more necessary. By addressing the administrative and financial barriers that primary care clinicians and children’s mental health professionals face in providing behavioral and mental health services to children and adolescents, we hope to improve access, collaboration, and coordination for pediatric mental health care. The National Business Group on Health has endorsed this document.

Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project

BACKGROUND: Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. METHODS: Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35 335 encounters. PCC surveys assessed satisfaction and impact on access to care. RESULTS: The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10 114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0–245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. CONCLUSIONS: PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

Behavioral Health Care For Children: The Massachusetts Child Psychiatry Access Project

Access to behavioral health care for children is essential to achieving good health care outcomes. Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet childrens need for behavioral health care. The Massachusetts Child Psychiatry Access Project has addressed this problem by delivering telephone child psychiatry consultations and specialized care coordination support to over 95 percent of the pediatric primary care providers in Massachusetts. Established in 2004, the project consists of six regional hubs, each of which has one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the 1.5 million children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children. Pediatric primary care providers enrolled in the project reported a dramatic improvement in their ability to meet the psychiatric needs of their patients. Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States.

Bridging the Divide Between Child Psychiatry and Primary Care: The Use of Telephone Consultation Within a Population-Based Collaborative System

The Massachusetts Child Psychiatry Access Project is a public system for improving access to care for children with mental health problems in which the provision of telephone consultation by child psychiatry teams to pediatric primary care providers (PCPs) plays a central role. In this article, the practice of telephone consultation within this system is explored through the examination of case studies, demonstrating its use in common clinical scenarios. The telephone consultations provide immediate case-based clinical education, and also serve as a gateway for the provision of as-needed direct child psychiatry evaluation and care coordination services. Most importantly, the telephone consultations build sustaining collaborative relationships, enhancing the ability of PCPs to meet the needs of children with mental health problems.

Developing Effective Child Psychiatry Collaboration with Primary Care: Leadership and Management Strategies

By working in collaboration with pediatric primary care providers, child and adolescent psychiatrists have the opportunity to address significant levels of unmet need for the majority of children and teenagers with serious mental health problems who have been unable to gain access to care. Effective collaboration with primary care represents a significant change from practice-as-usual for many child and adolescent psychiatrists. Implementation of progressive levels of collaborative practice, from the improvement of provider communication through the development of comprehensive collaborative systems, may be possible with sustained management efforts and application of process improvement methodology.

Is There a Psychiatrist in the House? Integrating Child Psychiatry Into the Pediatric Medical Home

The Patient-Centered Medical Home (PCMH) is a model of primary care practice incorporating core principles of accessibility, coordination, comprehensiveness, continuity, cultural competence, and respecting and valuing the preferences of families. As our nation struggles to reformourhealthcaresystem,thePCMHmodelis widely acknowledged to be the foundation of a high-value, effective system of care that better meets the needs of patients and produces better health outcomes. Although most PCMH initiatives currently underway around the country focus on the management of chronic diseases of adults, the model has its roots in pediatric practice and the care of children with special health care needs. These features were codified in the Joint Statement on the Principles of the Medical Home, 1

Integrating Mental and Physical Health Services Using a Socio-Emotional Trauma Lens ☆

This article provides a synthesis of the lessons learned from the Pediatric Integrated Care Collaborative (PICC), a SAMHSA-funded project that is part of the National Child Traumatic Stress Network. The high prevalence of trauma exposure in childhood and shortage of mental health services has informed efforts to integrate mental and behavioral health services in pediatric primary care. This article outlines strategies to integrate care following the six goals of the PICC change framework: create a trauma/mental health informed office; involve families in program development; collaborate and coordinate with mental health services; promote resilience and prevent mental health problems through a particular focus on trauma-related risks; assess trauma-related somatic and mental health issues; and address trauma-related somatic and mental heath issues. We conclude with a summary of key strategies that any practice or practitioner could employ to begin or continue the process of integration.

Childhood Obsessive-Compulsive Disorder

1. Barry Sarvet, MD 1. Division of Child and Adolescent Psychiatry, Baystate Health System, Springfield, MA. * Abbreviations: CBT: : cognitive behavioral therapy DSM-IV-TR: : Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition , Text Revision ERP: : exposure and response prevention GABHS: : group A β-hemolytic Streptococcus OCD: : obsessive-compulsive disorder PANDAS: : pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection PCP: : primary care provider SCARED: : Screen for Anxiety Related Emotional Disorders SSRI: : selective serotonin reuptake inhibitor Obsessive-compulsive disorder (OCD) affects up to 3% of children and adolescents, with nearly 75% of these experiencing comorbid diagnoses. Physicians need to familiarize themselves with the diagnostic criteria and basic screening tests, including the Pediatric Symptom Checklist and the Screen for Anxiety Related Emotional Disorders, as well as the principles of effective treatment, including Cognitive Behaviorial Therapy and pharmacologic agents. After completing this article, readers should be able to: 1. Know the definition of obsessive-compulsive disorder (OCD) and be familiar with its signs and symptoms. 2. Understand the biological and environmental contributions to the development of OCD. 3. Be aware of the comorbidities associated with OCD. 4. Know the therapies available for treating OCD, both cognitive and pharmacologic. 5. Understand the role of the primary care physician in the management of OCD. Joseph is an 11-year-old boy whose mother has brought him to the pediatrician for a concern about his hands. The skin is dry, cracked, and erythematous. Joseph is wearing gloves in the office and is unhappy about being there. He does not want to show his hands to the doctor. No other area of skin is affected. The condition has worsened gradually over several months. Joseph’s mother has noticed that he washes his hands often and consumes large quantities of hand sanitizer gel throughout the day. Joseph vehemently denies this behavior. In addition, there is a several-year history of frequent hand-washing, increasing in severity over the past several months, and avoidance of touching door knobs, handles, playing cards, books, and toys that are not his own. He wears gloves everywhere he goes outside of his house. Joseph worries about germs and getting sick, and he avoids …

Public-Academic Partnerships: Public-Academic Partnerships to Address the Need for Child and Adolescent Psychiatric Services

There is a severe shortage and a maldistribution of child and adolescent psychiatrists in the United States. Public-academic collaborations play a major role in attempting to address these conditions. This column describes examples of two types of collaborations: newer programs that emphasize consultation, education, and support to primary care providers and more traditional efforts that provide consultation to general psychiatrists and psychiatric nurse practitioners. In both cases videoconferencing plays a role in reaching difficult-to-serve populations. Residency programs for both child and adolescent psychiatrists and primary care providers should include training in collaborative treatment approaches.

Medico-Legal Risk Associated with Pediatric Mental Health Telephone Consultation Programs

Clinicians providing consultation through mental health telephone consultation programs express concern about the potential legal risk of the practice. In this survey of six state mental health telephone consultation program directors, we report the annual number of children referred for consultation and the number of lawsuits against consultant clinicians. Between 2004 and 2010, 3,652 children per year were referred nationally, and there were no medical malpractice lawsuits against clinicians related to telephone consultation program activity. Although medico-legal risk is always present, the findings of this national study suggest the risk for clinicians providing mental health telephone consultation may be lower than perceived.