Jane Meschan Foy

Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Childrens Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Co-location of Mental Health Professionals in Primary Care Settings: Three North Carolina Models

The pressing need for identification and treatment of behavioral health disorders in primary care has renewed interest in the concept of co-located models of care. The purpose of this article is to describe three North Carolina practice models in which mental health professionals are co-located with pediatric primary care providers. Each of the models was sustainable, partly due to systemic changes brought about by advocacy efforts. In addition to providing practical guidance for possible replication in primary care, this article reflects on how advocacy efforts can impact the success of co-location models.

Referral by Pediatricians of Children with Behavioral Health Disorders

A standard interview guide focused on behavioral health referral practices and communication patterns was developed and administered to 47 pediatricians in private practice. Results suggested that the most frequent reasons for referral to a mental health provider were diagnostic uncertainty, failure to respond to treatment, presence of severe affective symptoms, and need for ongoing psychotherapy. Only a third of the providers indicated that their patients frequently followed through with recommendations to receive mental health care. More than half of the pediatricians wanted more information regarding their patients referred for mental health services, and they expressed a strong interest in colocation with a mental health provider.

Enhancing Pediatric Mental Health Care: Algorithms for Primary Care

In 2004, the American Academy of Pediatrics (AAP) Board of Directors appointed the Task Force on Mental Health and charged it to assist pediatricians and other primary care clinicians* in enhancing the mental† health care they provide. The task force determined that 3 goals were important to accomplishing its purpose: The task force recommended addressing the goals sequentially; that is, before implementing the clinical process proposed in this report, clinicians need to (1) accomplish system changes such as payment for mental health services provided by primary care clinicians1,2 and development of clinical relationships with mental health specialists,3 (2) achieve mental health competencies,4 and (3) enhance their office systems by applying chronic care methods to the care of children with mental health problems.5 Strategies the task force used to address these goals are summarized in the introduction to this supplement.6 In this report, the task force proposes a clinical process for delivering mental health services in pediatric primary care settings. The report summarizes key features of this clinical process, then provides algorithms developed in collaboration with informaticians from the AAP Council on Clinical Information Technology; these algorithms are intended to ensure clarity of the proposed process and facilitate its translation to electronic systems. Appendix S5 lists procedural codes that can be used in billing for each step of the process. An accompanying toolkit to assist with implementation is scheduled for distribution in spring 2010. The concepts and process proposed in this report were developed by consensus of 4 groups, the members of which are listed in Appendix S6. These members recognized that the “primary care advantage”7 is the opportunity for longitudinal relationships with children and families—relationships … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Enhancing communication skills for pediatric visits through on-line training using video demonstrations

BackgroundTraining in communication skills for health professionals is important, but there are substantial barriers to individual in-person training for practicing clinicians. We evaluated the feasibility and desirability of on-line training and sought suggestions for future courses.MethodsBased on successful in-person curricula for communication skills and our previous on-line curricula, we created an on-line course consisting of 28 modules (4.75 hours CME credit) about communication skills during pediatric visits that included a mental health concern; each module included a brief case, a multiple choice question, an explanation, and a 1–2 minute video demonstrating key skills. Specific communication skills included: greeting, setting an agenda, discussing diagnosis and treatment, and managing negative interactions. The course was announced by emails in spring, 2007; the course was available on-line for 60 days; we aimed to enroll 50 clinicians. Outcomes were analyzed for those who evaluated the course within 75 days of its initial availability.ResultsOverall, 61 clinicians registered, of whom most were nurses (N = 24), physicians (N = 22), or psychologists or social workers (N = 12). Of the 36 (59%) clinicians who evaluated the course, over 85% agreed that all course objectives had been met; over 90% reported greater confidence in greetings and agenda-setting; and over 80% reported greater confidence in discussing diagnosis and treatment and managing negative interactions. Nearly all, 97% would recommend the course to other clinicians and trainees. Suggestions for improvement included a library of additional video vignettes and written materials to accompany the on-line training.ConclusionOn-line training in communication skills for pediatric mental health visits is feasible, desirable and associated with increased confidence in key skills. Positive feedback from clinicians suggests that a comparison of on-line versus in-person training is warranted.

Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community

Pediatricians and other primary care clinicians* caring for children traditionally have focused their attention on meeting the health care needs of individual children they see in their offices and clinics. However, effective care of the growing number of children and families who are experiencing chronic medical and mental disorders will also require a “population” health perspective. Many policy statements from the American Academy of Pediatrics (AAP) have pointed to the importance of the population perspective in providing and improving pediatric health services.1–10 From this perspective, all members of a community are affected by the health of its individual members. For children, mental health resides not solely within the child but within the web of interactions that connect the child, the family and school, health and other child service systems, and the neighborhood and community in which the child lives.11 This is not to deny that biology is a determinant of mental health and mental illness; rather, biological factors interact with the psychosocial environment to result in mental health, mental illness, and recovery from mental illness. Primary care clinicians who are interested in enhancing mental† health services in their community will need to form partnerships. Key partners for a community mental health advocacy effort include other primary care clinicians, developmental-behavioral pediatricians, adolescent health specialists, the local public mental health agency, representatives of the mental health care provider community (eg, psychiatrists, psychologists, social workers, substance abuse counselors, psychiatric nurse practitioners), community mental health activists including parents and youth, school system representatives, early childhood educators, Early-Intervention (EI) system representatives, representatives of the child protective and juvenile justice systems, and the local department of public health. Primary care clinicians cannot feasibly pursue the strategies that follow in the absence of such partnerships. In every region of the United … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Integrating Mental Health Care Into Pediatric Primary Care Settings

R t s m s s m t s i a d c c t fi r t e p r d t d m b v a h d s a SCOPE OF THE PROBLEM E pidemiologic data from the U.S. Department of Health and Human Services have estimated that 10% to 20% of children meet the diagnostic criteria for a mental disorder. However, 40% to 80% do not receive mental health services, reflecting the fact that many are not identified and many do not have access to needed care. A national shortage of child psychiatrists, exacerbated by geographic maldistribution, is part of this problem. Early identification of children with treatable psychiatric disorders may decrease long-term adverse consequences. Pediatric primary care providers are well positioned to detect children at risk for mental health problems, initiate preventive interventions, and provide early treatment. Integrating mental health care into pediatric primary care settings would involve child psychiatrists and other mental health professionals in prevention and expand opportunities for treatment. To do this will require practice changes, policy changes, and training—in some cases retraining— of clinicians.

Primary care management of child & adolescent depressive disorders.

This article outlines the importance of primary health care in addressing the public health challenge presented by pediatric depressive disorders. The current realities of depression management in primary care are discussed. The models emerging from intervention research and the barriers to their implementation in practice are then reviewed. Drawing on this background, recent new standards for primary care management of pediatric depressive disorders are discussed, along with resources that have been developed to support their achievement.

Behavioral Health Practices in the Midst of Black Box Warnings and Mental Health Reform

A standard guide was readministered to 42 primary care pediatricians after community interventions to assess changes in their behavioral health practices. Among the outcome findings: increased screening of young children (6 months to 5 years); attention deficit hyperactivity disorder continued to be the most frequent diagnosis, with a high level of diagnostic comfort and use of stimulants; decreased comfort in the diagnosis and treatment of depression, with a significant decline in use of selective serotonin reuptake inhibitors; nearly all continued to offer nonmedication, behavioral health treatment; and a significant increase in use of social workers for community referrals. Structured interventions had limited influence on the process of change. Black box warnings exerted a powerful effect on prescribing practices. Systemic changes involving financial incentives, increased access to mental health providers, practice guidelines, and technology for continuing education may offer possibilities for changing practice patterns.

Addressing Behavioral Health Issues During Well Child Visits by Pediatric Residents

The study examined practices by pediatric residents (n = 61) concerning psychosocial care during well child visits. A random sample (n = 719) of well child visits was selected, and a medical record review was conducted. Results suggested that a behavioral health issue was discussed in 38% of the cases. The most frequent type of problem discussed involved a medical component, while problems with mood were rarely discussed (<1%). Residents treated 67% of the cases and referred 20% of the cases with behavioral health concerns. Logistic regression suggested that residents were significantly more likely to treat medically focused problems (P = 0.05), but more likely to refer children with social/environmental or learning problems (P = 0.05). Results suggested the need for further training in recognition of internalizing disorders.