John H. Straus

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.

Emergency room use by low income children with a regular source of health care.

problematic by many hospital administrators and providers of emergency care. The hospital emergency room is primarily designed for the prompt treatment of victims of accidents/trauma and sudden emergent illnesses. In that setting it is difficult to address chronic and psychosocial problems of patients. Moreover, the care is expensive, and the presence of those seeking primary care contributes to crowding and long waits for all patients. With the advent of Medicaid in 1966, it was assumed that emergency room use by persons needing primary care would decrease. The Medicaid program was designed

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.

Clinicians’ Utilization of Child Mental Health Telephone Consultation in Primary Care: Findings From Massachusetts

OBJECTIVE The authors examined utilization of the Massachusetts Child Psychiatry Access Project, a mental health telephone consultation service for primary care, hypothesizing that greater use would be related to severe psychiatric diagnoses and polypharmacy. METHODS The authors examined the association between utilization, defined as the mean number of contacts per patient during the 180 days following the initial contact (July 2008-June 2009), and characteristics of the initial contact, including consultation question, the childs primary mental health problem, psychotropic medication regimen, insurance status, and time of year. RESULTS Utilization (N=4,436 initial contacts, mean=3.83 contacts) was associated with initial contacts about medication management, polypharmacy, public and private health insurance, and time of year. The childs primary mental health problem did not predict utilization. CONCLUSIONS Telephone consultation services address treatment with psychotropic medications, particularly polypharmacy. Joint public-private funding should be considered for such public programs that serve privately insured children.

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.

Massachusetts Child Psychiatry Access Project 2.0: A Case Study in Child Psychiatry Access Program Redesign

The Massachusetts Child Psychiatry Access Program is a statewide public mental health initiative designed to provide consultation, care navigation, and education to assist pediatric primary care providers in addressing mental health problems for children and families. To improve program performance, adapt to changes in the environment of pediatric primary care services, and ensure the programs long-term sustainability, program leadership in consultation with the Massachusetts Department of Mental Health embarked on a process of redesign. The redesign process is described, moving from an initial strategic assessment of program and the planning of structural and functional changes, through transition and implementation.