Katherine Hobbs Knutson

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.

Preliminary Outcomes from an Integrated Pediatric Mental Health Outpatient Clinic

An estimated 1 in 5 children in the United States meet criteria for a diagnosable mental disorder, yet fewer than 20% receive mental health services. Unmet need for psychiatric treatment may contribute to patterns of increasing use of the emergency department. This article describes an integrated pediatric evaluation center designed to prevent the need for treatment in emergency settings by increasing access to timely and appropriate care for emergent and critical mental health needs. Preliminary results showed that the center provided rapid access to assessment and treatment services for children and adolescents presenting with a wide range of psychiatric concerns.

Payment for Integrated Care: Challenges and Opportunities

A multidisciplinary team approach to care and robust care coordination services are primary components of almost all integrated care delivery systems. Given that these services have limited reimbursement in fee-for-service payment arrangements, integrating care in a fee-for-service environment is almost impossible. Capitated payment models hold promise for supporting integrated behavioral and physical health services. There are multiple national examples of integrated care delivery systems supported by capitated payment arrangements.

Health Complexity and the Interaction Between Physical and Behavioral Health Conditions in Children and Youth

There are multiple domains that act independently and in concert to influence the health of children/youth. Children/youth with multiple factors in each domain and/or in multiple domains are likely to present with increased health complexity resulting in poor health outcomes and increased cost. Addressing these issues in a holistic manner, with a focus on relationship and continued joint effort, may reverse these potential negative outcomes. By simultaneously addressing the clinical, social, and health-system barriers to health improvement for vulnerable populations, there is a significant potential to reduce reliance on high-cost treatments. Interestingly, lower-cost and community-based care may result in better health outcomes for children/youth compared to treatment in high-cost environments, such as inpatient units and the Emergency Department. Treatment for chronic medical and BH conditions in children/youth necessarily requires long-term continuous relationships with providers. This type of care is best delivered in an outpatient community setting as opposed to the fragmentation that often occurs when children/youth transition between levels of care. PICM managers have the expertise and ability to help maintain children/youth in these lower cost and higher quality treatment settings.

Care Coordination for Youth With Mental Health Disorders in Primary Care

Many children are treated for mental health disorders in primary care settings. The system of care (SOC) provides a framework for collaboration among pediatric mental health providers, but it is unclear if youth treated for mental health disorders in primary care receive such coordination. At the South Boston Community Health Center from September /2012 to August 2013 for 74 individuals ≤18 years, the odds of contact with SOC agencies (mental health, education, child protective services, juvenile justice and developmental disabilities) were compared for mental health treatment in primary versus specialty care. The odds of SOC contact within primary care were lower compared to specialty care (OR = 0.43, 95% CI = 0.29-0.66), specifically for mental health (OR = 0.54, 95% CI = 0.25-1.2), education (OR = 0.12, 95% CI = 0.050-0.28), and child protective services (OR = 0.64, 95% CI = 0.22-1.9). As care coordination may improve health outcomes, increased support and education for care coordination specific to youth treated for mental health disorders in primary care settings may be warranted.

Physicians’ Contributions to Building and Participating in a Population-Based Case Management Centers of Excellence

Value-added case management has a bright future as a contributor to population health management. It utilizes trained health professionals to assist and support individual patients, identified using aggregate service use data related to an accountable population, with various levels of health complexity. In successful population health management programs, population-based work processes, including case management, are designed to achieve improved clinical, functional, and economic outcomes (Struijs JN et al. (Health Policy 119(4):522–529, 2015)) in a healthcare environment that often retards, rather than promotes, health.

Patient Health Care Assist and Support Services, Integrated Case Management, and Complexity Assessment Grids

The practice of medicine is much more complicated than in the day of the “old fashioned” house call. Providing respectful patient-centered care remains at the heart of clinician assessments and treatments. However, with the introduction of the Patient Protection and Affordable Care Act (ACA), there is now also an expectation that physicians and other treating clinicians, e.g., clinical nurse specialists, physician assistants, non-physician behavioral health (BH) professionals, will optimize clinical outcomes and reduce costs in the populations of patients for whom they and their group are responsible. Thus, the face-to-face encounter is only one of several components of an increasingly complicated care delivery process. In addition to completing a patient evaluation and providing appropriate treatment, physicians are being asked to improve their communication and collaboration with others involved in the patient’s care, to use health resources efficiently, and to do so in a way that maximizes and documents long-term clinical and functional improvement for the population as a whole, not just the individual patient (McClellan et al., Health Aff., 29(5):982–90, 2009; Epstein et al., Health Aff., 33(1):95–102, 2014). In the USA, often these goals are carried out through integrated clinician and health administrative networks, called Accountable Care Organizations (ACOs).

Health Complexity and the Interaction Between Physical and Behavioral Health Conditions in Adults

The first chapter of the Physician’s Guide goes into great detail about patient health care assistance and support programs and its case management subcategory, which requires the skills of licensed professionals with case manager competencies that match increasing levels of assist and support program intensity. Since assistance and support programs and the published literature are generally indiscriminant in their use of terminology to describe assistance and support interventions regardless of program intensity or the personnel competencies of those providing services, we will rely on the concepts of program intensity and assist and support personnel competency used in Chap. 1 throughout this book. “Case management” will remain the term that demarcates programs with higher intensity and “case managers” the professionals needed to meet program and patient needs.

Organizing and Implementing Value-Added Integrated Case Management

Physicians should now have a grasp of the types of assist and support services, a conceptual framework for the value that ICM can bring to populations of patients with health complexity, how ICM can complement clinical practice, the effects of the interactions between medical and BH conditions on clinical and financial outcomes, and the foundational components of ICM and PICM used in patients. It is now time to discuss when and how an ICM program should be considered in an organizational setting and the high-level decision-making associated with its deployment. For purposes of this chapter, “ICM” will be used to refer to both the adult and pediatric components.