This Web site was supported in part by Grant No. G95MC05434 from the US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, to the AAP.
The American Academy of Pediatrics (AAP) Task Force on Mental Health (TFOMH) has supported the development of collaborative projects of care among primary care clinicians and mental health professionals toward a goal of continually improving delivery of health care to children and their families. Collaborative models of care include rural and mental health care models. A number of primary care clinicians have had success with employing, co-locating with, and collaborating with social workers, psychologists, and nurse practitioners with specialized training to provide mental health services for children.
Please note that the list of projects below were compiled from a number of sources, including AAP Chapter Presidents, Vice Presidents, Executive Directors, Pediatrics for the 21st Century symposium presenters, AAP mental health listserv participants, AAP Task Force on Mental Health members, AAP Council on Community Pediatrics Rural Health Special Interest Group members, Bright Futures members, and others. The list is not exhaustive. Please contact firstname.lastname@example.org should you wish to submit a model for consideration or update your current project.
Select a State:
Mental Health Project
Statewide - AL
The chapters Mental Health Project has evolved into a very active, multidisciplinary, statewide effort to increase the number of children screened and referred for mental health services. Within a short period of time, the Mental Health Project Advisory Committee was formed, and developed a questionnaire to survey primary care clinicians on their attitudes regarding the availability of mental health services for children. The committee also planned and implemented a series of educational dinner meetings that were being held at 4 different regions across the state. The sessions consist of 1-hour presentations by child and adolescent psychiatrists and 1 hour of roundtable discussion between pediatricians and mental health professionals. Attendance at these continuing medical education (CME) dinners has been very good, with more than 250 people attending the first 2 meetings. As a result of the project, many resource tools have been developed, including 4 regional mental health directories and standardized referral/follow-up forms to improve communication between pediatricians and child/adolescent psychiatrists.
Web Address: www.alaap.org
Indian Health Service Telehealth Program
- Active clinical telehealth experience in Indian Health Service (IHS) and Tribal facilities across the country
- Leading clinical applications are radiology, dermatology, psychiatry, retinal screening, and cardiology
- Experience with over 30 different types of clinical telehealth
- Emerging capability in home telehealth, chronic illness care, telepharmacy, rehabilitative services, eICU, and other services
- Focuses on business modeling, infrastructure development, and collaborations
- Innovative uses of new media for distance learning and training
The tools of telehealth care can improve access to care and chronic illness care management for patients, families, and communities. Innovation in clinical service delivery also offers opportunities for enhancements in quality and cost efficiency.
Tuba City Indian Medical Center
Tuba City, AZ
In 2000, a pediatrician member of the Medical Staff and Information Technology Department at the Tuba City Indian Medical Center became interested in telemedicine applications in our remote setting in northeast Arizona. The Arizona Telemedicine program through the University of Arizona (U of A) had been established several years earlier and was interested in expanding its network into rural areas.
Because of staff shortages in mental health that disproportionately affected children and adolescents with emotional and behavioral concerns, we worked toward establishing a Telemedicine link with the U of A Department of Child and Adolescent Psychiatry. Our links were set up at both of our local high schools (a public high school and a former Bureau of Indian Affairs high school that is now a charter school but continues to offer boarding to students who come from even more remote settings). In a unique manner, the schools are tele-connected with the hospital via a wireless radio system. The hospital employs a DS3 connection with the Arizona Telemedicine network.
The local high schools were eager to participate in the proposed telemedicine program. After meetings with Parent Advisory groups, counselors, and school administrators, a consent form was developed and a standard protocol for student referral was established. Collaborative agreements between the schools and the hospital already existed because of a thriving School-based Health Program sponsored by the Pediatrics, Family Medicine, and Midwifery Departments.
We have been providing in-school telemedicine mental health services on a continual basis for the last 4 school years. The primary provider from University of Arizona is a PhD psychologist, and the Adolescent and Child Psychiatry division director acts as a liaison for more difficult cases or those requiring medication management problems. The Director of Adolescent Health Services oversees all students who do require medication with selective serotonin reuptake inhibitors (SSRIs), but these tend to be the minority of patients seen. We currently provide a total of 6 hours of telepsychiatry per week, a number that is often insufficient to meet need/demand and are exploring other options. The psychologist primarily engages the students in cognitive behavioral therapy. She sees the entire gamut of diagnoses. Our largest area of fallout is students who are in need of urgent care. These students get referred to the emergency department at our hospital and are handled by the members of our Mental Health Department at the Tuba City Indian Medical Center.
Web Address: www.telemedicine.arizona.edu
Fresno Healthy Steps Pediatrics: Child Development Training
Healthy Steps (http://www.healthysteps.org/) is an innovative, evidence-based approach to primary health care for young children that support mothers and fathers in their role as nurturers of the emotional, behavioral, and intellectual growth of their children. Healthy Steps adds a new member to the primary care faculty team, the Healthy Steps Specialist (HSS), an expert in child development. Healthy Steps services to families include enhanced well child care, home visits, a child development telephone information line, developmental and psychosocial screening, written informational materials, parent groups, linkages to community resources, and literacy promotion through Reach Out and Read. We have shown a 26% reduction in severe and harsh punishment with toddlers, a 24% increase in breastfeeding, a 50% increase in reading to babies, and a 34% decrease in premature water and solid food feeding of babies.
Fresno Healthy Steps not only provides services to children from birth to 5 years of age and their families, but also effective training for primary care residents. The HSS teaches residents normal child development through structured experiential and didactic sessions. At the core of the Healthy Steps training the HSS precepts residents with their patients, including both office well child examinations with the focus on normal child development, as well as joint home visits with high-risk children. Using the Ages & Stages Questionnaires Child Monitoring System (http://www.agesandstages.com/), residents provide the highest quality developmental screening while improving their child development skills. Residents have shown significant improvement in practice behaviors and knowledge as measured by a beginning- and end- of-year survey and rate Healthy Steps as #1 among all the developmental and behavioral training experiences.
Web Address: www.fresno.ucsf.edu/pediatrics/program_info.htm
The Childrens Clinic (TCC), Serving Children and Their Families
Long Beach, CA
The Childrens Clinic (TCC), Serving Children and Their Families, is continuing work to incorporate mental health services into its scope of practice. Community needs assessments and surveys of our patients indicated this is a service that is sorely needed by the population the clinic serves. The Childrens Clinic hired 3 masters-level social workers to assist in screening for mental illness and referring to community providers; however, there are several barriers that patients face in accessing mental health services, including stigma, lack of insurance, language/cultural barriers, insufficient funding, limited number of mental health professionals with long waiting lists, and lack of communication between health care and mental health professionals. The Childrens Clinic held a meeting with several local mental health professionals to explore these issues and develop collaborative relationships. Memorandums of understanding were developed to facilitate mental health referrals. One agency, Pacific Clinics, volunteered to colocate therapists on-site at TCC to provide mental health counseling to pediatric patients at a place that is familiar to them and is without stigma. The referral relationships and colocated services allowed patients to access appropriate mental health services. The Childrens Clinic Social Services Manager is participating in various work groups, councils, and coalitions that focus on mental health to ensure that TCC is aware of the local issues in mental health care and to advocate for the needs of TCCs patient population. This has resulted in a relationship with Los Angeles County Department of Mental Health, which eventually will allow TCC access to county funding streams for the provision of mental health services.
Web Address: www.thechildrensclinic.org
(Consultation Liaison in Mental Health and Behavior)
Child Health Clinic and The Children's Hospital
Description: Project CLIMB infuses comprehensive mental health services into a high volume inner-city primary care residency training clinic and enhances the capacity of primary care clinicians to identify and treat common mental health concerns in children. The intervention involves co-location of mental health clinicians - child psychiatrist (1), child psychologist (1), and trainees including psychiatry fellows, postdoctoral fellows in childhood anxiety and in infant mental health, psychology interns, and psychology graduate students - in the primary care training clinic. CLIMB clinicians are present daily during continuity care clinics and provide on-site services for pediatric providers, children, and their families. This program includes the following components:
- Healthy Steps for Young Children implementation to enhance developmental services in pediatric primary care settings; delivered during well-child visit.
- Developmental, socio-emotional and postpartum depression screening at well-child checks using validated tools.
- Resident training using multimedia toolkit, didactics in clinic, noon conference and other venues, and case collaboration.
- Precepting residents and clinical trainees during their continuity care clinics in order to provide consultation and intervention as needed; consultation available from child psychiatry fellows and a psychology intern.
- Direct services for children and their families: psychopharmacology clinics, postpartum depression groups, psycho-educational groups for parents and children, clinic-based individual treatment, liaison to outside mental health services, and outpatient treatment.
- An evaluation component to assess impact of our intervention on family satisfaction and improvement in pediatric resident's attitude, knowledge, skill, and proficiency in providing basic developmental and mental health services.
- Systems building and integration through consultation, collaboration, and outreach with state and local agencies/partners invested in providing comprehensive care to pediatric populations.
Funders for the program include Rose Community Foundation, The Colorado Health Foundation, and American Academy of Child and Adolescent Psychiatry.
Brian Stafford, MD, MPH, FAAP
Ayelet Talmi, PhD
The Child Health and Development Institute, a non profit research and policy center dedicated to improving children's health and mental health in Connecticut, has funded 4 primary care sites to integrate behavioral health services into their practices and to partner with a behavioral health agency. The 4 primary care sites are developing collaborative relationships with behavioral health organizations that have been designated as Enhanced Care Clinics by the state Medicaid program. Enhanced Care Clinics are paid 25% more than prevailing Medicaid rates for ensuring improved access to services and for developing memoranda of understanding with primary care practices. The 4 primary care sites that are pilot testing collaborative relationships are as follows:
Bridgeport Hospital Primary Care Center
Description: Bridgeport hospital, home of Child First, a primary care based behavioral health screening and consultation program, is extending existing services in 5 ways: 1) Support services for a psychiatric APRN have been added so that the clinician can spend more delivering clinical services; 2) Psychiatric medication management consultation is provided to primary care physicians, with back up and supervision by a psychiatrist from the Child Guidance Center of Greater Bridgeport; 3) Efforts to screen for maternal depression and connect mother-infant dyads to services have been strengthened by collaboration with the Department of Obstetrics and Gynecology; 4) A care coordinator to oversee care plans for identified children across the Child First program, enhanced care clinic, and community based programs has been hired to work at the primary care clinic; and 5) The psychiatric APRN participates in the education of pediatric and family medicine residents as they rotate through the primary care center.
Fair Haven Community Health Center, Inc.
New Haven, CT
Description: Fair Haven Community Health Center is partnering with Clifford Beers Clinic to colocate a behavioral health clinician on site to serve young children. Immediate consultation for primary care providers is provided as well as direct assessment and treatment services for children. Psychiatric consultation is provided by Clifford Beers, and a care coordinator maintains an electronic tracking system. All practice staff receive training in behavioral and developmental health topics, and utilization of standardized screening tools. Mothers are being screened for depression also, and connected to adult mental health services at the Community Health Center.
Pediatric Associates, LLC
Saint Mary's Hospital Incorporated Primary Care Center
Description: Pediatric Associates, a large private pediatric practice in Bristol, is working with Wheeler Clinic to extend the on-site behavioral health services they currently have in place. They have doubled the number of children served by the behavioral health clinician. An increase in the practice's number of children expected to need services has resulted from implementation of an expanded screening program. Screening is integrated with well child services and uses 2 validated instruments, one for younger children and one for adolescents. The use of a web based screening tool has been explored. Medication management is done collaboratively with consultation to the practice by Wheeler psychiatrists and educational programs.
Saint Mary's Hospital is strengthening the primary care center's capacity to serve children with behavioral health concerns using 4 strategies: 1) The program has implemented a standardized screening tool into well child services; 2) The practice has integrated behavioral health into the developmental service that was already operational within the primary care center; 3) The practice has developed consultation, referral, and information sharing protocols for seamless coordination of care with the Child Guidance Clinic of Greater Waterbury; and 4) The practice has undertaken an internal review of billing and administrative processes in an effort to develop a system of service delivery that can be sustained by third party reimbursement.
Duval County Community Clinics
Description: This model consists of a pediatric psychiatrist who works in collaboration with pediatricians and pediatric residents in the Duval County Health Department community clinics. The collaboration began in July 2003 with the hiring of a pediatric psychiatrist by the Duval County Health Department and the University of Florida Department of Pediatrics. The purpose of the collaboration is to train pediatricians and pediatric residents in the diagnosis and treatment of behavioral and mental health problems. The pediatric psychiatrist initially spent half a day, every 2 weeks, in 7 community clinics. The collaboration involves the psychiatrist and the pediatrician or resident seeing patients together and discussing diagnosis and treatment. Previously seen patients also might be discussed, as well as any other questions the pediatrician might have relating to mental health problems. The pediatricians were educated about the diagnostic criteria for mental health disorders in childhood and the appropriate interventions for these disorders, including the use of psychotropic medications. The success of this model has been dependent on the pediatricians interests in expanding their practices to include mental health problems. After 2 years, the pediatric psychiatrist continues to work in collaboration in 4 of the 7 community clinics and is available for consultation for all pediatricians within this health system. There has been a documented increase in mental health diagnoses in each of the community clinics since implementation of this model. Future plans include an expansion of the training of pediatric residents in mental health, and elaboration of the collaborative model.
Social/Emotional Screening and Referral
Multiple Cities throughout IL
This project aims to improve the delivery and financing of preventive health and developmental services for children from birth to 3 years of age. The project goals will be reached by offering educational programs, including office-based presentations for primary care clinicians, allied health care professionals, and their office staff. It aims to increase medical professionals knowledge of social and emotional development, including the use of screening tools to recognize the early signs of delay and facilitate discussion with families and caregivers on social/emotional health and how this can impact the child's long-term development. It is also a desire to increase providers' awareness of community referral resources. By helping to provide health care professionals with a range of strategies they can implement to most effectively provide comprehensive, developmentally oriented health care. The program provides an overview of social/emotional development and teaches how to incorporate screening and referral procedures, for social, emotional and developmental growth into the practice setting. Resource binders are distributed to each practice, along with ideas for how to disseminate the binder's contents appropriately and efficiently. The content is offered at basic to intermediate levels, in an attempt to reach the knowledge of all staff/faculty of the clinic/practice.
Web Address: www.edopc.org
Childrens Hospital of Illinois at OSF Saint Francis Medical Center
: This project addresses the unmet mental health needs of children in central Illinois through the development of a coordinated system of care, which incorporates:
- Routine screening for behavioral/mental health problems into general pediatric practices
- Increased training on the diagnosis and treatment of depression to pediatric primary care clinicians (pediatricians and nurse practitioners)
- Primary care-linked case coordination and educational services for patients and families
- Increased collaborative associations between mental health professionals and pediatricians
The initial focus is on the identification of depression in children and adolescents and piloting academic detail training of the pediatricians and nurse practitioner in a medical school-based primary care practice. Individual case coordination, parent/family education, and psychiatric backup to the pediatric primary care clinicians will be provided by a centralized resource center called Resource Link, which is supported by community collaborative efforts. The project is funded by a 3-year grant from the Illinois Childrens Healthcare Foundation. The program will secure other funding for long-term sustainability by the third year. Provided the project is successful, the model will expand with regard to the number of patients served, encompassing a more broad age range. Over time, it is probable that the project will expand to address a more broad range of mental health issues. It is anticipated that a 3-year analysis of program and client outcomes will demonstrate the effectiveness of an interdisciplinary, interagency team working collaboratively to reduce the significant community burden from childhood depression.
Treating Child and Adolescent Depression in Primary Care
Through this project, the Illinois AAP Chapter and Childrens Hospital of Illinois at OSF Saint Francis Medical Center developed a 90-minute office-based training that covers the screening, diagnosis, and treatment of depression in children and adolescents. The training content is tailored to meet the specific needs of the primary care physician practice. However, in general the following topics are covered:
- Prevalence of depression among children and adolescents.
- Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for depression and differentiating depressive symptoms in adults from those in children and adolescents.
- Instructions for incorporating depression screening into the primary care practice by utilizing the Center for Epidemiological Studies Depression Scale for Children.
- A review of evidence-based treatments for depression.
- An overview of common medications for treating depression in children and adolescents. This includes a discussion of the Food and Drug Administrations (FDA's) black box warning and call for close monitoring.
- Question-and-answer session during which practice staff may ask questions about specific medications, disorders, or patients.
The training is presented onsite at the primary care practice and it is recommended that as many practice staff as possible attend, including physicians, nurse practitioners, nurses, and office staff. This enables the practice to discuss specific staff roles with regard to the screening and treatment of depression. The format is modular so that it can be completed all at once or broken into 3 half-hour modules. At the conclusion of the training, the practice receives a manual that includes current research articles focusing on child and adolescent depression, case vignettes, informational handouts for parents, a guide for billing for depression screening, a list of Web sites for more information about child and adolescent mental health and tools such as a consent to release health and mental health-related information, the CES-DC screening for depression, and a progress report form to assist with communication between the counseling provider and the physician.
Web Address: www.childrenshospitalofil.org
Contact Phone: 309/624-9781
Illinois DocAssist — Answering Your Child and Adolescent Behavioral Health Questions
Statewide - IL
Description: Illinois DocAssist is designed to improve the delivery and coordination of mental health and substance use care in Illinois by supporting the work of Medicaid-enrolled primary care providers treating children and youth up to age 21. Given the well-documented shortage of child and adolescent psychiatrists in the United States, it is not surprising that about 75% of youth with psychiatric disorders are seen in primary care settings and about half of all pediatric office visits involve behavioral, psychosocial, and/or educational concerns. Primary care physicians need support as they diagnose and treat children and youth with mental health and substance use symptoms and illnesses.
Illinois DocAssist services include:
- Problem-based consultations to guide the mental health and substance use assessment of children and youth and provide evidence-based treatment options including medication management strategies.
- Education and technical assistance via office-based training workshops and web-based clinical resources. Education sessions include access to and training on the use of screening tools and diagnostic aids, stepped-care algorithms to guide clinical decisions including when to treat and when to refer, as well as determining ways to improve the integration of mental health and substance use assessment and treatment into the clinic routine.
- Referral services to identify local community referral options for youth that cannot be managed in a primary care setting.
Primary care providers including physicians, nurse practitioners, and other health professionals enrolled with the Illinois Department of Healthcare and Family Services (Illinois’ Medicaid agency) and involved in the care and treatment of children and adolescents up to the age of 21 may consult with an Illinois DocAssist child and adolescent psychiatrist Monday through Friday, 9am-5pm, at 1-866-986-ASST(2778). Consultation services and trainings may also be accessed through the DocAssist Web site at www.psych.uic.edu/docassist.
Illinois DocAssist Program, University of Illinois at Chicago, Institute for Juvenile Research, 1747 W. Roosevelt Road, Chicago, IL 60608 MC-747
Consultation Line Number:
Web Address: www.psych.uic.edu/docassist
Healthy Mental Development Health Provider Education Initiative
Statewide - IA
There are 4 modules (4 hours) for physicians, nurse practitioners, physician assistants, and nurses that include
- Healthy Mental Development of Young Children in Iowa
- Clinical Implementation of Surveillance for Development; Social, Emotional and Behavioral Health; and Family Risk Factors
- Clinical Implementation of Screening in 4 Domains: Development; Social, Emotional and Behavioral Development; PDD/Autism, and Parental Risk Factors
- Developing Community Partnerships for Referral and Systems Development
For department supervisors, nurse and/or office managers, coders and billing personnel there is one module (1 hour) that includes Office Implementation of the Guidelines.
Web Address: www.iowaepsdt.org
Prevention and Awareness of Teen Hardships and Suicide
Statewide - KY
The Prevention and Awareness of Teen Hardships and Suicide (P.A.T.H.S.) grant has been successfully completed. Kentucky Pediatric Society conducted 5 P.A.T.H.S. events in Northern Kentucky, Barren River, Purchase District, and Lake Cumberland. More than 150 child health providers attended the statewide trainings. Nearly 70% report, as a result of this training, that they will apply the knowledge gained in current work situations and share their handouts and other information with colleagues. In addition, more than 80% of participants rated the workshops and programs or presentations; the organizations include the Kentucky School Counselors Association, the Kentucky School Nurses Association, Jefferson County Public Schools, and representatives from the Kentucky Telehealth Network. In an effort to provide ongoing education to child health providers about the prevention of teen suicide in Kentucky, selected materials created for the P.A.T.H.S. program will be posted on the Kentucky Pediatric Society Web site
Web Address: www.kyaap.org/joomla/index.php?option=com_content&task=view&id=12&Itemid=33
Kennebec Pediatrics: From Infancy to Independence
Children with behavioral and/or learning problems have special needs that require additional help and support. Parents, teachers and care providers have to work through many challenges to help children with special needs achieve success. This program model enables families of children with disruptive behavior disorders to access services and care coordination through the primary care clinicians.
Kennebec Pediatrics Cares Program (KP Cares) provides outreach to families to help them consistently follow through on their treatment plans in school and home settings, reduce crises, and improve school performance and social functioning. KP Cares enhances continuity and quality of care for children with behavior disorders by
Web Address: www.mainegeneral.org/body.cfm?id=76
- Creating a primary care team to provide supportive services to the child's family and school
- Adding the family perspective directly to team deliberations
- Coordinating more effectively with the child's therapeutic behavioral health support
- Creating a database that contains key information on patients for the team's ongoing work with the child and family and for evaluation of the program
The D-TECKT (Developmental Troubleshooters Eclectic Checklist for Kids and Teens) is a template developed by the Maryland Chapter AAP Committee on Emotional Health. The D-TECKT is designed to assist pediatric clinicians in systematically considering what underlying conditions may be contributing to behavior problems in children and adolescents. The D-TECKT is a checklist that is divided into Intrinsic Factors (biomedical, normal development, temperament, and child psychopathology) and Extrinsic Factors
(situational, parenting difficulty, communication problems, family dynamics issues, and parental psychopathology). By referring to the checklist, the clinician can develop a differential diagnosis of what issues are contributing to the presenting behavior problem. The clinician can then develop primary care intervention strategies that directly address the underlying problems. The D-TECKT was published in the August 2005 issue of Contemporary Pediatrics. A working copy of the checklist also can be provided for evaluation. The D-TECKT has been presented at pediatric grand rounds at several medical centers in Baltimore, and has been integrated into the behavioral pediatrics rotation at University of Maryland.
Mental Health Training for Pediatric Residents
An experiential mental health curriculum is being developed for residents in the Johns Hopkins pediatric residency training program. Residents will work closely with several licensed mental health professionals in 2 settings: the Harriet Lane Clinic (an urban primary care resident continuity clinic) and a community child and adolescent mental health center. The 2-week experience will occur during the 4-week required community and advocacy rotation in the PL-3 year. The content and format of the 2-week experience is guided by a baseline Web-based needs assessment. The objectives for the experience fall within the 6 core competencies of residency training and include the following:
- To recognize and manage common mental health problems and emergencies in patients and families
- To recognize the impact of psychiatric dysfunction and psychosocial distress on youth and families
- To understand the complex system of care for children and families with mental health problems and become familiar with community-based resources
- To communicate effectively with mental health professionals to facilitate effective referral for the diagnosis and treatment of mental health problems in children and adolescents
The curriculum will include didactic, small group, and one-on-one teaching with participating faculty and staff in the Harriet Lane Clinic and the community mental health center.
Cambridge Health Alliance - Healthy Tomorrows
In 2004, the Cambridge Health Alliance (CHA) began the Healthy Tomorrows project in its pediatric clinics. This collaborative model of practice includes mental health screening using the Pediatric Symptom Checklist (PSC) and co-location of a clinical social worker (LICSW), supervised by a child psychiatrist. To date, more than 2,000 children have been screened and 180 previously unrecognized children have been identified as needing mental health support. Key elements for success include a collaborative management team that represents psychiatry and pediatrics, planning and monitoring the model, adequate reimbursement, and buy-in from practitioners. Funding from the Healthy Tomorrows Partnership for Children helped catalyze the project and provided start-up funding for the LICSW. The multifaceted evaluation examined impediments to progress, changes in the number of identified children, the relationship of PSC score to demographic variables, provider satisfaction, and costeffectiveness. Key findings include an 80% increase in identification and referral of children with mental health issues and a significant relationship between PSC score and insurance status. The project also has proven to be cost efficient, with the LICSW salary covered by revenue. The numerous benefits of this model include increased access, improved referral processes, and increased provider satisfaction. The model also increased awareness of mental health issues in pediatric practice, decreased stigma for families, and improved communication between pediatrics and psychiatry. We are spreading the model to a second site because it has proven highly sustainable. Additionally, we are incorporating the PSC into the electronic medical record, which will allow spread throughout CHAs 11 pediatric sites.
Web Address: www.challiance.org
The Massachusetts Child Psychiatry Access Project (MCPAP)
Statewide - MA
The Massachusetts Child Psychiatry Access Project (MCPAP) is aimed at assisting pediatric primary care clinicians to effectively respond to mental health concerns in primary care. Statewide, 6 mental health teams have been developed. Each team includes child psychiatrists, therapists, and a care coordinator, and is led by child psychiatry divisions of academic medical centers, including Baystate Medical Center, Massachusetts General Hospital, McLean Hospital, University of Massachusetts Medical Center, North Shore Medical Center, New England Medical Center, and the Childrens Hospital of Boston. The goal of each team is to have all the pediatric and family physician primary care clinicians in their area who see children or adolescents enrolled in the project. Once enrolled and oriented to the project, primary care clinicians may have access to a number of services for their patients, including telephone consultation, psychiatric/diagnostic evaluation, care coordination to assist in finding available mental health providers, brief psychotherapy, and local educational programming. Funding comes from the Department of Mental Health. The program is open to all children and adolescents regardless of insurance status. Design and administration is under the leadership of Dr. John H. Straus at the Massachusetts Behavioral Health Partnership which is the state Medicaid behavioral health managed care vendor. Child psychiatrists Barry Sarvet and Joe Gold are the program medical directors.
As of the end of August 2007, the MCPAP project has successfully formed teams in all 6 regions of the state, providing mental health support for 92% of the 1.5 million children and adolescents in the population. Satisfaction surveys of PCPs report that, because of MCPAP, they are now able to meet the psychiatric needs of children and adolescents in their practices.
Web Address: www.mcpap.orgPediatrics Article: Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project
CentraCare Integrative Behavioral HealthCare Initiative
St Cloud, MN
CentraCare Health System in partnership with BlueCross BlueShield of Minnesota and the Medica Health Foundation has launched an initiative that will integrate behavioral health services and primary care in all of the primary care clinics throughout the health system, including pediatrics, family medicine, obstetrics and gynecology, and internal medicine. The initiative calls for mental health screening at all well visits across the age span, incorporating the use of electronic tablets and Web-based electronic platforms for screening. Each clinic will have a licensed mental health professional to conduct crisis mental health assessments and provide patient education, case management, and consultation on-site. In addition, child and adolescent psychiatrists and adult psychiatrists will provide scheduled consultations to primary care clinicians, and weekly emergency psychiatric appointments will be available for patients who are seen by the primary care clinic-based mental health professional or who are currently being treated by the primary care clinician. Treatment and management protocols are being developed for depression, anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), eating disorders, and substance abuse, which will guide the primary care physician in the ongoing management of the condition, such as how often to follow up, what to do at the follow-up appointments, and how to appropriately monitor for safety and treatment effectiveness.
BlueCross BlueShield has agreed to pay for mental health screening, the clinic-based mental health crisis assessments, and physicianto-physician consultation. CentraCare and BlueCross BlueShield have committed to evaluating outcomes and cost over the next 3 years. Other health plans are being approached to support the integrative model as well. The state of Minnesota has passed legislation that calls for psychiatrists to primary care physician consultation to be reimbursed for Medicaid patients. Efforts are underway in the state to expand this reimbursement for all health plans as well.
The CentraCare Integrative Behavioral HealthCare Initiative is a model that has evolved from 3 specific efforts by St Cloud Hospital and CentraCare Clinics to improve access to children's mental health care and the quality of the mental health care received. These past efforts have included co-location of child and adolescent psychiatry and primary care pediatrics with ongoing open access for informal consultation; a school-based integrative care model and outreach effort that has involved a school-based mental health professional conducting crisis triage mental health assessments and referring high-acuity students to emergency child psychiatric appointments; and, finally, multiple community and professional education efforts to provide opportunities to increase awareness and practical clinical understanding of diagnosis, treatment, and management of common children's mental health problems. These initial efforts have shown that children attending school and receiving care in the areas with access to these services had a reduced utilization of high-cost inpatient adolescent psychiatric hospitalizations and, ultimately, had access to care much faster.
Web Address: www.centracare.com
Children's Hospital at Montefiore
Comprehensive Family Care Center
Family Care Center
At the Children's Hospital at Montefiore in the Bronx, we condut innovative Healthy Steps programs to address the mental health and well-being of families and young children. These programs include universal screening of all infants and toddlers regarding social emotional development, universal screening of all mothers of infants and toddlers regarding depression, and an intensive Healthy Steps program for select families, based on either risk status or being a first time parent. The programs are implemented at two continunity clinics in the Division of General Pediatrics at CHAM, which together provide care for more than 25,000 patients annually, with a combined staff of 60-65 residents and 20-25 attending physicians.
Programs are staffed by psychologists (trained in infant and toddler development and/or trained to work with adult caregivers of these children), a psychiatrist, and a social worker. Staff members conduct extensive trainings of medical students, residents, and attending physicians as part of weekly clinic conferences, month-long roations (Ambulatory Pediatrics for medical students and Development and Behavior for residents) and via case consultation. Trainings review infant and toddler development, partne-child relationships and infant brain development within a relationship context, postpartum depression, and attachment theory.
Families enrolled in the intensive Healthy Steps program receive co-managed well child visits, a weekly parent support group, a telephone information line, home visits as needed, extensive formal screening and assessment, coordination of referrals, and on-site (within the pediatric clinic) psychological and psychiatric care for adult caregivers or Healthy Steps infants and toddlers.
Extensive evaluation activities provide data to suggest the efficacy of these programs in terms of identifying early mental health and development warning signs in infants and toddlers, identifying and treating mental health symptoms in caregivers, and increasing knowledge regarding these topics in providers.
We are fortunate to receive funding from multiple sources, which allow us to continue this work. To date, we have received funding from The Altman Foundation, The Price Family Foundation, The Edith Glick Shoolman Children's Foundation, and the New York City Department of Health and Mental Hygiene.
Web Address: www.montekids.org/programs/healthy-steps
Contact Name: Rahill D. Briggs, PsyD
Contact Address: Comprehensive Family Care Center
Montefiore Medical Group
1621 Eastchester Rd
Bronx, NY 10461
Contact E-mail: email@example.com
Contact Phone: 718/405-8040, ext 2532
New York City Metropolitan Pediatric Clinics - Integrated Mental Health Primary Care Program
New York City, NY
Description: The Integrated Mental Health-Primary Care Program (IMP) is a unique collaboration between the Columbia University Departments of Pediatrics and Pediatric Psychiatry and the Ambulatory Care Network at Morgan Stanley Childrens Hospital of New York Presbyterian. Since 2002, psychiatrists and psychologists have practiced in 5 community-based general pediatric clinics in a Hispanic community in Northern Manhattan, working collaboratively with primary care clinicians. This novel treatment system offers psychiatric evaluation and short-term treatment services in the medical home setting. Seventy-two percent of IMP staff are Latino and Spanish speaking, with all staff trained in cultural sensitivity. Patients are seen on site, immediately, reducing parental anxiety, reducing the need for emergency department/crisis service/outside referrals, and simultaneously contributing to pediatrician education, based on patients the pediatrician has referred. Communication between mental health staff and pediatricians is immediate and brief, tailored to busy pediatric clinical schedules. Pediatricians have access to an electronic medical record to track psychiatric treatment. A 2004 survey of IMP-served primary care practices revealed that 86% of primary care physicians reported improved access to psychiatric services, with 88% reporting referring to IMP, and 91% reporting that the referral was helpful. Ninety percent of physicians said patients reported being satisfied or very satisfied with the IMP referral, and 95% of primary care clinicians reported being satisfied or very satisfied with the IMP program. A wide variety of diagnoses have been treated, with 40% of children having ADHD. The program is supported by Medicaid revenues to the hospital clinic and will be sustained.
Web Address: www.nyp.org/news/hospital/1099.html
Starlight Pediatrics, Monroe County Health Department
(dedicated to the health of children and adolescents in foster care)
Monroe County, NY
Description: Starlight Pediatrics is a primary care pediatric practice located at the health department, and serves as the medical home for children and teens in foster care. In addition to all routine and acute pediatric services, Starlight Pediatrics serves as the health care coordinator for this population. Customers include children and teens, their foster and birth parents, caseworkers, legal professionals, courts, and other health providers. Because the office is under county management, there are minimal communication barriers among health and casework staff. Systems to share information with casework, legal, and mental health professionals have matured over time. Through collaboration with several mental health agencies, Starlight Pediatrics is able to provide contextual evaluations in either the foster home and/or child care setting for children up to age 6 years, as well as intake mental health evaluations through a single mental health professional for older children and adolescents.
Starlight Pediatrics, in collaboration with the behavioral health program at the University of Rochester, is embarking on routine mental health screening of all children older than 7 years at admission to foster care. In addition, Starlight Pediatrics will re-screen children who remain in foster care every 6 months. The collaboration with the University of Rochester benefits patients of Starlight Pediatrics through timelier access to mental health services. The feasibility, acceptance, and impact of periodic mental health screening of this high-risk population in the medical home setting will be evaluated.
A developmental pediatrician from the local University performs some on-site developmental evaluations. Starlight also is involved as a clinical site for nurse practitioner and resident education.
Web-based Child Psychiatry Access Project
Description: The primary goal of the Web-base Child Psychiatry Access Project (Web-CPAP) was to improve children's mental health by making child and adolescent psychiatric services more assessible to primary care professionals throughout the 8 counties in the chapter's region. Initial steps to carry out the overall goal included the formation of the AAP NY3 Child Mental Health Collaborative (CMHC), comprised of 27 multidisciplinary professionals. A sub-committee of CMHC was formed to establish a core group of primary care clinicians and child psychiatrists committed to collaborating on the project. This group revised the Ronald Steingard encounter form, adapted the Steingard model for the Web, developed the other forms to be adapted for the Web, and worked closely with the Web developer to construct and revise the Web site. The domain name selected was www.nyaapcpap.org to reflect all three New York AAP chapters even though the pilot was being conducted in NY Chapter 3.
The program was designed to answer pediatricians' questions on a range of non-emergency mental health problems seen in the practice setting, with an emphasis on attention problems and anxiety/depression. For the pilot project, patient names were excluded from the site and strict security measures were enforced. In Web-CPAP, clinicians log into the system to add a child and post a question related to that child by completing an intake form. Upon submission of a question, an email notification was sent to all particpating psychiatrists. One of the psychiatrists responds and completes a clinical consulation form. Depending on the complexity of the question, the psychiatrist could request a phone discussion with the clinician. The psychiatrist is required to complete a clincial consultation form for each response posted for the clincian. When deemed appropriate, the psychiatrist would close the consultation. The clincian is notified via email to fill out a follow up form. Legal consultation with the NY Chapter 3 attorney led to the development of a disclaimer to protect all parties involved in the pilot program. Six practices participated in the pilot project, including a large teaching hospital, small private practices, and school-based health centers. The smallest practice had one clinician, while the largest had 76. Recruitment of differing sites was done intentionally to determine what practice setting would benefit most from this service. Among the five participating psychiatrists, a schedule was determined to ensure coverage throughout the work week. From Monday to Friday, a psychiatrist was available for 1.5 hours to respond to any questions posted on the Web site. It was emphasized that the site was not to be used for any emergent mental health issue. Results of this pilot and the next steps determined will be shared with the New York state health plans.
Aegis Winston East Pediatrics
Our model of colocated care was developed with the out-stationing of a mental health provider into an urban pediatric practice with a high volume of Medicaid-enrolled patients. The mental health professional was an employee of the local community mental health center and provided consultations, therapy, and case management to the practice. This structural arrangement allowed the pediatricians easy access to psychiatry consultations through the mental health agency. The mental health agency was responsible for all billing and record keeping. The model was implemented with funding from the Duke Endowment. The community mental health center reimbursed the grant with patient fee collections. Monthly reports with expenses and collectibles suggested that the model was self-sustaining. Benefits of the model included increased comfort by medical providers to address their patients mental health issues, convenience to the patient and family, immediacy of services, decreased stigma and increased comfort for patients seen for mental health services in their pediatricians office, increased follow-through by patients for recommended mental health services, and regular communication between the MH provider and primary care clinicians. Difficulties with the model included significant paperwork required by the mental health system to open a case on a child with Medicaid. Satisfaction with services was rated high by the pediatricians (5/5). Keys to success included buy-in by the medical providers and a committed practice manager.
This model has the potential to be replicated and sustained elsewhere by community mental health agencies, if the population served is insured and if reimbursements are sufficient to cover expenses. The model at Aegis Winston East Pediatrics was transitioned to a new configuration after state mental health reforms resulted in failure of the mental health agency; since January 2006, Wake Forest University Health Sciences (WFUHS), the regional academic medical center, has employed the co-located mental health professional. Paper work was simplified. Satisfaction of pediatricians remains high, and, as of February 2007, reimbursements are approaching a level consistent with sustainability. A WFUHS psychiatrist funded by a grant provides on-site consultation during a half-day session every other week and periodic lunch-and-learn sessions for the pediatricians.
Guilford Child Health, Inc.
Guilford Child Health, Inc (GCH), was established in 1997 to provide primary and specialty health care services for underserved children. Motivated by the goal of providing the highest quality, comprehensive, family-centered pediatric care available, all staff members at GCH believe in caring for the whole child. By providing health care services for a childs medical, social, and emotional needs, GCH works to ensure that each child is developmentally prepared at home, at school, and in the community.
Guilford Child Health serves as a pilot for Mental Integration in Primary Care. This pilot involves the use of a mental health collaborative team4 licensed clinical social workers, 2 developmental and behavioral pediatricians, 1 colocated child psychologist, 1 contracted child and adolescent psychiatrist, and primary care clinicians GCH provides child and adolescent psychotherapy. The psychiatrist sees referrals but also has case-review sessions with the primary care clinician regarding the care of the primary care clinicians patients. In addition, psychiatric evaluation and counseling is offered on site. Screening and treatment of maternal depression is also provided. Through a team approach, there is collaboration and treatment coordination for both primary and mental health care. The Developmental and Behavioral, Mental Health Team of providers meets weekly to review referrals and coordinate services.
Web Address: www.gchinc.com
Sustaining Psychosocial Screening in Everyday Practice Flow
The Healthy Development Collaborative used breakthrough series methodology to engage families and health care providers to improve developmental outcomes of children birth to age 5 through improved office systems in the following areas: (1) eliciting parents experiences communicating with their childs health care provider regarding family issues (eg, depression) and (2) identifying and referring children at risk of poor developmental outcomes through routine structured psychosocial screening.
At the end of the 12-month collaborative, the following key factors were identified as important to successful implementation: (1) a desire in the practice team to make real changes in the way health care is provided to children and families; (2) determining which issues the practice wishes to focus on, which screens best fit the practices needs, and identifying a screening schedule; and (3) collecting data that enable practices to measure the impact of changes and adjust efforts accordingly.
Supplemental funding supported measurement and learning session participation. However, practices completed all data collection without additional resources. An evaluation with a control group was completed; analysis is forthcoming. A lack of regular, systematic screening for family psychosocial problems was identified through chart audits and parent feedback at project start-up. Using the breakthrough series collaborative model, participating practices worked toward implementing and sustaining psychosocial screening in everyday practice flow. Preliminary findings show 60% of families received psychosocial screening. Participating practices indicated through exit interview plans to sustain changes past their participation in the collaborative. One practice indicated that the collaborative provided the motivation to implement psychosocial screening. A proposal has been submitted to replicate this model.
NC Chapter AAP/NC Pediatric Society
The North Carolina Chapter engages in a statewide initiative known as ICARE. This is an acronym for integrated, collaborative, accessible, responsive, evidence-baseda model that we are using to integrate mental health and primary care, which includes training events and resource networking among a variety of organizations. The Web site lists multiple training opportunities of which the North Carolina Chapter is a contributor and supporter. ICARE has grant support from private philanthropy and pharmaceutical companies and is housed in a private nonprofit foundation affiliated with state government.
In addition, the North Carolina Chapter is connected to the southeastern North Carolinas Southern Regional Area Health Education Centers Evidence-Based Practices Center, located at www.ncebpcenter.org. This site is dedicated to support evidence-based mental health practices, treatments, and interventions. The site includes information on the following modalities: assertive community treatment, supported employment, family psycho-education, wellness (illness) management and recovery, and integrated dual disorder treatment.
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Web Address: www.icarenc.org
Healthy Connections for Families - Family Care Center
Description: Since 1997, Healthy Connections has been providing mental health services to children through pediatric Services in St Vincent Mercy Family Care Center and the Medical University of Ohio. By using a collaborative approach, primary care clinicians receive training and resources to identify and refer children with behavioral health problems to the mental health professionals located within the same facility. Providing all of the services within the medical home facilitates access and utilization for the families. A case manager is available to support the family, reduce barriers to service, and facilitate communication among physicians, families, and behavioral health care providers. Families have a strong rapport with their primary care clinician and are open to behavioral health treatment connected to their primary health care, reducing the stigma of mental health. Healthy Connections has used grants to implement this model of integration, such as Mercy Childrens Hospital Foundation, Ohio Hospital Association Foundation for Healthy Communities, Healthy Tomorrows Partnership for Children, and Administration for Children & Families (ACF) Integrated Mental Health Services. Outcomes are measured through length of time from referral to first appointment, show rates, patient satisfaction, and the Ohio Outcomes System. Among the benefits of this model are a collaborative and cohesive approach to mental health care for families, an increase in access and use of mental health services, and higher satisfaction. Healthy Connections will continue to submit grants at the local, state, and federal level and obtain state certification to expand services to other pediatric services.
Beaufort Pediatrics, PA
Description: Beaufort Pediatrics is an 8-provider single-specialty practice located on the coast of South Carolina. The practice handles approximately 60% Medicaid patients, and sees large numbers of Caucasian, African American and Hispanic Patients. Because of a lack of mental health professionals in the community, the practice has hired its own mental health professional to provide on-site counseling. Providing mental health services within the pediatric office is well accepted by patients, many of whom would feel stigmatized going to a mental health center. This arrangement also facilitates consultation between the pediatric staff and the mental health professional, including the use of a joint medical record. Beaufort Pediatrics has rural health clinic status, which enables the practice to receive a more favorable reimbursement rate from Medicaid for those clients. The practice provides free office space and allows the mental health professional to keep 100% of his collections to make his practice financially feasible.
Over the past 15 years, Beaufort Pediatrics has developed a comprehensive screening program to identify those families most at risk for poor mental health and developmental outcomes early in the child's life. The practice now screens for maternal depression, family substance abuse, domestic violence, socioeconomic distress, community connectedness, and developmental status, using a variety of instruments. The practice uses a professional social worker to help refer those families identified as at risk on screening to home-based parenting support and other services within the community. Beaufort Pediatrics believes that, to be successful, satisfactory mental health services must include a preventive and screening component.
Caring for the Whole Child Program
Statewide - SD
Through its Caring for the Whole Child program, the South Dakota Chapter intends to make developing emotionally healthy children a top priority for the state. The Childrens Mental Health Awareness Initiative Advisory Group was established and the group along with input from the South Dakota Voices Coalition for Children, prepared the document, Childrens Mental Health Awareness, Multi-Year Plan for South Dakota. The document outlines the following 2 goals:
- Increase community understanding of strategies and resources to help develop emotionally healthy children.
- Increase community recognition of
- Efficacy of early detection, intervention, and treatment of mental illness.
- Emotional and developmental precursors of mental illness in children.
- Where to go for help.
In each goal, health care providers are considered 1 of the 4 target audiences. The chapter president plans to visit every pediatric practice in the state and include those interested family practitioners to inform them about the 2 goals. The intent is to survey them about their understanding of community strategies and resources available related to detection, intervention, and treatment of childrens mental health illnesses. The project includes education by providing 2 valuable AAP resourcesBright Futures in Practice, Mental Health Volume I and II and The Classification of Child and Adolescent Mental Diagnosis in Primary Care (DSM-PC Child and Adolescent version).
Web address: www.beaufortpediatrics.com
Hogg Foundation for Mental Health: Integrated Health Care Initiative Grant Program
Houston/El Paso, TX
: In April 2006, the Hogg Foundation for Mental Health, an administrative unit of The University of Texas at Austin, launched its Integrated Health Care Initiative grant program. The 5-grantee organizations will receive more than $2.6 million over 3 years to promote the effective identification and treatment of mental health problems in primary care settings.
The grantees treat mental health problems in different age groups. Three of the 5 organizations provide treatment for children. One focuses exclusively on ADHD, and the other 2 treat a variety of mild to moderate disorders.
The 5 organizations funded through this initiative adopt the collaborative care model and address the implementation barriers they encounter. Adapted from Wagners Chronic Care Model, collaborative care is an integrated health care approach in which primary care and mental health professionals partner to manage the treatment of persons with mental health problems in the primary care or pediatric setting. Two decades of research have demonstrated that the collaborative care model improves primary care patients mental health outcomes with a minimal investment of resources.
For more than 65 years, the Hogg Foundation has accomplished its mandate through grant making to mental health services, research, policy, and public education projects in the state of Texas.
Web Address: www.hogg.utexas.edu
Texas Adolescent Mental Health in Primary Care Initiative
San Antonio/Longview/El Paso/Gonzales, TX
The purpose of the Texas Adolescent Mental Health in Primary Care Initiative (TAMHPCI) is to improve the health of adolescents in the state of Texas by engaging private and public partnerships and creating sustainable system changes. This collaborative project involves 8 academic health centers, 6 professional organizations/associations, 2 patient advocacy organizations, and 3 state governmental agencies. This initiative is aligned with the goals of the President's New Freedom Commission on Mental Health, the Institute of Medicine, the Substance Abuse and Mental Health Service's Federal Action Agenda, and the fundamental transformation of the Nation's mental health system. The TAMHPCI implementation sites include the Brooke Army Medical Center (a pediatric military clinic), the Community Health Center of South Central Texas, Inc (a Federally Qualified Health Center [FQHC]), the Longview Wellness Center (a FQHC look-a-like), the Texas Tech University Health Sciences Center (TTUHSC) Fabens Clinic (a border school-based clinic), and the TTUHSC Family Practice Center (an academic family practice clinic). Unlike other projects that have examined either 1 or 2 disorders, the TAMHPCI includes a broad spectrum of psychosocial health, suicide ideation, depression, ADHD, and at-risk drinking, that present among adolescents in primary care settings, using a standardized protocol, while allowing for some variation across local delivery systems to achieve generalizability to real-world clinical settings.
Military Youth Coping With Separation: When Family Members Deploy
San Antonio, TX, and multiple military bases nationally and internationally
The teen support video, Youth Coping with Separation: When Family Members Deploy, has been finished and is being distributed. The Department of Defense has considered rapid deployment of the video through its online distribution channels. This would be an initial wave of release that hopefully will peak interest in the subject and provide a tangible resource to youth, families, and youth serving professionals as we continue to work on a more comprehensive distribution plan that will include the ability to make hard-copy packages of the DVD program (video, facilitator guide, interactive military youth stress management plan, and other resources) available through outlets such as Military One Source. The next phase of the teen support project will focus on development of an interactive multimedia form of the currently available military youth stress-management plan and an enhancement to the video that includes parent- and youth-serving professional video perspectives. The other exciting news is that the new Mr. Po and Friends is also nearing its final stages of development. The script has been modified and the story will now be animated rather than a puppet show for the elementary-age demographic. The new target for completion of the elementary product is May 2007. The possibility of using the teen and elementary video programs as a basis for the Youth component of the Battlemind Program being developed by the Army is being pursued. Battlemind is a psycho-educational program that helps soldiers and their families anticipate, understand, healthfully cope with, and find resources to address the stresses that are associated with the various stages of deployment.
Web Address: www.aap.org/sections/unifserv/deployment/
University Health Care Neurobehavior Healthy Outcomes Medical Excellence Program
Salt Lake City, UT
The Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program is a University of Utah-based, colocated specialty clinic. It began in July 2000 as part of the Medicaid Redesign Project with the Utah State Department of Health, sponsored by the Robert Wood Johnson Foundation Center for Health Care Strategies. The program receives the blended Medicaid medical and mental health funding streams to provide comprehensive health care to individuals with developmental disabilities. The interdisciplinary focus of this program is to provide care in an integrated, collaborative, cost-effective manner to a generally underserved population who often receive fragmented specialty care. Our clinicians have training and experience in working with the complex medical and mental health concerns often presented by patients with traumatic brain injury, epilepsy, genetic syndromes, birth trauma, autism spectrum disorders, and mental retardation.
Services are provided by 2 triple-board physicians (in Pediatrics, Adult Psychiatry, and Child and Adolescent Psychiatry), a Child and Adolescent psychiatrist, a family practice physician, 2 advance practice nurses, 4 clinical social workers, 2 clinic case managers, 4 state-employed case managers, a behavior specialist, a billing/coding specialist, 2 medical assistants, and administrative support staff. Services include the following:
Web Address: www.healthcare.utah.edu
- Primary and preventive medical care
- Psychiatric care
- Coordination of care with university-affiliated specialty care, such as neurology, genetics, physical medicine and rehabilitation, orthopedics, and pulmonology
- Case management and triage of crises
- Individual and family psychotherapy and group psychotherapy
- Functional behavior analysis and supports
- Autism Diagnostic Testing
- Dietitian/Nutritional counseling
- School accommodations advocacy
- Home visits to assess habilitative needs
- Electronic medical records
- Coordination of insurance benefits
- State disability services advocacy
- Community outreach
- Education and training for residents in psychiatry, family practice, dentistry, social work, and psychology, and nurse practitioner and physician assistant students
Hagan and Rinehart Pediatricians, PLLC
Our small primary care practice of 2 pediatricians, 2 pediatric nurse practitioners, and an excellent support staff employs 2 innovations to enhance our behavioral health care:
Upper Valley Pediatrics
- Case management services for children and youth with special health care needs
- Medical home model of care coordination with care plans, family-centered team collaboratives, and an extensive community resource network
- Collaborative practice with clinical psychologists
- Clinical psychologist and post-doctoral fellow are on site part-time to see patients on referral, collaborate with pediatric staff on shared cases, and provide behavioral telephone callback for families
What began as a Community Access To Child Health grant to a solo pediatrician in 1994 has resulted in a practice with 1 pediatrician, 5 part-time nurse practitioners, and 7 full- and part-time mental health therapists and social workers. The nurse practitioners help with the "nuts and bolts" pediatrics (ie, well child checks and acute episodic illnesses). This allows the pediatrician time to concentrate on children with the behavioral, emotional, and learning problems. The licensed clinical social workers and mental health counselors help to deliver direct psychotherapeutic services to patients at the practice site. These personnel are able to be credentialed by third-party insurers, and the practice has been able to obtain reimbursement such that the practice has actually profited financially. Upper Valley Pediatrics is a practice much better able to respond to patients' "new morbidities," and the extensive use of mental health professionals has allowed us to be financially successful as well. We feel that our collaborative, co-location model is superior because of the following:
Web Address: www.nlmed.com/valleypeds
- Collaboration between physician and therapist, especially in managing children on psychotropic medication.
- Better continuity and quality of psychotherapy than at Community Mental Health Center, where the therapists are generally entry-level employees who leave as soon as they gain credentials and experience
- Less stigma receiving mental health services at pediatric office
- Lower costs to state Medicaid, as we are reimbursed at a lower rate than services delivered at Community Mental Health Center
High Point Medical Center, Puget Sound Neighborhood Health Centers
Behavioral health integration was achieved by hiring a behavioral health specialist (BHS) and training primary care physicians, nurses, and other appropriate staff in a community health center to provide integrated care. Training included scope of BHS practice, referral sources, assessment, engagement, negotiation of collaborative care, and triage. This model led to an 80% adherence to the treatment plan. Key factors to success include champions on the clinical team, a childrens integrated preventive model in place, limited wait time for a behavioral health appointment, the convenience and cohesion of on-site care that minimizes obstacles to change and provides a less-fragmented experience for patients, and collaboration between professionals that provides better patient support and facilitates a consistent message from all providers. This allows patients to focus on step-by-step problem solving and achieve small changes on a regular basis, which leads to the maintenance of change over time. Benefits include substantial increases in the goals of assessment of mental health problems and promotion of healthy mental development for children and families at the clinic. An on-site BHS creates an additional resource on the provider team for mental health concerns. Providers are better able to focus on nonmental health medical and dental concerns. The BHS builds immediate relationships with patients so they are not necessarily required to go outside the clinic to address mental health issues. This increases the likelihood that patients will follow through with attending therapy meetings. The clinic is already sustaining the model and the Kids Get Care program has plans to replicate it.
Web Address: www.metrokc.gov/health/kchap
Washington Partnership Access Line
Statewide - WA
The Washington Partnership Access Line is a consultation and education service designed to help primary care providers throughout Washington State to deliver more rapid, accessible and evidence based mental health treatments. Primary care providers using the service call a toll free number whenever they have a mental or behavioral health question about any child they see, giving them rapid access to one of 6 academic center affiliated child psychiatrists. The team provides curbside consultations, tools for improving care delivery (like parent handouts, algorithms, and rating scales), referral assistance from PAL team social workers, and community education outreach through 4 community training events per year. Since service delivery started in April 2008, the program has provided thousands of case consultations, and has provided local, free mental health CME to over 500 of Washington’s primary care providers. When a curbside consultation cannot fully address a primary care provider’s questions, the program further offers rapid access to full appointment consultations (either in person at one of two locations, or using telemedicine for a patient assessment in less populated areas) for children with Medicaid coverage.
The program is funded by Washington Medicaid (DSHS) and the Washington State Legislature. Dr. Robert Hilt is the medical director, and Jim Myers is the program’s business director.
Web Address: www.palforkids.org
Click here to view poster.
Office Management of Pediatric Mental Health: Promoting Resiliency in Trying Times
This comprehensive, 1.5-day CME course, sponsored by the AAP Wisconsin Chapter, an array of experts who gave didactic presentations as well as a case study workshop, all applying directly to pediatric primary care practices. Topics covered:
Web Address: www.wisaap.org/WIAAPAnnualMeeting.htm
- Learning DisabilitiesPractical Aspects of Screening and Helping Families With LD Children
- Depression: Overview of Trends, Diagnosis, and Treatment Options
- Practical Management of Outpatients With Eating Disorders
- Brief Office-based Interventions for Behavioral Problems and Conflict
- Maximizing Reimbursement for Provision of Mental Health Care
- Assessment and Treatment Planning on Aggressive, Bipolar, Oppositional, and Conduct Disorders
- Use of Screening Tools for Behavioral and Mental Health Disorders
- Case Studies Panel
- Autism: WI Prevalence Data and Current Thoughts on Medication Management
- Balancing a Professional Career: Minimizing Burnout for Ourselves and Our Staff
Wyoming Partnership Access Line
Statewide - WY
The Wyoming Partnership Access Line is a new consultation and education service, started in late 2010, designed to help primary care providers throughout Wyoming to deliver more rapid, accessible and evidence based mental health treatments. This program is modeled after a similar program in Washington, and through use of technology is using the same clinical team. Primary care providers using the service call a toll free number whenever they have a mental or behavioral health question about any child they see, giving them rapid access to one of 6 academic center affiliated child psychiatrists. The team provides curbside consultations, tools for improving care delivery (like parent handouts, algorithms, and rating scales), referral assistance from PAL team social workers, and community education outreach through 4 community training events per year. Because there are occasions when a curbside consultation cannot fully address a primary care provider’s questions, the program will be recruiting telemedicine sites where they can offer rapid access to full appointment consultations for children with Medicaid coverage.
The program is funded by the Wyoming Department of Health. Dr Robert Hilt is the medical director, and Jim Myers is the program’s business director.
Web Address: www.wyomingpal.org
Federal Program to Promote Models of Integrated Health Care
New York, Montana, Tennessee, Massachusetts, and Ohio
On the basis of its recognition of the importance of mental health to childrens overall health and well-being, the limited access that young people have to mental health services relative to primary care services, and its documentation of the paucity of models that address these issues, the Maternal and Child Health Bureau has supported the 2-phase initiative, Integrated Health and Behavioral Health Care for Children, Adolescents, and Their Families, since 2000. It has competitively awarded 23 two-year planning grants across 3 cohorts and, thus far, 6 three-year implementation grants to health care organizations to develop community-responsive model systems of care that integrate physical and mental health care and substance abuse services. Models are required to address such dimensions as governance, multidisciplinary staff configuration and interactions, financing, legal and regulatory issues, managed care environment, education and training, information systems, medical records and community involvement, and sustainability.
The 6 implementation sites are in New York (2 sites), Montana, Tennessee, Massachusetts, and Ohio, and include an urban ambulatory care center; 11 family medicine practices affiliated with a not-for-profit county-wide health care system; and a health care system that provides services in a family practice, a pediatric practice, and a community health center. Each site serves patients with a mix of private and public health insurance and screens patients using standardized forms that were developed for use in primary care settings. In general, behavioral health clinicians meet identified families in the primary care site and perform further assessment. A national evaluation has been conducted, showing promising results.