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Learning Objectives
By the end of this presentation and discussion you will be able to: • Describe the changing epidemiology of behavioral
health needs in pediatrics • Identify alignment and variation between adult and
pediatric models of integrated behavioral health • Describe a public health model of integration and how
we applied this model within our practice • Identify opportunities and barriers for implementing
behavioral health integration within a pediatric population
10% to 11% of
children and adolescents
have both a mental health disorder and
evidence of functional impairment
US Department of Health and Human Services, “Mental Health: A Report of the Surgeon General”, 2000
The New Morbidity
Half of all lifetime
prevalence of mental health disorders in
adults present before the age of 14
US Department of Health and Human Services, “Mental Health: A Report of the Surgeon General”, 2000
The New Morbidity
Specialty mental health care for children falls far short of need, particularly among children in rural areas and lower SES
Thomas CR, Holzer CE III. The continuing shortage of child and adolescent psychiatrists. J Am Acad Child Adolesc Psychiatry. 2006;45(9): 1023–1031.
The New Morbidity
HRSA, “The Mental and Emotional Well-Being of Children: A Portrait of States and the Nation”, 2007
The New Morbidity
Oregon Healthy Teens, 2017
8.7% of 8th graders and 6.8% of 11th graders
report 1 or more attempts in the past 12 months
Where Are They Being Seen?
Luoma JB et al. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159:909-916.
Room For Improved Screening
Do pediatricians ask about adverse childhood experiences in pediatric
primary care?
Kerker et al. Acad Pediatr. 2016 Mar; 16(2): 154–160.
Room For Improved Screening
Do pediatricians ask about adverse childhood experiences in pediatric
primary care?
Kerker et al. Acad Pediatr. 2016 Mar; 16(2): 154–160.
A Call To Action
2009: “Establish a practice environment that normalizes integration of mental health and incorporates medical home principles for the care of children with mental health concerns as for children and youth with other special health care need”
- The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care
A Brief History
• BH was integrated in 2011
• Started with 1 pediatric psychologist at 1 site
• Over the next 5 years, BH team gradually expanded to include 1 pediatric psychologist and 1 pediatric clinical social worker at all 4 sites
• The BH team also includes care managers and patient service coordinators
Continuum of Behavioral Health for Primary Care
Referral based
Consultative Co-located Integrated
Established partnerships with
community BH clinics and providers
BH on-site but referral
based– fee for service
BH integrated in care
team across levels of
care
To learn more about six levels of collaboration/integration, visit SAMHSA
Center for Integrated Health Systems.
Improved
collaboration
Tier III
Tier II:
Tier I:
All Patients
PCPs administer screening + provide patient education
Pediatric Primary Care Without Integrated Behavioral Health
BH support provided by PCPs,
primarily in Well Child Visits,
Screenings, and Patient
Education
Patients with At-Risk or Clinical
concerns are referred out
PCPs may provide medical
interventions for some BH
concerns
The Co-Located Model
Tier III:
Pediatric Psychologists provide
intensive interventions to patients
with diagnosed behavioral problems
& mental illness
based on referral
Tier II
Tier I
Assumes pathology
Inefficient use of
resources
Does not “capitalize”
on opportunity for
prevention/promotion
What if kids can improve with less intensive intervention? Many can. And we often have access to them when problems first arise.
Current definition of “Integrated” Behavioral Health
BH providers practice
alongside PCPs
BH providers have
no/limited scheduled
appts so available for
brief (usually 30 min.),
same day visits
Helps to address
barriers to BH
contact—get face time
with BH provider +
reduce stigma Tier III
Tier II:
SOME
Identified as at-risk in screening
Tier I
Emphasis on
penetration or quantity–
how many patients can
we “touch”?
Underlying assumption: all patients require/benefit from brief same day consultation Proactive Psychoeducation
Tier II heavy model
Current definition of “Integrated” Behavioral Health
We lose patients/
motivation from Tier II to
referral
Without follow up (for
some), how are we
enhancing care from the
screen-refer model?
BH care can feel
disjointed
With no Tier III (planned follow
up), families face waitlists &
gaps in service for most in
need
Care
planning?
Why aren’t we
shaping what is
happening
here?
Tier III
Tier II:
SOME
Identified as at-risk in screening
Tier I
With this emphasis on
penetration, are we
valuing quantity over
quality?
Current definition of “Integrated” Behavioral Health
13 y/o with depression + ED
who is cutting– waitlists for
DBT
Waitlists, waitlists,
waitlists
Patients with
distrust of BH +
motivated PCP
4 year old with medical trauma
due to brain cancer
Patient with cystic
fibrosis & medical
phobia needs
injections/draws
Tier III
Tier II:
SOME
Identified as at-risk in screening
Tier I
14 y/o with depression
and suicidal ideation
with open DHS case
Functional Abdominal
Pain
Child or Youth
Family
Educational Services
Social Service Agencies
(DHS)
Outside providers (medical,
behavioral health
Challenges In Implementation of Tier II Heavy Model
We treat systems,
not just kids:
• Assessment
We treat systems,
not just kids:
• Assessment
• Intervention
Child
Family
Other agencies: School,
mental health, DHS
Just as child behavioral
health problems are created
in systems, they require
system involvement to heal…
Challenges In Implementation of Tier II Heavy Model
1. Not sensitive to unique aspects of practice in a pediatric setting
• We treat systems, not just kids: parents, family, school, DHS, foster care, juvenile justice
• Assessment and intervention require systems
• Building rapport often takes time
2. Misses opportunity for impact (true population reach) at Tier I
• Patient education
• Program development
• PCP education and consultation
3. Assumes all patients have Tier II needs, and that this level of service can meet their need
• Some needs can be adequately addressed at Tier I
• To be effective, some require more (Tier III) in time-limited fashion
Challenges In Implementation of Tier II Heavy Model
If I see a Tier III patient at Tier II, I am ineffective.
If I see a Tier I patient at Tier II, I am not efficient with my resources.
That being said:
We don’t have ALL the resources, and we acknowledge that we can’t do EVERYTHING. (There is still an appropriate time to refer out)
Here is what we think we can do well.
Redefining Integrated BH in Pediatric Primary Care
• We hope to create a model that:
– Is sensitive to the unique aspects of delivering BH in a pediatric setting
– Emphasizes population reach and matching level of resource to level of need
– Maximizes resources and opportunity for prevention and promotion in this setting
Tier III:
FEW
Brief, EBP intervention Care coordination
Tier II: SOME
Identified as At-Risk in Screening
Assessment/triage
Same day/week consultation
Tier I: ALL
Prevention + Promotion programming
Universal Screening
A Public Health Model in Pediatrics
Tier III: Few
Tier II: Some
At-Risk
Tier I: All
Prevention + Promotion
Medical
• Type I Diabetes, Cancer,
Cystic Fibrosis
• Asthma Action Plan
• Obesity intervention for at-risk
• ADHD med management
• Immunizations
• Developmental
Screening
• Well Child
• BH Education & Promotion
Programming (Resilience)
• PCP education
• Care planning
• Universal Screening
• Address at-risk for common BH
concerns (anxiety, depression,
behavior, ADHD)
• Same day consultation
• Assessment/triage
• Referrals
• Brief, solution focused
interventions (2-12 sessions)
• Care Coordination for high-risk
• In-house treatment for few
(medically complex patients)
Behavioral
A Public Health Model in Pediatrics
Tier III:
Few
Brief, EBP intervention
Care coordination
Tier II:
Some
Identified as At-Risk in Screening
Assessment/triage
Same day/week consultation
Tier I:
All
Prevention + Promotion programming
Universal Screening
Who We Are and What We Do Across Tiers
LCSW
• PCP education + Care team
• Program
Development
• Community/
referral
partnerships
• PCP education + Care team
• Program
Development
• Education– behavioral health
blog
• Parent workshops
Pediatric Psychologist
Tier III:
Few
Brief, EBP intervention
Care coordination
Tier II:
Some
Identified as At-Risk in Screening
Assessment/triage
Same day/week consultation
Tier I:
All
Prevention + Promotion programming
Universal Screening
LCSW
• Brief, same-day consultation
• Assessment + triage
• Connect patient to resources
• High-risk families
• Brief, same-day consultation
• Assessment + triage
• ADHD assessment
Pediatric Psychologist
Who We Are and What We Do Across Tiers
Tier III:
Few
Brief, EBP intervention
Care coordination
Tier II:
Some
Identified as At-Risk in Screening
Assessment/triage
Same day/week consultation
Tier I:
All
Prevention + Promotion programming
Universal Screening
LCSW
• Care Coordination
• School
• Therapist
• DHS
• Brief, solution-focused
interventions
• Medical needs
• Medical trauma/phobia
• Functional Abdominal Pain
• Parent Child Interaction Therapy
Pediatric Psychologist
Who We Are and What We Do Across Tiers
Tier III:
Few
Brief, EBP intervention
Care coordination
Tier II:
Some
Identified as At-Risk in Screening
Assessment/triage
Same day/week consultation
Tier I:
All
Prevention + Promotion programming
Universal Screening
Decision point
Decision point
Who We Are and What We Do Across Tiers
Patient Services
Coordinator
Care manager
Medical
Assistants
Advice Nurse
Benefits Of This Model
• Prevention and promotion focused
• Incorporates data-based decision making
• Tiers patients to ensure intensity of intervention and resources match identified need
• Maximizes resources
• More consistent with base rates of mental illness
• Meets unique needs of pediatric populations
• Screening
– PHQ-2 (11-19) at all visits
– PHQ-9 (11-19) at all well child visits
• Promotion
– Resiliency curriculum
• PCP education and consultation
– Care Team meetings, pre-visit planning
• Patient Education
– BH Blog, handouts
Tier I: All
Prevention + Promotion programming
Universal Screening
Tier I For Depression
Tier II for Depression
• Assessment/Triage
– Moods & Feelings Questionnaire
– Risk/Suicide Assessment, Safety Planning
• Brief, same-day consultation (Evidence-Based Practice EBP)
– Psychoeducation on Depression/CBT for depression
– Behavioral Activation (BASEs)
• Possible referral to community provider
Tier II: SOME
Identified as At-Risk in Screening
• Brief, solution-focused intervention (~3 sessions) (EBP)
– Psychoeducation on depression/CBT for depression
– Behavioral Activation
– Cognitive Restructuring
• Ongoing assessment/progress monitoring
– Match patient to community therapist (if indicated)
– Refer patient back to PCP for medication management (if indicated)
• Bridging the gap for high-risk patients who aren’t connected to resources, yet
• Care coordination
Tier III: Few
Intensive, Specialty
Care coordination
Tier III For Depression
Challenges and Opportunities
• Financial sustainability
– Payment models often not aligned to care models
– Carve-outs introduce barriers around credentialing, claims, co-pays
– Tension between open access and reimbursed visits
– Balance between PMPM and visit-based reimbursement
Challenges and Opportunities
• “What gets measured, gets managed”
• Unanticipated patient/family demand
Challenges and Opportunities
• Next steps for us:
– Continue to develop tier I assessment and intervention: universal ACEs screening
– Standardization of workflows
– Building on workforce strengths and differences across clinic sites
– Development of brief solution focused treatment protocols that center on “active components” of EBPs
Take Aways
• Children are a unique population with unique needs
• Mental health needs of many children are under-identified and go unmet
• A tiered, population-based model has the largest reach and impact
• Increasing well-defined tier III interventions in primary care settings increases timely access to care
• Funding models should meet the needs of the population and be tied to meaningful measurement