TRANSLATIONS

Integrating Mental Health Care Into PediatricPrimary Care Settings

Penelope K. Knapp, M.D., AND Jane Meschan Foy, M.D.

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SCOPE OF THE PROBLEM

E pidemiologic data from the U.S. Depart-ment of Health and Human Services haveestimated that 10% to 20% of children meet

the diagnostic criteria for a mental disorder.1

However, 40% to 80% do not receive mentalhealth services, reflecting the fact that many arenot identified and many do not have access toneeded care. A national shortage of child psychi-atrists, exacerbated by geographic maldistribu-tion, is part of this problem.

Early identification of children with treatablepsychiatric disorders may decrease long-termadverse consequences. Pediatric primary careproviders are well positioned to detect childrenat risk for mental health problems, initiate pre-ventive interventions, and provide early treat-ment. Integrating mental health care into pediat-ric primary care settings would involve childpsychiatrists and other mental health profes-sionals in prevention and expand opportunitiesfor treatment. To do this will require practicechanges, policy changes, and training—in somecases retraining— of clinicians.

AMERICAN ACADEMY OFPEDIATRICS INITIATIVESThe American Academy of Pediatrics (AAP) rec-ognizes the primary care advantage in prevent-ing, identifying, and addressing mental healthproblems and advocates prevention-focused in-tervention for emotional and behavioral disor-ders in the pediatric medical home. To enhancepediatricians’ readiness and capacity to addresschildren’s mental health issues in their practice,the AAP Task Force on Mental Health devel-oped clinical algorithms2 and resources3 toassist in identifying and addressing commonbehavioral and social-emotional problems, and

the task force developed a Mental Health Practice

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eadiness Inventory and assembled informationo guide pediatricians in specific aspects of careuch as confidentiality, family-centered care,edication management and screening, and as-

essment instruments. Resources for decisionupport include guidance for the primary careanagement of seven common symptom clus-

ers seen in children 0 to 5 years old withocial-emotional problems, children with learn-ng difficulties, and children with symptoms ofnxiety, depression, inattention and impulsivity,isruptive behavior and aggression, and adoles-ents with substance use and abuse. For eachluster, the toolkit describes screening resultshat suggest a problem, symptoms and clinicalndings associated with the symptoms, theange of conditions that may present withhe symptoms, tools for further assessment,vidence-based and -informed interventions,lans of care, resources for clinicians, andeferences. These materials will foster earlyetection, use of a common language for men-

al health interventions, and smoother proce-ures for referring to or sharing care withental health providers and assisting with

illing for mental health screening and inter-entions. These products may improve thelignment of children’s clinical needs for mentalealth care with provider type and lead to theevelopment of an integrated system that wouldupport the child and family across primary carend specialty mental health domains.

TRAINING ISSUES: DIVERGENCEOF PEDIATRIC PRIMARY CAREAND CHILD PSYCHIATRYThe Accreditation Council of Graduate MedicalEducation Pediatric Milestones Project4 has notedthat in the United States, medical education em-

phasizes the diagnosis and treatment of disease

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TRANSLATIONS

over preventive care and thus poorly preparesphysicians to practice preventive medicine. Itcalls for providing opportunities during trainingto develop these skills, setting a standard for thephysician to be able to interview patients andfamilies about their medical condition with spe-cific attention to psychosocial, behavioral, familyunit, and environmental correlates of the disease,and to be able to adjust treatment plans topatients’ goals with a consideration of patients’mental health status. Nonetheless, in general,pediatric training provides limited experience inscreening or intervening for mental disorders. Incontrast, child psychiatry training emphasizesthe treatment of children with established psy-chiatric diagnoses and typically offers limitedexperience with children at risk for mental disor-ders or children whose symptoms do not reachthe threshold for diagnosis. Current reimburse-ment perpetuates this divergence.

Moreover, in tertiary settings, where trainingoften occurs, the practicalities of funding caremitigate against providing the time and oppor-tunity for pediatricians to learn mental healthtreatment and for child psychiatrists to practiceprevention. Current mechanisms of funding pe-diatric and child psychiatry Graduate MedicalEducation for institutions with predominantlypediatric populations (and thus fewer Medicareprimary beneficiaries) require that they dependon non-Medicare funding sources, which fluctu-ate with annual local, state, or federal appropri-ations processes. Thus, the challenge is to changethe financial incentives to support the develop-ment of a workforce for integrated care.

FEDERAL REGULATIONSThe Affordable Care Act (Public Law 111-148)requires mental and behavioral health coveragein an essential benefit package at parity withmedical benefits. This could incentivize the inte-gration of care.

Increasing attention has been directed tomeasuring the quality of pediatric care, andchild mental health is an area ripe for improve-ment in quality measurements. Core measure-ments developed by several organizations, in-cluding those recommended by the Children’sHealth Insurance Program ReauthorizationAct, would cover behavioral health services:preventive screening for potential delays insocial and emotional development and follow-

up care.5 i

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Existing models of mental health care forchildren span a range from integrated to siloedcare. Some pediatric practices have a mentalhealth professional on the primary care team;others have effective processes for collaborationwith community-based providers; still othersfunction in parallel with the mental health sys-tem. Co-located, integrated services are held tobe ideal.2 However, many insurance plans do notllow billing for multiple services by differentractitioners within the same provider organiza-

ion on the same day; some do not pay primaryare providers for providing mental health ser-ices. Health maintenance organizations mayrovide care in house or to carved-out contrac-

ors. Telemedicine may be used to provide men-al health services where distance or other accessarriers exist. New models of collaborative careequire the evaluation of cost versus benefit andf clinical outcomes.

CHALLENGES AND STRATEGIESFOR CHILD PSYCHIATRISTSAND PEDIATRICIANS6

If the clinical needs of children and their familiesare to be met by integrated care, continuedcollaboration across medical specialties must oc-cur to advocate for policy changes. Professionalorganizations must transcend guild-specific con-cerns and collaborate to increase the political willto reallocate and invest public dollars for childhealth care that will increase prevention, reim-burse for early detection, and adequately fundtreatment of child mental health problems.

Challenge 1Current financing structures reward treating es-tablished diagnoses, not providing preventiveservices, because payment for visits, with fewexceptions, requires a DSM-IV diagnosis. If the

iagnostic Classification of Mental Health andevelopmental Disorders of Infancy and Earlyhildhood (DC:0-3) diagnostic scheme is used,hich provides richer detail for understanding

merging disorders in children younger than 5ears and which allows the recognition of rela-ionship disorders, it must be cross-walked to aSM-IV diagnosis for payment.trategy. Inclusion of prevention-focused inter-entions in the essential benefits package will

ncentivize states to make use of legislative and

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KNAPP AND FOY

regulatory mechanisms to require public andprivate insurance payments for preventive fo-cused interventions. Improved use of screeningwill aid an earlier recognition of emerging psy-chopathology.

Challenge 2Billing codes identifying the child as the patientmake family-focused intervention difficult to re-imburse. Research on the treatment of child men-tal health conditions has strongly indicated thebenefit of treating the child and the caregiver as“the patient,” but public and private plans fre-quently do not pay for family-focused treatment.Although some billing codes exist for collateralservices, the need to identify the child as thepatient makes family-focused interventions diffi-cult to support financially; likewise, payment forcaregiver-only or collateral sessions is lacking.Strategy. At the practice level, this makes familyengagement tactically essential; at the systemslevel, strong advocacy is needed to modify bill-ing codes.

Challenge 3Underuse of Evidence-Based Practices. The limiteddissemination and implementation of evidence-based practices (EBPs) is partly due to inadequatepayment for core elements of most EBPs, specifi-cally the inclusion of the family in the service andthe completion of an adequate number of sessions.Also, training is required for competence in usingEBPs and support is required to maintain fidelity toprotocol; becuase this is not classified as direct care,separate funding is required.Strategy. Influence legislative and regulatory mech-

anisms to require public and private payers to pay for

4. Benson B, Burke A, Carraccio C, et al. The Pediatrics MilestoneProject. The Accreditation Council for Graduate Medical Educa-

5

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evidence-based treatments, embed training inEBPs into licensing requirements, or require cer-tification in specific EBPs as a condition forpayment. Health reform legislation establishesa federal grant program to fund delivery ofEBPs.

Challenge 4Consultation between providers (care plan over-sight meetings) may not be billable because it isnot regarded as a direct service.Strategy. Increase the use of the telephone andtelemedicine, which is reimbursed by Medic-aid. Note that telehealth services for behavioralhealth problems are to be tested by the newlycreated center for Medicare and MedicaidInnovation.

Challenge 5Child psychiatrists and pediatricians should betrained in competencies that support collaboration.Strategy. Co-preceptors (child psychiatrist andpediatrician) in residents’ training clinics or, ide-ally, merging child psychiatry and pediatric out-patient training, can provide real-time clinicallybased training in team care. &

Accepted July 23, 2012.

Dr. Knapp is with the University of California–Davis. Dr. Foy is withWake Forest University School of Medicine.

Disclosure: Drs. Knapp and Foy report no biomedical financialinterests or potential conflicts of interest.

Correspondence to Penelope K. Knapp, M.D., University ofCalifornia, 22657 Sylvan Way, Monte Rio, CA 95462; e-mail:pkknapp@ucdavis.edu

0890-8567/$36.00/©2012 American Academy of Child andAdolescent Psychiatry

http://dx.doi.org/10.1016/j.jaac.2012.07.009

REFERENCES1. Cooper JL, Aratani Y, Knitzer J, et al. Unclaimed children revisited:

the status of children’s mental health policy in the United States.National Center for Children in Poverty; 2008. www.nccp.org/publications/pub_853. Accessed March 1, 2012.

2. Foy JM. The American Academy of Pediatrics Task for on MentalHealth. Enhancing pediatric mental health care: algorithms forprimary care. Pediatrics. 2010;135:S109-S125.

3. Addressing mental health care in primary care: a clinician’s toolkit.American Academy of Pediatrics (AAP) Task Force on Mental Health.www.aap.org/pcorss/demos/mht.html. Accessed March 1, 2012.

tion and the American Board of Pediatrics. www.acgme.org/acWebsite/RRC_320/320_PedsMilestonesProject.pdf. AccessedMarch 12, 2012.

. Findings on children’s health care quality and disparities: factsheet. Agency for Healthcare Research and Quality. www.ahrq.gov/qual/nhqrdr09/nhqhdrchildo9.pdf. Accessed April 18,2012.

. Kavanagh JE, Brooks E, Dogherty S, et al. Meeting the mentalhealth needs of children. Evidence to Action No. 2. PolicyLab:Center to Bridge Research and Practice; 2010. http://policylab.

us/images/pdf/e2a2-mental%20health.pdf. Accessed April 18,2012.

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