Around the country, there is a growing need for pediatric mental health problems to be treated in primary care settings (DeMaso et al., 2010). Ask any pediatrician or family doctor nationwide — there simply aren’t enough mental health providers. In Rhode Island alone, according to 2011 Department of Health data, about 25% of teens report feeling depressed, and about 9% have attempted suicide (Rhode Island Department of Health, 2012). Despite the need in Rhode Island and nationwide, mental and physical health have historically not only been treated separately, but also insured and reimbursed separately, creating barriers that keep mental health from integrating into the rest of medicine (DeMaso et al., 2010). However, this landscape is slowly changing, as psychiatric and pediatric medical providers attempt to fill this gap by practicing in a more collaborative and integrated fashion.
This article summarizes a modest pilot project in integrated care at the primary care clinic of Hasbro Children’s Hospital this past year. The goal was to see if a mental health provider (myself) could successfully integrate and work collaboratively with pediatrics providers according to the guidelines suggested by the American Academy of Child and Adolescent Psychiatry in A Guide to Building Collaborative Mental Health Care Partnerships in Pediatric Primary Care (DeMaso et al., 2010). These guidelines state that in order to successfully integrate psychiatric services in a primary care setting, there must be (1) timely access to consultation, (2) direct psychiatric services, (3) care coordination, and (4) primary care provider education. What follows are some details and reflections regarding the year’s work.
Initial discussions with personnel in the primary care clinic suggested the need for some kind of referral clinic where primary care physicians (PCPs) could easily send patients. However, no such referral clinic was available, and I had some reservations about creating one, as I was concerned it would fill up quickly, making it hard to accept new referrals. In addition, the referral clinic model seemed to reinforce the idea that what mental health professionals do is not only unknowable but separate from primary care. Massachusetts originally started out with telephone-only consultation to PCPs. This model avoided the issue of full clinics but did not involve one-on-one time with patients. Not seeing patients directly also seemed like it would make it hard to give accurate recommendations and may leave PCPs to implement the majority of the plan, with which they may or may not feel comfortable.
In the end, the attempt was to create a consult service that was both co-located and collaborative, meaning that the emphasis was on teaching primary care providers to start to provide mental health services themselves while giving me the option to step in and see patients directly if the situation called for it. I would be located directly in the working area of the clinic, making timely access to consultation, as well as direct psychiatric evaluations, easy. However, I anticipated that referring patients to places where they could receive further treatment would be a large portion of what I would be doing. It was a goal to make sure time was devoted to emphasizing aspects of the mental status and neurological examinations that are often glossed over for the sake of time. I also planned to do some teaching didactically (via morning reports on depression, anxiety, psychosis, and ADHD) that would also double as advertisement to the pediatricians of the availability of my services.
The pilot project was in operation between August 2013 and June 2014. The majority of the patients seen were school-age children and adolescents who had managed Medicaid insurance. Typically, PCPs had questions about where to send patients for mental health services. Concerns about ADHD, depression, anxiety, and dysregulated behavior (e.g., anger, aggression, tantrums, and oppositionality) were also very common. In about two-thirds of the cases, we were able to resolve the issue without my becoming directly involved. In the remaining third of the cases, I went in the room to see the patient, at times accompanied by the PCP.
The majority of interventions involved education provided to the PCP, generally case discussion — such as exploring other diagnoses, discussing how to ask about psychiatric symptoms, and providing handouts or journal articles related to the patient’s condition. The next most frequent interventions involved referring patients to community mental health providers and suggesting that pediatricians use a standardized way of tracking patient symptoms given that patients do not always get seen by the same provider in the clinic and sometimes may answer differently on paper as opposed to when interviewed. Scales widely available on the Internet were generally used, such as the PHQ-9 for depression, the SCARED for anxiety, and Vanderbilt parent and teacher forms for ADHD. In a sizable number of cases, there were questions about psychiatric medications, and in some cases, we initiated medications at the end of the visit. Less frequently, additional neurological examination, cognitive testing, or brief individual therapy was done with patients (e.g., motivational interviewing and relaxation training).
This was a relatively small sample of data comprising about a year’s worth of time in the Hasbro primary care clinic. These results suggesting an emphasis on case management and education are not surprising. As mentioned in the introduction, care coordination and primary care provider education were two out of the four components AACAP identified in order to create successful psychiatric-primary care collaboration (DeMaso et al., 2010). The first two components, timely access to consultation and direct psychiatric services, however, are necessary in order to create full integration.
This model attempted to fulfill all four components. There were, of course, a number of limitations. I was only available ½ to 1 day a week. Ideally, there could have been a consistent psychiatry presence in the clinic 4–5 days a week. Also, the high number of referrals out to community mental health centers was necessary because there was no clinic to which I could directly and expediently refer patients. There is definitely a need for a referral clinic where primary care patients can be seen for short courses of treatment. Ideally, it should be located within the primary clinic itself, as that is where patients are used to going.
Having a mental health referral clinic outside the confines of a primary care clinic with support staff familiar with psychiatric coding, billing, and prior authorization is a model used by many places around the nation, and not much different from how specialty care has always been provided. If my experiences over the last year can serve as evidence, however, the lack of co-location may result in a failure of integration. Many times, pediatricians did not come to me with a fully formed question, so this required a short but more extensive discussion to flesh out. In addition, communication was easy since we could talk in person. Trying to get a busy pediatrician going in and out of rooms on the phone would have resulted in hours of frustrating phone tag. In theory, information could have been exchanged through the medical record, but given that it was sensitive information that often needed to be discussed, not all of it belonged in the chart.
I would add a fifth component to AACAP’s criteria for successful integration — in order for integration to be sustainable, it must be financially feasible. This is the main challenge that integrative care has at this point, as no one is sure how exactly to do that. The traditional way health care is reimbursed (payment in exchange for services) does not work for integrative care, as much of it involves education and case management, which are important for both patients and providers but haven’t (traditionally) generated revenue.
However, I remain optimistic. As more health care systems start moving to capitated models, where a lump sum of health care dollars is provided to manage patients, there will be more incentives to help patients be as healthy as possible (rather than as sick as possible). In addition, within the next few years, we will hopefully see the results of mental health parity, and hopefully the time that patients and providers now spend obtaining prior authorization for psychiatric services will be a thing of the past. Until we get there, mental health professionals should continue to push for change in the medical arena. If we as mental health providers wish to be on equal footing with our medical colleagues, they need to see us doing our work. They also need to understand what it is we do and how to find us, and that there is nothing inherently magical about mental health evaluation and treatment — that with some training, they, too, can start to do some of it. However, if this is to happen, we need to take responsibility for our image and advocate for ourselves not only within the hospital system, but also in the field of medicine as a whole.
DeMaso, D, et al. A guide to building collaborative mental health care partnerships in pediatric primary care. AACAP Committee on Collaboration with Medical Professionals. 2010; http://www.aacap.org/App_Themes/AACAP/docs/clinical_practice_center/guide_to_building_collaborative_mental_health_care_partnerships.pdf.
Rhode Island Department of Health. Rhode Island data brief: Kids at risk. RI Youth Risk Behavior Survey. 2012; http://www.health.ri.gov/publications/databriefs/2011RIHighSchoolHealthRisks.pdf.