Policy Brief
Behavioral Health
Integration in Pediatric
Primary Care Settings
Traci Sawyers, July-August 2014
THE PROBLEM
One in five children experience mental health problems
and up to one-half of all lifetime cases of mental illness
begin by age 14.1 Yet, it’s estimated that 70 percent of
children and adolescents who need treatment do not
receive mental health services.2 With concerning rates
of adolescent depression and drug use – not to mention
the tragic trend in school shootings - the behavioral
health of children and youth is an urgent public health
issue. 3
The prevalence and early onset of mental health issues
combined with research on brain development and
early risk and protective factors, as well as the
increased availability of screening and assessment tools
and evidence-based practices all support the rationale
for integrating behavioral health services in pediatric
primary care settings for children and youth. 4
BACKGROUND
The National Institute for Health Care Management
defines children’s mental health as “successful
performance of mental functioning resulting in
productive activities, fulfilling relationships with other
people, and the ability to adapt and to change and to
cope with adversity; mental health is indispensable to
personal well-being, family and interpersonal
relationships, and contribution to the community or
society.”5 The terms mental and behavioral health are
often used interchangeably. However behavioral health
includes substance abuse addiction, mental illness and
emotional well-being, and encompasses promotion,
prevention, early intervention and treatment.
Pediatric primary care, which includes pediatricians and
family medicine providers, has unparalleled access to
children: nationally, 94.5 percent of children birth to
five-years old are estimated to have health insurance,
and 89.7 percent report having a preventative well child
visit in the last 12 months.6 Therefore, pediatric
primary care providers have a unique opportunity to
prevent and address behavioral health in the medical
home. Pediatric primary care providers typically have
longstanding and trusted relationships with families and
can routinely screen for emerging problems in child or
family functioning, promote healthy lifestyles, build
resilience and protective factors and mitigate toxic
stress.7
Despite this potential to address behavioral health
challenges early, there are two main roadblocks:
pediatric primary care clinicians are not fully trained to
diagnose or treat behavioral health problems, and,
referrals to community-based mental health providers
can be a challenge. National studies show that over half
of primary care doctors are not successful in referring
patients to mental health services for a variety of
reasons including stigma, insurance and payment
barriers, or a shortage of mental health providers that
result in long waitlists. As a result, depression and
other behavioral health problems can go undiagnosed
or are not treated adequately. 8
In response, Bright Futures: Guidelines for Health
Supervision of Infants, Children and Adolescents, the
American Academy of Pediatrics (AAP) and others have
recommended that pediatricians address pediatric
behavioral health problems - such as depression,
anxiety and substance abuse - by routinely screening,
providing anticipatory guidance and referring for
additional treatment when necessary.9 In this way, they
can reach a large number of children who otherwise
would not seek out behavioral health care until
problems worsened.
the pediatric practice hires embedded behavioral health
staff.12
Many children in the U.S. have behavioral health
symptoms that do not rise to the level of a formal
disorder diagnosis but are still significant. This number
is estimated to be twice the prevalence of children with
severe emotional disorders.10 Getting support from the
pediatric provider can again be the difference between
prevention/mitigation or waiting for much more costly
interventions if problems escalate.
INTEGRATION – Primary care practice has behavioral
health clinicians on staff.
Research, especially over the last 10 years, has proven
that prevention and early intervention can lessen risks
and build protective factors which impact health
outcomes, school readiness and health costs.11
Protective factors include a stable and loving family,
economic security, and connections with healthy
schools and communities.
Risk factors include
traumatic events, maternal depression, parental
substance abuse and poverty. These are all important
parts of pediatric health supervision and the medical
home.
While AAP and others have called for more behavioral
health training for pediatric providers, coordination and
co-location with behavioral health specialists or hiring
behavioral health staff in the pediatric practice can help
significantly with diagnosing and treating behavioral
health issues. Collaboration between primary care and
behavioral health specialists generally fall in to three
areas: 1) consultation with a behavioral health expert
and referral, if necessary; 2) co-location of behavioral
health staff in a pediatric practice; or 3) full integration
of behavioral health and primary care services where
CONSULTATION – Behavioral health experts are
available by telephone or video conference to provide
consultation and help with referral.
CO-LOCATION – Primary care and behavioral health
clinicians are physically located in the same treatment
setting.
Behavioral health specialists include psychiatrists,
clinical psychologists, clinical social workers, licensed
professional substance abuse counselors, nurses with
advanced psychiatric training, family therapists,
neurologists,
early
intervention
specialists,
developmental-behavioral pediatricians and adolescent
medicine specialists.13
The federal Substance Abuse and Mental Health
Services Administration reports that the United States
has only one-fourth of the child psychiatrists it needs.14
Waiting lists for these services can be very long.
Therefore, in Vermont and nationally, child psychiatry
consultation models have become more prominent,
assisted by the increasing use of telemedicine. In these
models, primary care and other providers are able to
access a psychiatrist who provides consultation when
issues emerge. In some cases, psychiatric services are
delivered directly via telemedicine from a remote site.
Another promising integration approach is care
coordination. Care coordination is defined as a patientand family-centered, assessment-driven, team-based
approach designed to meet the needs of children and
youth while enhancing the care giving capabilities of
families.15 Care coordination is typically delivered by
nurses or clinical social workers and can be centralized
or embedded in a practice. It addresses interrelated
medical, social, developmental, behavioral, educational
and financial needs to achieve optimal health and
wellness outcomes. Care coordination has been found
to decrease unnecessary primary care or emergency
department visits and hospitalizations, as well as
improving family satisfaction.16
An AAP policy
statement on this topic, “Patient and Family Centered
Care Coordination: A Framework for Integrating Care
for Children and Youth across Multiple Systems,” was
published in Pediatrics on May 1, 2014.
Whatever approach, integrated care is the seamless
provision of health care services from the perspective of
families – and involves them throughout the process. It
also makes a fundamental shift from treatment of
disorders to prevention, with the focus on identifying
early onset of behavioral health concerns and mitigating
the consequences.
WHAT IS BEING DONE
There are several behavioral health integration projects
being piloted in pediatric primary care settings
throughout Vermont. These largely fall into four
categories.17
1) Psychiatric consultation which often includes
technical assistance and training for primary care
providers. In this model, psychiatry is offered via
contract or other mechanisms with a university or
private practice either on site, by phone, by
telemedicine, by email, or as part of grand rounds.
Consultation is used by medical practices, Designated
Agencies (i.e. Vermont’s Community Mental Health
Centers) and Federally Qualified Health Centers
(FQHC’s).
Providers include Otter Creek Associates, the University
of Vermont’s Department of Psychiatry’s Vermont
Center for Children, Youth and Families (VCCYF), the
Brattleboro Retreat, and Dartmouth Hitchcock Medical
Center’s Department of Psychiatry.
2) A licensed, Ph.D. psychologist on-site within a
pediatric primary care practice.
Co-located
psychologists are integrated in practice sites and
provide treatment, behavioral health consultation,
triage and referral assistance and other support to the
primary care physicians and staff.
3) Case management which involves a medical social
worker co-located in a pediatric primary care practice.
A medical social worker provides case management for
Medicaid eligible children, especially those with
demonstrated behavioral health needs. This is a
Department of Mental Health contract with the area
Designated Agency.
4) Care coordination within pediatric primary care.
The Vermont Blueprint for Health’s Community Care
Teams, located in each region of Vermont, work with
primary care providers to assess patients’ needs,
coordinate community-based support services, and
provide multidisciplinary care for the general
population including adults. Care coordination is part of
this work. Those on Community Care Teams include
nurses, a health educator, a community resource social
worker, a behavioral health social worker, and a
certified dietician. These teams are formed on a
population basis and can be accessed by primary care
providers in the region.
In Chittenden County, Hagan, Rinehart and Connolly
Pediatrics, joined with University Pediatrics and
Timberlane Pediatrics to form a Community Health
Team specifically focused on pediatric primary care.
These practices receive embedded care coordination
staff via the Blueprint and focus on child and family
needs using Bright Futures guidelines, care coordination
and collaborative community teaming.
The Vermont Children’s Health Improvement Project
(VCHIP) has also created a statewide Pediatric Care
Coordination Learning Collaborative further supporting
this care coordination work, using evidence-based tools
and findings. This group of primary care providers will
develop learning objectives and materials based on
Boston Children’s Hospital’s
“Pediatric Care
Coordination Curriculum” published in 2014. The
learning collaborative has regular in-person learning
sessions or conference calls through January 2015. This
work also includes understanding the landscape of
health care reform, collaborating with Vermont’s Title V
Maternal and Child Health Program and understanding
and using Medicaid care coordination codes and
advocating for payment of these services by all payers.
1) Support the expansion of behavioral health
integration initiatives and strategies as
described above – including consultation, colocation with behavioral health specialists or
integration by hiring embedded behavioral
health specialists in the pediatric primary care
practice. Instead of having children on long
waiting lists to see psychiatrists or other
specialists, it makes sense to have pediatric
providers access support and consultation when
needed. This continues to build the capacity
and skill of the practice in this critical area.
Across the state there are other care coordination
initiatives that have been formed at the community
level and are often supported financially through feefor-service models and grants. For example, as part of
project LAUNCH, two practices – the Community Health
Center of Burlington and University Pediatrics - are
piloting a care coordination model using clinical social
workers and with a focus on Chittenden County’s
growing New American population.
2) Use and develop health information technology
to support integrated care. This includes
electronic health records, and also using
technology to improve systems and provide
care (e.g., telehealth).
Beyond these four general areas and its outpatient
clinic, VCCYF also provides several related supports
including a Child and Adolescent Psychiatry Residency
Training program, a Child Psychology Internship
program, Family Wellness Coach Training and much
more. VCCYF, VCHIP and Vermont’s Integrated Family
Services Division have also created a Center for Training
in Evidence Based Approaches to Family Treatments
with the goal of reducing childhood emotional and
behavioral disorders. Trainings are offered to mental
health clinicians located in pediatric primary care,
Designated Agencies and FQHC’s.
RECOMMENDATIONS
There are many important steps that Vermont should
take to support pediatric primary care providers in
promoting the behavioral health and well-being of the
children they care for.
3) Understand the landscape of quality metrics
(e.g., National Committee for Quality
Assurance) and health care reform. Moving
from procedure and episodic-based payment,
to payment based on health outcomes makes
this type of integration key. Understand that
children are not the drivers of current health
care costs but their healthy development is key
to containing long-term costs.
4) Support
increased
behavioral
health
competencies of pediatric primary care staff.
The American Academy of Pediatrics has
proposed
competencies
for
providing
behavioral services in pediatric primary care
settings and recommends steps toward
achieving them. However, AAP does not
consider this a current expectation. It will
require innovations in residency training and
continuing medical education, as well as
systems changes in the ways behavioral health
is financed before enhancements in clinical
practice can happen.
5) Increase reimbursement to cover screening and
preventive services so they are provided in
primary care. The evidence is there that proves
this makes a difference and saves money down
the line.
6) In addition to screening and assessment of
children’s social and emotional health and
development, ensure that validated, reliable
screening tools are also available and used for
maternal depression, family violence, substance
abuse and other family issues that affect
children.
7)
Sources:
1
Marshall, N., Integrating Behavioral Health and Primary
Care for Children and Youth, SAMHSA-HRSA Center
for Integrated Health Solutions, 2013.
2
Ibid.
3
Ginsburg, S., and Foster, S., Strategies to Support the
Integration of Mental Health into Pediatric
Primary Care, National Institute for Health Care
Management, 2009.
4
Ibid.
Improve or establish effective coding and
billing systems for integrated services. Practices
must be able to use Medicaid codes routinely
and private insurers must pay for care
coordination and other integration approaches.
5
Ibid.
6
National Survey for Children’s Health, 2011-12
7
American Academy of Pediatrics, The Future of
Pediatrics: Mental Health Competencies for
Pediatric Primary Care, Pediatrics, 2009.
8) Address barriers to referral, communication and
information sharing between primary care and
behavioral health staff.
Even a regular
exchange of information is currently a
challenge.
8
Ibid.
9
Ibid.
10
Ibid.
9) Encourage a family based approach to pediatric
care such as the model VCCYF uses. It considers
risk, protective factors and the emotional
health of the entire family when deciding on
treatments. This is important because the child
is influenced by genetic factors, environmental
factors and their interaction.
As health care reform continues in our county and
specifically in Vermont, one of the most fundamental
pieces of that work should be the integration of
behavioral health in primary care. Gains are clearly
seen in the pediatric setting. Vermont must do all it can
to continue the important work it has started in this
area so all children and families have access to this
comprehensive, family centered care.
11
Ginsburg and Foster.
12
Ibid.
13
AAP - The Future of Pediatrics: Mental Health
Competencies for Pediatric Primary Care,
14
http://www.aboutourkids.org/articles/may_mental_h
ealth_month_factoftheday
15
American Academy of Pediatrics, Patient-and FamilyCentered Care Coordination: A Framework for
Integrating Care for Children and Youth Across
Multiple Systems, Pediatrics, 2014.
16
17
Ibid.
The Vermont Children’s Health Improvement
Project
About These Policy Briefs:
This is one in a series of policy briefs designed to focus
our collective attention on issues that affect our young
children and families. These briefs, as well as an annual
How Are Vermont’s Young Children? report are part of
an initiative by Building Bright Futures State Advisory
Council, connected to the Vermont Early Childhood
Framework recently unveiled at Governor Shumlin’s
Early Childhood Summit in 2013. For more information,
call Building Bright Futures at 802-876-5010 or find out
more on line: www.buildingbrightfutures.org)
About Project LAUNCH:
Project LAUNCH (Linking Actions for Unmet Needs in
Children’s Heath) is a federal initiative funded by the
Substance Abuse and Mental Health Services
Administration (SAMHSA). The Vermont Department
of Health (VDH) received a five-year SAMHSA Project
LAUNCH grant in 2012. Project LAUNCH is being piloted
in Chittenden County and is grounded in a
comprehensive view of health that addresses the
physical, emotional, social, cognitive and behavioral
aspects of well-being. Building Bright Futures State
Advisory Council, Inc. serves as the grantee of VDH for
Project LAUNCH implementation.
About the Author:
Traci Sawyers holds a M.A. in public policy from Tufts
University and has 25 years experience in child and
family policy, maternal/child health and behavioral
health. In these areas, she has been a writer, lobbyist,
researcher, planner, program administrator, consultant,
facilitator, grant writer/administrator, elected official,
and organizational director. She is currently the Early
Childhood Health Policy Expert for Building Bright
Futures and Vermont’s Project LAUNCH initiative.