One in five children and adolescents will receive a behavioral or mental health diagnosis by 18. That is more than the number of women diagnosed with breast cancer (1 in 8). According to the American Academy of Child and Adolescent Psychiatry, 50 percent of pediatric office visits involve behavioral, social-emotional, or developmental concerns. Seventy percent of behavioral health medications are prescribed by primary care clinicians. However, this data is from before the COVID-19 pandemic. Youth depressive symptoms have doubled since the onset of the pandemic, with one in three high school students feeling sad or hopeless. Visits to the emergency room for mental health concerns increased by 24 percent.
We all feel the stress and strain of providing more services that may not have been integral to our medical training. How can we pivot to provide the correct care at the correct time to the correct patient?
Our organization provides behavioral and mental health care within the primary care home. We are a single specialty pediatric medical group located in San Diego and the second-largest pediatric group in the country. Across our 28 offices, we care for approximately 270,000 patients from birth to 21 years of age. Forty-five percent of our patients are insured through the state Medicaid program. We successfully integrated behavioral/mental health care into our practices and made it part of the DNA of our organization. However, it was not always this way. What does it take to bring about a change in your organization?
1. Identify a champion
In 2015, I presented to our president/CEO and medical director. I outlined how I thought we could harness the knowledge of our clinicians providing behavioral/mental health care and educate those who are hesitant. Fortunately, our leaders recognized the importance of this care and gave me the leeway to start crafting a program. I met with clinicians across our organization and those who provide specialty mental health services in our community (developmental-behavioral pediatricians, child and adolescent psychiatrists, therapists, clinicians at local federally qualified health centers (FQHC), administrators within our organization, and the local children’s hospital). Everyone was willing to listen to my questions, provide clear guidance and become partners in caring for our mutual patients. Forming that network has been invaluable as we continue to expand the services offered within CPCMG.
2. Partner with community-based organizations
As a pediatrician, you don’t have to provide all the care your patients and families need. You do need to know where to send them for further help. Just as we don’t take our patients to the operating room when they have a broken leg that requires pinning, we will not provide the evidence-based therapy they require. We are the quarterback to help coordinate the care.
We partnered with a non-profit community-based organization (CBO) in San Diego County that has provided mental health care since 1957. Their behavioral health consultative services program allows families to call directly and talk to a licensed clinician who helps them review services available within the community and appropriate for their child’s or family’s needs. In addition, they will help families review insurance policy coverage. They then send that list to the family and fax it to the primary care clinician. This allows for improved communication regarding action items. A second arm of this program is a peer-to-peer phone line where pediatricians, family practitioners, internal medicine providers, OB/GYNs, nurse practitioners, and physician assistants (anyone who is providing behavioral/mental health services to patients) can call and talk to a child and adolescent psychiatrist or psychiatric nurse practitioner for advice. The recommendations are sent to the calling clinician. By scanning this into the electronic health record (EHR), it can be referred to when patients come back and need to be reminded of the next step.
This program has been invaluable to my colleagues and me. It means we have a partner when connecting families to needed services. Having an “on-call psychiatrist” as a backup makes us more comfortable trying a new skill. In addition, our families are very appreciative to have two people helping their children on the road to wellness.
3. Support open communication and provide education
Clear and direct communication is key to achieving significant changes within any organization. Our behavioral/mental health committee has worked closely with our management group, front and back office staff, information technology (IT) department, and administrators to recognize potential challenges and celebrate successes. By identifying our goals early, we are far more likely to achieve them.
A multi-pronged approach is essential to demonstrate to our clinicians the ongoing commitment to providing evidence-based care. All our clinicians receive training in ADHD, anxiety, and depression through The Reach Institute, which includes six months of follow-up. This allowed our clinicians to have a common language and understanding of the “big 3” behavioral/mental health diagnoses. Every new hire will undergo this training within the first six months of employment, paid for by our group. Our specialty care colleagues provide ongoing CME two times a month via Zoom that covers various behavioral/mental health topics.
Key leaders from our behavioral/mental health committee visit offices to follow up with our clinicians to identify sticking points in patient care. During these sessions, we can give direct guidance to help our clinicians and staff become more comfortable with this essential care.
Our patients need our help. Parents and guardians look to us for guidance on which bottle to use, how frequently to breastfeed, when to start feeding their children, what green poop means, and how to talk to their children about difficult topics. We also need to be there to provide the best care possible regarding behavioral and mental health topics. We can care for the whole child.
Hilary M. Bowers is a pediatrician.
