Q: We are interested in addressing social-emotional development and mental health issues for the children and adolescents who come to our practice. What is the best way to get started?
Addressing these needs for our patients and families is a part of being a medical home, a concept with which pediatricians are familiar. As the medical home, we provide a family-centered, interdisciplinary partnership in the primary care setting; a source of accessible preventive, acute, and chronic care services that are coordinated, compassionate, continuous, comprehensive, and culturally effective; and an entry point to community medical and non-medical services, especially for those with chronic/complex conditions. In particular, because of its comprehensive perspective, a medical home also means caring for the whole person, considering physical, social-emotional and mental health together, and “not separating the head from the body.”
The American Academy of Pediatrics (AAP), through the work of the Mental Health Task Force, has described mental health competencies for primary care clinicians (PCCs) that include eliciting concerns, assessing and/or triaging children and adolescents with mental health or substance use symptoms, addressing emerging or undifferentiated problems or ones not rising to the level of a diagnosis, referring, co-managing, and monitoring.
The Task Force also identified four symptom areas with mild or moderate levels of impairment that primary care pediatricians should be able to manage: ADHD, anxiety, depression, and substance use disorders.
There is a “primary care advantage” in addressing social-emotional issues within the medical home because of the longitudinal relationship between the family and PCC. PCCs have unique opportunities for prevention and anticipatory guidance, as well as an understanding of common social-emotional issues and learning problems in the context of development. They are familiar with co-managing with specialists in the care of children and adolescents with chronic/complex conditions. Practice improvements may include implementing routine strength and risk screening as part of well care, utilizing psychosocial and social-emotional screening tools, improving the mental health referral process, and applying the chronic care model to children and adolescents with mental health problems.
Getting Started with Implementing an Office Process
Implementation begins with an office readiness assessment in areas such as familiarity with community resources, health care financing, support for children and families, clinical information systems, and decision support for clinicians.
The readiness assessment allows the practice to identify the key areas needed to facilitate the process change. Involving staff at all levels is very important. Often the clinician is not aware of a workflow issue that might be obvious to a front office staff person.
Another key element to successful implementation is networking to build relationships with community partners and specialists. To sustain change in the office system, the process needs to become a routine part of a practice-wide guideline/procedure.
The process needs to be reliable, not dependent on a particular staff member to be present in order to occur. Roles at each level should be clear and understood, and a new kind of communication to facilitate the process beyond the practice with specialists and community resources is necessary. Agreements on how to exchange information (eg, standardized referral and feedback process/forms) are best discussed and planned prior to beginning implementation.
Finally, there needs to be a plan for the participatory role of the family. This includes having a parent/youth partner in screening, helping drive change by asking for service, and giving feedback on referral sources and communication.
Office preparation also includes having parent/youth materials selected and available; having relationships with key referral sources (including local mental health crisis services); having established contacts with school nurses, community supports, etc.; and having a follow-up and tracking plan. As relationships with mental health providers develop, use of a shared-care plan for comanagement is essential.
Consider New Models of Collaboration
What has been described thus far involves moving beyond the referral model typical of the past to an enhanced model of referral with a feedback plan and engagement in co-management. There are a growing number of practices that not only enhance their referral/feedback processes, but also utilize a co-location or integration model. In co-location, a mental health professional (such as a licensed clinical social worker or licensed professional counselor) utilizes clinical space in the practice and sees patients as referral from the PCC. This person may do their own billing, or the practice may bill and pay them as a contracted employee. The co-located mental health professional (MHP) may be an employee of another agency or an independent practitioner. The advantages of the co-location model include the possibilities for “hallway consults,” a shared chart, greater convenience for families, and removal of stigma for families. The shared chart greatly facilitates communication, allows the PCC and MHP to align and support therapeutic goals, and facilitates co-management.
In an integrated model, the MPH works within the clinical flow of the practice and is usually an employee of the practice. The advantages of this model also include the “hallway consult,” shared chart, and reduction of stigma; however, the significant added advantage is the ability for the PCC to make a “warm handoff” in the visit, providing shared care. In this model, the MHP is fully a member of the patient-centered medical home team. Having an integrated MHP is different than simply having mental health services under the same roof. With integration, the MHP partners with the PCC during the course of routine visits; is involved routinely in visits for children with chronic/complex conditions; accepts a “warm handoff” and may see a family for a several-visit course; and can liaison with the specialty mental health system, schools, and other agencies. The MHP also engages in brief interventions within the course of office flow — very different than the standard 50-minute mental health visit. Roles for the MHP include immediate triage in response to a positive screen, follow-up using specific secondary screens, brief interventions to short-term therapy, self-management counseling for children/adolescents with chronic medical conditions, and communication with external mental health providers and teachers.
Whatever the model — enhanced referral and feedback, co-location, or integration — the relationship means knowing when and how to refer; creating a partnership among the PCC, MHP, and the patient/family; establishing effective communication, and maintaining a co-management plan.