Mental and behavioral health concerns are an increasing proportion of presenting problems in pediatric clinic visits. Many traditionally trained pediatricians feel they lack the knowledge and skills to address mental health concerns and prefer to refer to mental health specialists. The referral system into specialty mental health care is problematic because there are insufficient numbers of child and adolescent psychiatrists. Psychotherapists skilled in working with children may be difficult to identify, waitlists are often long, families often do not follow through on referrals, and mental health insurance coverage is often inadequate, despite parity laws.
The American Academy of Pediatrics has formally called for pediatricians to identify and treat common pediatric mental health disorders.1 Pediatricians are well positioned to do so as they have long-term relationships with patients and families and can identify conditions early in their course and intervene before symptoms become severe or problems complex. Pediatricians are well trained in anticipatory guidance and basic motivational and behavioral-modification strategies. Importantly, most patients and families prefer to access mental health care in the familiar setting of their pediatrician's office rather than be referred to a specialist.2
Introducing mental health care into an existing scope of practice involves iterative cycles of motivation, learning, and practice in the context of accessible consultation. Our experience indicates that the process usually starts small, often with a few “champions” who take on simpler cases with which they can develop competence and confidence and then care generalizes to others in the practice. In more mature practices, clinicians address children earlier in the course of treatment with more pre-emptive strategies and also begin to take on more challenging cases.
A key element of this iterative process is consultation with a mental health specialist. Consultative relationships between mental health and primary care have evolved in various models across the country, dictated by clinician preference, geography, and economics. Many consultative relationships include formal training on mental health care basics, ranging from seminars to online educational modules or online learning collectives.
Models of Mental Health Consultation and Collaboration
Telephone Consultation Lines
Many states are currently served by a mental health telephone consultation line via which primary care clinicians can review cases and seek advice on diagnosis and treatment in real time. A pioneering example is the Massachusetts Child Psychiatry Access Program, which provides direct telephone consultation with a child psychiatrist, behavioral health clinician, or a referral specialist. The program provides education for participating providers and has a referral network of behavioral health clinicians.2
Online Learning Collaboratives with Case-Based Guidance
Project ECHO (Extension for Community Healthcare Outcomes) was developed at the University of New Mexico to help rural primary care clinicians expand their scope of practice in settings where specialty access is impractical. It works on a spoke-and-hub model, grounded in “telementoring,” in which the participating clinician receives guidance from specialists while maintaining responsibility for managing the patient.3
Some pediatric practices elect to bring a mental health specialist under their roof to facilitate access to care. These specialists range from clinical social workers to psychiatrists. Co-location is not synonymous with co-management, and practices vary widely in the extent to which they may share an electronic record, track progress, or maintain involvement in the mental health care of patients referred to their co-located colleagues.4
The collaborative care model was developed in adult primary care clinics at the University of Washington AIMS (Advancing Integrated Mental Health Solutions) Center.5 In this model, the primary care provider (PCP) is the director of the treatment team, responsible for identification and treatment of patients. The PCP provides direct care to the patient, including prescribing psychiatric medications. The PCP is supported by a behavioral health care coordinator whose responsibilities include maintaining a registry to track patient progress, provide psycho-education, and in some settings provide brief therapy. A psychiatrist reviews the registry with the care coordinator, identifies patients who are not improving, and provides direct consultation to the PCP. The psychiatrist may see patients of increased complexity for brief consultation with referral back to PCP for continued, ongoing care.
Core principles of collaborative care include evidence-based, patient- centered care, population-based care, and measurement-based treatment to target. Population-based care is a strategy of identifying patients in a clinical population with a treatable condition and making practice-level efforts to improve that condition in all identified patients. Measurement-based treatment to target requires that the severity of the treatable condition can be measured, and that the practice goal is to move patients to remission on that measure. The patient registry is critical to managing measurement-based treatment to targeted remission for the clinical population.
Expanding Scope of Practice to Include Basic Mental Health Care: Considerations
There are a range of strategies and resources available for pediatricians who wish to expand their scope of practice to address common mental health conditions, including attention-deficit/hyperactivity disorder (ADHD) as well as mild to moderate disruptive behaviors, anxiety, and depression. More details can be found in the resources listed in Table 1. Each clinician or practice must decide what didactic training they wish to use and the type of collaborative or consultative relationship they want to develop with a mental health specialist. Some clinicians may want comprehensive training before moving forward, whereas others may prefer to start with a few straightforward cases and targeted education on their management.
Models of Mental Health Consultation and Collaboration in Primary Care Pediatrics
If your practice wishes to implement a collaborative care model, the following steps may be helpful.
Assess your practice. Perform an assessment of your current practice, including current resources and provider interest in collaborative medicine.
Identify champions. A physician champion functions as a leader of the collaborative care initiative within the practice and encourages other physicians to participate in the model. The physician champion takes the lead in trouble-shooting the model and seeking out information when needed.
Who and what do you want to treat? Consider the current needs of your patient population and the mental health diagnoses you encounter frequently in practice. Identify a condition (eg, ADHD or mild anxiety) and an age range (pre-adolescents) and develop skills and comfort in treating this condition. Over time, your scope of mental health care practice will likely expand.
Training. With any expansion of scope of practice, you must identify the training needs of clinicians and support staff. Clinicians will need an intensive introduction to mental health care and the diagnosis and treatment of the conditions they wish to target. Nursing staff will need the skills to inquire about mental health symptoms and treatment. Front desk staff must feel comfortable acknowledging mental health concerns as reasons for visits. If you are adopting a formal collaborative care program, the care manager will require training in maintaining a registry and tracking patient outcomes.
Toolkit. Mental health care toolkits contain the standardized elements that a practice needs to effectively and efficiently provide evidence-based care. Toolkits may include:
- Brief diagnostic summaries and treatment algorithms
- Screening tools and rating scales to track response to treatment
- Patient educational material for parents and patients, including overviews of the disorders, brief strategies for managing symptoms, medication information, and online references
- A library of “dot phrases” or other short-cuts in the electronic record to guide documentation of the visit, medication recommendations, patient advice for the after-visit summary, safety planning, and for creation of common communications such as letters to school requesting a 504 plan.
Screening protocol and monitoring response to treatment. There is no perfect universal screening approach to mental health disorders in primary pediatric care. Decisions about screening practices must take into account the conditions for which to screen; target age range; whether to administer screens to children, caregivers, or both; preference for public domain screening instruments; whether to administer screens on paper or on electronic media, and in the clinic or online from home; who will score the screens; how the screening results will be conveyed to patients and guardians; and how they will be documented in the medical record.6,7 Many, but not all, screening instruments are also appropriate for monitoring care and quantifying response to treatment. Guides to screening and monitoring instruments are available in Table 1.
Consultation model. Be clear about roles and availability and create a communication protocol.
- When is the consultant available (days and hours)?
- What type of availability (telephone, fax, email, shared electronic medical record, telemedicine)?
- What will the consultation include and not include?
- Will the consultant document in the patient record?
- What are procedures for routine, urgent, and emergency requests?
Referral base. The practice should consider its referral base of psychotherapy providers and what staff will assist with the referral process.
Billing. Review the practice's billing policies and how collaborative care can be incorporated into billing practices.8,9 Review your state's laws regarding billing for mental health screening and collaborative care.
Outcomes measurements in pediatric mental health care. Expanding scope of practice to include mental health care may not be clearly cost-efficient, especially early on when visits take more time. A recent cost-effectiveness model of collaborative care for adolescent depression, however, showed decreased cost and improved quality of life in the treatment group.10 Value-based care contracts increasingly contain incentives for quality metrics, including aspects of mental health care.11 Practice networks may decrease leakage by referring less to out-of-network mental health specialists. Increased access to mental health care in primary care may reduce emergency department visits for mental health crises, but the evidence on this is mixed in adult populations12,13 and not well studied in pediatric populations.
Our hypothetical physician practices in a group of nine pediatricians. The department of psychiatry at the local children's hospital sent a survey to area pediatricians asking about their interest in mental health care training and support. The department then invited practices to participate in a pilot program based on the collaborative mental health care model. Our hypothetical physician and his colleagues decide to join.
After a welcome session, the program requires that participants complete an online course covering mental health care concepts and the diagnosis and treatment of ADHD, pediatric anxiety, and depression.
Once the participants have completed the education component, they may refer patients. In this version of the collaborative care model, patients receive an initial evaluation and treatment plan through a care team that is conveyed to the pediatrician for implementation and management. A coordinator phones the parents of referred children, sends an electronic link to assessment tools, and sets up an appointment with the program psychologist. The psychologist reviews the assessment tools and conducts a clinical interview with the child and parent. They write an assessment and treatment recommendations together with the team psychiatrist who makes medication recommendations if indicated. If the recommendations include psychotherapy, the team provides a short list of therapists who have been vetted for evidence-based practice and who are in-network and available to treat the child.
Our hypothetical physician refers his first patient, a 9-year-old girl with recurrent stomachaches for which he has found no medical cause. Two weeks later, the care team reports that the girl has been diagnosed with separation anxiety and recommends cognitive-behavioral therapy with a plan to add sertraline if not improving by 6 weeks of therapy.
Within 4 months, our hypothetical physician has referred six patients to the program. He is managing three children on stimulant medications for ADHD, one on escitalopram for anxiety, and observing two in therapy for anxiety. His colleagues are managing similar cases. They participate in a monthly conference call with the treatment team to review cases. Our hypothetical physician finds himself more confident and efficient in addressing mental health. He finds that his patients are getting better, succeeding in school, and are happier. Parents of patients are delighted to have their children's needs met in the familiar and convenient setting of the doctor's office.
- Committee on Psychosocial Aspects of Child and Family Health and Task Force on Mental Health. Policy statement—the future of pediatrics: mental health competencies for pediatric primary care. Pediatrics. 2009;124(1):410–421. doi:10.1542/peds.2009-1061 [CrossRef] PMID:19564328
- Van Cleave J, Holifield C, Perrin JM. Primary care providers' use of a child psychiatry telephone support program. Acad Pediatr. 2018;18(3):266–272. doi:10.1016/j.acap.2017.11.007 [CrossRef] PMID:29197641
- Zhou C, Crawford A, Serhal E, Kurdyak P, Sockalingam S. The impact of project ECHO on participant and patient outcomes: a systematic review. Acad Med. 2016;91(10):1439–1461. doi:10.1097/ACM.0000000000001328 [CrossRef] PMID:27489018
- Platt RE, Spencer AE, Burkey MD, et al. What's known about implementing co-located paediatric integrated care: a scoping review. Int Rev Psychiatry. 2018;30(6):242–271. doi:10.1080/09540261.2018.1563530 [CrossRef] PMID:30912463
- University of Washington AIMS Center. Collaborative care. Accessed September 24, 2020. https://aims.uw.edu/collaborative-care
- Beers LS, Godoy L, John T, et al. Mental health screening quality improvement learning collaborative in pediatric primary care. Pediatrics. 2017;140(6):e20162966. doi:10.1542/peds.2016-2966 [CrossRef] PMID:29114061
- Shemesh E, Lewis BJ, Rubes M, et al. Mental health screening outcomes in a pediatric specialty care setting. J Pediatr. 2016;168:193–7.e3. doi:10.1016/j.jpeds.2015.09.046 [CrossRef] PMID:26505291
- Carlo AD, Unützer J, Ratzliff ADH, Cerimele JM. Financing for collaborative care - a narrative review. Curr Treat Options Psychiatry. 2018;5(3):334–344. doi:10.1007/s40501-018-0150-4 [CrossRef] PMID:30083495
- Carlo AD, Corage Baden A, McCarty RL, Ratzliff ADH. Early health system experiences with collaborative care (CoCM) billing codes: a qualitative study of leadership and support staff. J Gen Intern Med. 2019;34(10):2150–2158. doi:10.1007/s11606-019-05195-0 [CrossRef] PMID:31367872
- Wright DR, Haaland WL, Ludman E, McCauley E, Lindenbaum J, Richardson LP. The costs and cost-effectiveness of collaborative care for adolescents with depression in primary care settings: a randomized clinical trial. JAMA Pediatr. 2016;170(11):1048–1054. doi:10.1001/jamapediatrics.2016.1721 [CrossRef] PMID:27654449
- Bao Y, McGuire TG, Chan YF, et al. Value-based payment in implementing evidence-based care: the Mental Health Integration Program in Washington state. Am J Manag Care. 2017;23(1):48–53. PMID:28141930
- Serrano N, Prince R, Fondow M, Kushner K. Does the primary care behavioral health model reduce emergency department visits?Health Serv Res. 2018;53(6):4529–4542. doi:10.1111/1475-6773.12862 [CrossRef] PMID:29658993
- Breslau J, Leckman-Westin E, Han B, et al. Impact of a mental health based primary care program on emergency department visits and inpatient stays. Gen Hosp Psychiatry. 2018;52:8–13. doi:10.1016/j.genhosppsych.2018.02.008 [CrossRef] PMID:29475010
Models of Mental Health Consultation and Collaboration in Primary Care Pediatrics
|American Academy of Pediatrics
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Site includes toolkits, links to local chapter initiatives, and screening tools.
American Academy of Child and Adolescent Psychiatry
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Articles and materials related to implementation of collaborative mental health care.
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Overview of the Project ECHO model, local programs, and how to get involved
Massachusetts Child Psychiatry Access Program
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Overview of the program, toolkits, screening tools, newsletters, and regional programs
The REACH Institute
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The REACH Institute is a nonprofit that provides training and ongoing consultation to expand mental health care capacity in primary care.
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Introduces integrated care strategies from both primary care and mental health care viewpoints, includes focus on patient-centered medical home
University of Washington AIMS Center
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Overview of the collaborative care model, online training, tools, metrics, readiness assessments, and outcomes