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Integrating Pediatrics and Mental Health: The Reality Is in the Relationships

Integrating Pediatrics and Mental Health: The Reality Is in the Relationships One in 10 children in the United States suffers from mental health problems that affect their lives. The surgeon general has specifically called on pediatricians to improve screening and referral for child mental illness.1 In response to this national call, numerous studies have examined mental health screening in pediatric practices.2,3 However, little has been written about the realities of implementing an integrated model of primary care and mental health. Today, pediatricians are faced with increasing demands on their time. Productivity requirements, reimbursement dilemmas, and growing expectations for anticipatory guidance make success difficult.2,4 Yet, the need to identify mental health issues at the primary care visit is imperative in order to address the growing number of children with mental health issues. The Cambridge Health Alliance, Cambridge, Mass, introduced mental health screening in its pediatric clinic using the Pediatric Symptom Checklist.5 A clinical social worker supervised by the Department of Child Psychiatry was also colocated in the practice. A number of important implementation issues arose in the process. First, time and reimbursement structures did not readily support integration. Initial discussions with pediatricians revealed that although the majority (72%) felt prepared to discuss psychosocial issues with their patients, only 14% felt they had enough time to do so, and 100% felt they were inadequately reimbursed. Second, information technology systems for the departments of pediatrics and child psychiatry were on different platforms making scheduling, registration, and billing for the clinical social worker problematic. Office support practices such as medical records, clinical treatment space, and after-hours phone coverage were also handled differently in both departments. Third, there were numerous misunderstandings between the disciplines. Pediatricians wanted immediate responses to referrals, easy access to appointments, consultation, and follow-up. Psychiatry had standard procedures for referrals and billing that interfered with the pediatricians' desires. To address these issues of integration, leaders from the departments of pediatrics and child psychiatry worked together to solve operational issues and develop a flow process that would be seamless to patients and providers alike. The resulting procedure incorporated screening and referral without overburdening providers; parents fill out the Pediatric Symptom Checklist in the waiting room (3-5 minutes), providers score the tool in the examination room, and any family whose child scores higher than the cutoff is automatically referred to the on-site social worker. If a provider or the family has concerns, regardless of the score, a referral can also be made. As a member of the Department of Child Psychiatry, the social worker is able to bill for services and can readily access psychopharmacology and consultation. Perhaps most important to the success of the integration was the willingness of the Department of Child Psychiatry to redefine services by incorporating a provider-friendly and patient-centered approach. Meetings were held with pediatricians, and based on their feedback, the referral process was simplified. Pediatricians could either call a dedicated number or e-mail referral information. Pediatricians received notification of a patient's first appointment and missed appointments and periodic updates throughout therapy. With regard to access, the wait time for therapy was reduced from 1 year to less than 1 month and the Department of Child Psychiatry eliminated its extended evaluation process and moved to direct assignment of cases. The departments of child psychiatry and pediatrics must work together in a coordinated fashion to address the social and emotional needs of children. Although many different models will emerge, screening, assessment, and referral will all be components. As noted by Jeffrey Brosco, MD, PhD, "In the future, integration of pediatric and behavioral health will require that systems of care do not perpetuate myths about the distinction between the two fields . . . it is clear at both a biological and psychosocial level: distinctions between physical and behavioral health are specious at best, and generally impede attempts to maximize child health and well-being."6(p3) Back to top Article Information This study was funded in part through the Healthy Tomorrows Partnership for Children Program, a public-private partnership between the Health Resources and Services Administration Maternal and Child Health Bureau, Rockville, Md, and the American Academy of Pediatrics, Elk Grove Village, Ill. Correspondence: Dr Hacker, Institute for Community Health, 119 Windsor St, Cambridge, MA 02139 (khacker@challliance.org). References 1. US Department of Health and Human Services, Mental Health: A Report of the Surgeon General. Rockville, MD US Dept of Health and Human Services Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health National Institute of Mental Health1999; 2. Stancin TPalermo TM A review of behavioral screening practices in pediatric settings: do they past the test? J Dev Behav Pediatr. 1997;18183- 194PubMedGoogle ScholarCrossref 3. Jellinek MSMurphy JMLittle MPagano MEComer DMKelleher KJ Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med. 1999;153254- 260PubMedGoogle Scholar 4. Gardner WKelleher KJWasserman R et al. Primary care treatment of pediatric psychosocial problems: a study from pediatric research in office settings and ambulatory sentinel practice network. Pediatrics [serial online]. 2000;106e44Available at:http://pediatrics.aappublications.org/cgi/content/full/106/4/e44PubMedGoogle Scholar 5. Jellinek MSMurphy JM Screening for psychosocial disorders in pediatric practice. Am J Dis Child. 1988;142153- 117PubMedGoogle ScholarCrossref 6. Brosco J The future of primary prevention: why integrate care? Paper presented at: A Preview of the Future: Integrated Pediatric and Behavioral Health Care for Children and Adolescents conference June 12, 2003 New York, NY http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Integrating Pediatrics and Mental Health: The Reality Is in the Relationships

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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.158.8.833
Publisher site
See Article on Publisher Site

Abstract

One in 10 children in the United States suffers from mental health problems that affect their lives. The surgeon general has specifically called on pediatricians to improve screening and referral for child mental illness.1 In response to this national call, numerous studies have examined mental health screening in pediatric practices.2,3 However, little has been written about the realities of implementing an integrated model of primary care and mental health. Today, pediatricians are faced with increasing demands on their time. Productivity requirements, reimbursement dilemmas, and growing expectations for anticipatory guidance make success difficult.2,4 Yet, the need to identify mental health issues at the primary care visit is imperative in order to address the growing number of children with mental health issues. The Cambridge Health Alliance, Cambridge, Mass, introduced mental health screening in its pediatric clinic using the Pediatric Symptom Checklist.5 A clinical social worker supervised by the Department of Child Psychiatry was also colocated in the practice. A number of important implementation issues arose in the process. First, time and reimbursement structures did not readily support integration. Initial discussions with pediatricians revealed that although the majority (72%) felt prepared to discuss psychosocial issues with their patients, only 14% felt they had enough time to do so, and 100% felt they were inadequately reimbursed. Second, information technology systems for the departments of pediatrics and child psychiatry were on different platforms making scheduling, registration, and billing for the clinical social worker problematic. Office support practices such as medical records, clinical treatment space, and after-hours phone coverage were also handled differently in both departments. Third, there were numerous misunderstandings between the disciplines. Pediatricians wanted immediate responses to referrals, easy access to appointments, consultation, and follow-up. Psychiatry had standard procedures for referrals and billing that interfered with the pediatricians' desires. To address these issues of integration, leaders from the departments of pediatrics and child psychiatry worked together to solve operational issues and develop a flow process that would be seamless to patients and providers alike. The resulting procedure incorporated screening and referral without overburdening providers; parents fill out the Pediatric Symptom Checklist in the waiting room (3-5 minutes), providers score the tool in the examination room, and any family whose child scores higher than the cutoff is automatically referred to the on-site social worker. If a provider or the family has concerns, regardless of the score, a referral can also be made. As a member of the Department of Child Psychiatry, the social worker is able to bill for services and can readily access psychopharmacology and consultation. Perhaps most important to the success of the integration was the willingness of the Department of Child Psychiatry to redefine services by incorporating a provider-friendly and patient-centered approach. Meetings were held with pediatricians, and based on their feedback, the referral process was simplified. Pediatricians could either call a dedicated number or e-mail referral information. Pediatricians received notification of a patient's first appointment and missed appointments and periodic updates throughout therapy. With regard to access, the wait time for therapy was reduced from 1 year to less than 1 month and the Department of Child Psychiatry eliminated its extended evaluation process and moved to direct assignment of cases. The departments of child psychiatry and pediatrics must work together in a coordinated fashion to address the social and emotional needs of children. Although many different models will emerge, screening, assessment, and referral will all be components. As noted by Jeffrey Brosco, MD, PhD, "In the future, integration of pediatric and behavioral health will require that systems of care do not perpetuate myths about the distinction between the two fields . . . it is clear at both a biological and psychosocial level: distinctions between physical and behavioral health are specious at best, and generally impede attempts to maximize child health and well-being."6(p3) Back to top Article Information This study was funded in part through the Healthy Tomorrows Partnership for Children Program, a public-private partnership between the Health Resources and Services Administration Maternal and Child Health Bureau, Rockville, Md, and the American Academy of Pediatrics, Elk Grove Village, Ill. Correspondence: Dr Hacker, Institute for Community Health, 119 Windsor St, Cambridge, MA 02139 (khacker@challliance.org). References 1. US Department of Health and Human Services, Mental Health: A Report of the Surgeon General. Rockville, MD US Dept of Health and Human Services Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health National Institute of Mental Health1999; 2. Stancin TPalermo TM A review of behavioral screening practices in pediatric settings: do they past the test? J Dev Behav Pediatr. 1997;18183- 194PubMedGoogle ScholarCrossref 3. Jellinek MSMurphy JMLittle MPagano MEComer DMKelleher KJ Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility study. Arch Pediatr Adolesc Med. 1999;153254- 260PubMedGoogle Scholar 4. Gardner WKelleher KJWasserman R et al. Primary care treatment of pediatric psychosocial problems: a study from pediatric research in office settings and ambulatory sentinel practice network. Pediatrics [serial online]. 2000;106e44Available at:http://pediatrics.aappublications.org/cgi/content/full/106/4/e44PubMedGoogle Scholar 5. Jellinek MSMurphy JM Screening for psychosocial disorders in pediatric practice. Am J Dis Child. 1988;142153- 117PubMedGoogle ScholarCrossref 6. Brosco J The future of primary prevention: why integrate care? Paper presented at: A Preview of the Future: Integrated Pediatric and Behavioral Health Care for Children and Adolescents conference June 12, 2003 New York, NY

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Aug 1, 2004

Keywords: mental health,pediatrics

References