Care Transformation Center Blog

Pediatric behavioral health: Why a few changes make the difference

Behavioral health conditions can be difficult to manage, in part because they encompass a broad range of diagnoses, present at different points of the care continuum, and are pervasive in both adult and pediatric populations. Nearly 11% of teens ages 12 to 17 experienced a major depressive episode in 2013, and this figure has steadily increased over time. Programs that offer behavioral health services to pediatric populations must accommodate the unique needs of these younger patients.

Source: Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings,” NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD.

Pediatric patients generally present with a different assortment of behavioral health conditions relative to adults, with common diagnoses ranging from severe trauma, to undiagnosed autism spectrum, to mismanaged pharmacotherapy. In program design and implementation, pediaric populations require consideration of additional stakeholder groups, including parents, caregivers, and social and community representatives. There are also singular opportunities for partnership and collaboration with schools and school-based clinics to introduce reliable access points for screening and treatment.

Michigan Child Care Collaborative (MC3) is a multi-stakeholder initiative providing behavioral health consultations and treatment services across the state. This program has worked to expand access to behavioral health services for pediatric patients by offering a comprehensive suite of virtual and co-located services.

MC3's multi-faceted approach to behavioral health integration

The goal of the MC3 program is to connect patients with unmet needs to appropriate behavioral health services—more than 80% of the participants had not met with a psychiatrist prior to their MC3 consultation. MC3 incorporates three pathways to boost both patient and provider access to behavioral health expertise:

Embedded behavioral health consultants
In primary care practices with the highest patient volumes, behavioral health consultants are co-located to perform independent patient visits and collaborate with the primary care providers on care planning activities. Behavioral health consultants also support screening for pediatric patient as a part of these co-located, collaborative services. For primary care practices that already have their own embedded behavioral health providers, MC3 includes these practitioners in case conferences to boost access and referral adherence.

On-demand psychiatric consultations
Primary care providers may request a consult with an on-call psychiatrist to give recommendations within 2-4 hours (M-F; 8-5). These requests typically include questions on differential diagnoses, medication management, treatment planning, and qualification for community services. The program currently offers consultation services to 514 enrolled providers (including school-based clinics) across 40 counties.

Virtual patient interactions using telepsychiatry
For those patients with repeat consults or particularly complex mental health needs, the behavioral health consultant, on-call psychiatrist, and primary care provider make a joint decision to determine if a virtual telepsychiatry visit is appropriate. The community mental health agency then contracts to provide telepsychiatry to the primary care practice under Medicaid payments. In terms of telehealth investments, the program has purchased iPads and mobile units for the behavioral health consultants and a HIPAA-compliant videoconferencing platform to administer the visits.

PCP engagement is an essential ingredient

One of the biggest challenges MC3 has encountered in terms of program design and operations has been getting physicians to proactively refer appropriate patients to both consultation and tele-psychiatry services. Primary care practice enrollment doesn’t guarantee referral volumes. Since its initial launch in 2012, MC3 administrators have developed several operational tactics to boost physician engagement:

1. Streamline workflows to make referrals intuitive and easy
Minimizing process steps and creating a user-friendly information-sharing platform increases the likelihood that a time-stressed primary care provider will be able to follow through with referrals.

2. Address any liability concerns around telehealth and psychiatric screening
In many cases, primary care providers may not be familiar with liability, privacy, and documentation standards for psychiatric and telehealth services. Educating primary care teams on state requirements and organizational standards will alleviate provider reluctance.

3. Create a single point of contact for each primary care practice
Designating a dedicated behavioral health specialist who consistently works directly with the practice care teams builds trust and familiarity with the program.

4. Involve all members of the primary care team in behavioral health conversations
Maintaining relationships with several members of the primary care team can help reignite interest and engagement if any one primary care provider falls through the cracks.

5. Keep in touch, but be concise
MC3 sends program updates and newsletter style email blasts to participating practices to inform them of new developments and available resources. This type of informal, routine interaction also enhances transparency and can support quality improvement activities.

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