Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice

Abstract

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “Strategies for System Change in Children's Mental Health: A Chapter Action Kit” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them.This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma.Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in this report while recognizing that priorities for change and the sequence of change will be determined by the needs of the children and families whom the practice serves and by the capacity and resources of the practice.Children with mental health problems are children with special health care needs. Although many people can and do recover from their mental health problems, they may chronically experience symptoms and/or some level of impaired functioning. Although much of the literature on the chronic care model focuses on medical rather than mental health conditions and on adults rather than children with mental illness,5,6 the task force recognizes the applicability of chronic care methods to children with mental health problems and the potential importance of these methods in creating a “medical home” for children who experience mental health problems (Fig 1).The payoff at the practice level can be substantial. For example, a majority of studies on depressed adults managed with chronic care methods in primary care settings have documented significant improvement in quality and outcomes. Moreover, most studies have shown decreases in the cost of care or reductions in the use of health services.7Most practices will not be able to implement quickly all or even most of the elements of the chronic care model. Practice change is a slow and incremental process that requires learning and modification at the practice level. Primary care clinicians and managers can consider which strategies seem most feasible and are most consistent with other aspects of their practice and gradually plan the enhancements they choose.The Mental Health Practice Readiness Inventory (Appendix S3) can assist primary care clinicians and managers in assessing the strengths and needs of the practice and in setting its priorities. The inventory is organized in accordance with key elements in the chronic care model: (1) community resources; (2) health care financing; (3) support for children and families; (4) clinical information systems/delivery system redesign; and (5) decision support for clinicians. Individual clinicians and practices may have limited influence over some of these elements, but there are steps that any practice can take to improve mental health service delivery. Appendix S3 was designed to accompany reading of the following narrative and to structure practice-improvement initiatives.The task force envisions that clinicians typically will make changes first on behalf of children and adolescents with recognized mental health disorders in their practice. Discussions with specialists‡ about these patients will enhance the collaborative and clinical skills of primary care clinicians, and experience with scheduling, coding, and billing will build a business infrastructure for the practice's mental health services. Clinicians can subsequently apply the chronic care principles to children whose mental health problems do not meet the criteria of a diagnosable disorder but require care and monitoring nevertheless. With chronic care management and business systems in place, clinicians will be prepared to enhance their efforts to identify children with occult mental health and substance abuse problems; these efforts may include routinely screening for mental health and substance problems at health supervision visits (see discussion in Appendix S4). Efforts to implement screening before office systems, collaborative relationships, and referral supports are in place are unlikely to achieve sustainable benefits. Clinicians may choose to enhance their identification of children with mental health problems by focusing a screening effort on a particular age group or high-risk population within the practice or through mental health updates at acute care visits (see “Decision Support” below).Building resilience and promoting mental health in children and youth will require the participation of many organizations and individuals throughout the community. (See “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community”3 for a full discussion.) Treatment of children with mental illness will require strong collaborative relationships between primary care clinicians and the mental health specialty system. These collaborations will function in ways that will make practice better for both groups and care better for patients.This guide might include developmental- behavioral pediatricians, adolescent specialists, mental health and substance abuse specialists, family support groups, Early-Intervention (EI) services, human service agencies, child care consultants, parenting education programs, key school contacts, youth organizations, recreation programs, and others who are involved in supporting or serving children and families.The task force has developed a table to summarize key mental health services necessary to care for children with common mental health problems (Appendix S1). A variety of specialists may be qualified and reimbursed to offer evidence-based services, depending on state licensing policies and insurers' credentialing decisions.1 The selection of service providers depends on current information about the safety and efficacy of various treatments for the common childhood mental health disorders. Internet sources of this information include www.aap.org/mentalhealth,8 www.samhsa.gov,9 www.schoolpsychiatry.org,10 and www.aacap.org.11Methods to use in creating or adapting a resource guide for the practice are detailed in the chapter action kit1 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 Organizations in the community (eg, the public mental health agency; department of public health; local mental health association; local branches of consumer organizations such as the National Alliance on Mental Illness or Federation of Families for Children's Mental Health; support groups for families of children with specific disabilities such as autism or attention-deficit/hyperactivity disorder [ADHD]) typically benefit from such an inventory and are willing to participate in developing it or in building on one that is already in place.It is important to note the type(s) of third-party payment that each specialist or resource accepts and the types of assessment and/or therapies they provide. EI services are critical for young children who are experiencing socioemotional or developmental problems.3 As federally mandated services, they are universally available in the United States but variable in quality and accessibility. Details about EI referral criteria and intake procedures are important to include in the inventory.The burgeoning body of knowledge about early brain development calls attention to the critical importance of parenting, attachment, and high-quality child care on the emotional, social, and cognitive development of young children.12 Many communities have begun offering such services as nurse visits to pregnant and parenting women who are at high-risk, parenting programs, child care consultation, and therapeutic child care settings. These resources should be included in the inventory, along with resources to help parents and teachers who are dealing with anxiety, depression, substance abuse, mental illness, or other personal challenges that affect the quality or continuity of their relationships with young children.Schools are key partners in providing mental health services to children and in collecting data about children's academic and social functioning. In rural areas of the country they may, in fact, be the major provider of mental health services to children.13 Guidance counselors are typically the initial contact for clinicians seeking to establish a connection with the child's school; counselors, school nurses, or other school-based personnel may be helpful in making classroom observations, gathering behavior scales from teachers, assisting with implementation of classroom interventions, and pursuing testing for special educational services. They may also assist the primary care clinician in monitoring a child's progress and providing support and education to the family. A school psychologist can provide psychological testing; a school social worker can often provide counseling and linkage to other school and community resources; and the school system's special education officer can assist in determining a child's eligibility for special educational services or respond to questions about those services. School-based health centers may house additional professionals, including mental health specialists; when collaborative relationships exist between school-based health centers and primary care clinicians, these centers augment, rather than fragment, care.Involvement in extracurricular school activities enhances a child's attachment to school and improves his or her resilience.14,15 Involvement in community service and involvement in a faith community are also protective for youth.14–17 Recreation programs, youth groups, and family support groups may all play significant roles in providing children and adolescents with positive experiences and social skills; for this reason, all are relevant to child mental health and warrant inclusion in the practice's resource directory.Most clinicians are understandably reluctant to refer to sources that are unknown to them. The authors of “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community”3 suggest some strategies for getting to know mental health specialists and other child advocates through participation in efforts to address community mental health issues and gaps in services. In a policy statement on mental health competencies, the AAP suggests ideas for joint educational efforts, which may serve the additional purpose of fostering interpersonal relationships.4Referred families are also an invaluable source of information about community resources. Primary care practices can annotate their resource directory with the feedback received from children and families. This information will assist clinicians in creating matches between families and service providers or community programs.Previous understanding about respective roles of primary care clinicians and key mental health service providers can create efficiencies and improve coordination of care. For example, school-based personnel and primary care clinicians can meet to determine how they will collaboratively assess and monitor the progress of children with learning and behavior problems that affect school performance. Together, they can decide what circumstances or symptoms will trigger an evaluation at the school; what tools will be used to measure children's cognitive ability, academic achievement, and classroom behavior; who will gather the information and relay it to the primary care clinician; and what mechanisms will be used to convey the primary care clinician's assessment and care plan back to the school and monitor the child's progress in the classroom.18 Similarly, previous understanding with community agencies, such as child protective services or the juvenile justice system, about collecting a psychosocial and medical history from the biological parents before the child's placement in foster care or a juvenile detention facility can greatly improve continuity of care and assessment of the child's mental health needs. See the chapter action kit1 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community”3 for additional ideas about strengthening these relationships.Ultimately, collaborative clinical relationships are built through jointly caring for children and families. Personal contact and conversation are the starting point; yet, these can be challenging for the busy primary care clinician and a mental health professional. Mental health professionals often lack “front-office” personnel and instead function with little support and use voice mail to capture messages while they are in therapy sessions. They are also extremely protective of their patients' confidentiality, often exceeding standards of the Health Insurance Portability and Accountability Act (HIPAA). The primary care practice can develop office procedures to support collaboration (eg, routinely requesting families to sign a consent for exchange of information at the time of a referral; developing a previous understanding with mental health colleagues about a convenient time to chat; providing mental health colleagues with the primary care clinician's direct line; or hosting “lunch and learn” sessions for primary care clinicians and mental health professionals to exchange information, review cases, and coordinate care). Section “Prepare for Participation in the Full Range of Collaborative Models” provides more detail about the types of collaborative relationships that clinicians can nurture, and section “Put Office Systems in Place to Support Screening, Assessment, and Collaboration” elaborates on office procedures to support collaboration.To sustain innovations that improve care, primary care clinicians will require substantial enhancements in payment for their mental health services.The task force recognizes that many primary care clinicians in the United States are not adequately paid for the mental health care they provide. In some cases, this inadequate payment is because primary care clinicians are not aware of coding mechanisms that lead to payment. In other cases, it is because insurers do not pay for the mental health services that primary care clinicians provide (screening, assessment, early intervention to address emerging problems that do not rise to the level of disorders, interaction with schools and agencies, consultation with mental health specialty providers, care coordination, patient and family education, and family conferences). Furthermore, many insurers do not allow primary care clinicians to serve as mental health providers; instead, their insurance plans have mental health “carve-outs”—separate mental health provider networks with separate “gate-keeping” or intake procedures—that exclude primary care clinicians from participation and disallow payment of primary care clinicians for the mental health treatment services they provide to children with mental health diagnoses. For clinicians who function in this type of environment, preparation for enhancements in mental health practice will require advocacy efforts aimed at insurers of their patients and major purchasers of their patients' insurance plans. Strategies applicable to these efforts are detailed in the chapter action kit.1 A white paper developed jointly by the task force and the American Academy of Child and Adolescent Psychiatry addressing the administrative and financial barriers to providing collaborative mental health care was published in Pediatrics in April 2009.2Because mental health benefits and formularies are quite variable and often poorly understood by patients and families, many offices struggle to find out what resources are appropriate for referral or prescribing and what the patient cost-sharing for such services is likely to be. Increasingly, large insurers are providing online resources for rapid access. In addition, some creative vendors (eg, Rachel Systems19) provide such services for all insured patients in a region through a common Web portal so that office staff and clinicians can quickly identify appropriate resources and medications for any insured patients. Where such systems are not available, clinicians in a region (or perhaps AAP chapter or district) can collaborate or work through AAP chapter pediatric councils to acquire or develop such portals. Chapter pediatric councils are forums whereby pediatricians meet with health plan medical directors to discuss carrier policies and administrative practices that affect access to, quality of, coverage of, and payment for pediatric services.20The chapter action kit1 and “Enhancing Pediatric Health Care: Algorithms for Primary Care”21 (referred to throughout this article as “Algorithms for Primary Care”) provide tools to assist practices with coding and billing for mental health services. Informed by these tools and assisted by their practice manager and other staff members, primary care practices can create encounter forms to capture necessary documentation and ensure that the mental health services provided are billed for appropriately and efficiently. Supplemental Appendix S10 provides a listing of sample tools to assist primary care clinicians with these preparations.Pediatric primary care practices are typically child- and family-friendly places and can readily take additional steps to normalize and destigmatize mental health concerns. Engagement of children and their families in their own care is one of the best correlates of successful outcomes. Such efforts may focus on child and family motivation, education, skill-building, or emotional support. When mental health specialty care is needed, children and families need support in the referral process.Clinical staff, receptionists, and administrative staff may figure importantly in a child's and family's engagement or continuation in mental health care. McKay et al22 have developed a 1-day training that assists staff of outpatient mental health facilities in developing “first-contact skills” (including telephone engagement skills) and in identifying key barriers to seeking mental health care. Evaluation of sites that have implemented engagement strategies suggests that they have significantly higher appointment-keeping rates than sites that have not implemented these strategies. Although not developed specifically for primary care settings, the application of evidence-based engagement principles is likely to be beneficial to staff in primary care settings that provide mental health services.Creating an environment supportive of children and families facing mental health challenges requires that primary care practices address stigma. Clinicians can reflect with their staff members on the important role they can all play in making children and families comfortable to share and address mental health concerns. Staff members can examine their own knowledge and attitudes. They can affirm that mental illnesses are treatable; that children and adults living with these illnesses can achieve recovery and lead full and productive lives; and that mental illness is not a character flaw, a sign of moral weakness, or anyone's fault. They can eliminate language that contributes to stigma through defining people by their condition (eg, referring to someone as “a schizophrenic” or saying “he is bipolar,” instead of a person with schizophrenia or bipolar disorder). (See also “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3)Separation of mental health services from medical care contributes to stigma, poor coordination of care, and increased costs.23 The office environment can speak to the importance of mental health and substance abuse issues (eg, posters that invite mental health and substance abuse questions, educational materials about common mental health problems, brochures for crisis lines and support groups, and meeting places for evening support and treatment groups). By implementing Bright Futures guidelines,24 primary care clinicians can normalize mental health care and incorporate conversation about psychosocial issues into every routine health supervision visit. When given the opportunity during a well-child visit, most parents will express some concern about a behavioral or developmental issue.25Many primary care practices have concerns about the time and expertise required to address mental health concerns and about poor payment for the mental health services they provide.26 The use of previsit questionnaires and electronic tools to gather information from youth and families in advance of an office visit can allow clinicians to redirect their time from gathering data to addressing concerns.27–30 The practice can host educational sessions to assist clinicians in acquiring new skills (eg, improving diagnostic skills, gaining knowledge of treatment strategies, applying “common-factors” techniques to address concerns in primary care encounters, developing a contingency or crisis plan for urgent mental health problems, closing a visit in a supportive and efficient manner, and facilitating coding and billing that are specific to mental health).4,31Adverse childhood experiences may affect a person's mental health for a lifetime.12,32,33 Examples include trauma such as abuse or neglect, placement in foster care, death of a loved one, a move, separation and divorce of parents, military deployment of parent(s) or a sibling, incarceration of a parent or sibling, breakup of a relationship, and exposure to violence or a natural disaster. The clinician will need to view all future physical and mental health issues in the family through the prism of the traumatic experience(s).Children vary widely in their reactions to these events depending on their developmental level, temperament, previous state of mental health, coping mechanisms, parental responses, and support system. Practices should establish office systems that routinely collect information about such stressful experiences in the child's life and flag them in the health record of the child and siblings to signal clinicians' interest and support, monitor the child(ren)'s adjustment over time, and make appropriate referrals if the child's functioning is impaired. Conversely, overlooking such experiences and failing to follow-up on the child's and family's progress after a traumatic event are lost opportunities to connect with the child and family around important mental health issues.The anniversary date of a traumatic event or loss can also be recorded on the office calendar. Such practices as remembering a deceased loved one through use of his or her name during contacts with the child(ren) and family and sending them a note on the anniversary of the loved one's death can communicate support; it will also keep the door open to further conversations about the reactions of family members to trauma and loss and their effects on children.34People with mental health and substance abuse concerns are usually deeply concerned about confidentiality. Office procedures should ensure that all interactions between staff and children/families are private,24,35 including sign-in procedures, discussion of the reason for the visit or “chief complaint,” and each phase of the clinical process, including any referrals made to mental health or substance abuse specialists. In accordance with the HIPAA, the practice should post information about its privacy rules and offer families written information about them. Staff members can reinforce their commitment to maintaining confidentiality at the time they request consent for exchange of information with other health care providers and schools. All faxes should have cover sheets that label the information as confidential. When faxing information to schools or agencies that may have fax machines used by multiple staff members, previous arrangements may be necessary to ensure that the intended recipient is awaiting the fax and protects its confidentiality. Certain mental health information (eg, psychotherapy notes and any information related to substance abuse issues) is protected by federal statues that supersede the HIPAA.In states where minors are allowed to consent for their own mental health and substance abuse services, there should be a clear understanding with both youth and parents/guardians about “conditional confidentiality,” which is the clinician's right and responsibility to break confidentiality if he or she judges the youth or others to be in danger. Office procedures must ensure that youth treated for a mental health or substance abuse problem without their parent/guardian's knowledge express their preferences in relation to messages left on telephones and mailing of communications such as billing statements, laboratory results, and explanations of benefits. Further guidance for the protection of confidentiality of mental health and substance abuse information can be found in the chapter action kit under “Strategies to Collaborate With Mental Health Professionals,”1 and the AAP Policy Web site (www.aappolicy.org).Children gradually assume responsibility for their own health care. The timing and pace will depend on the child's maturity and cognitive abilities. By the time they reach adolescence, most of them will want an opportunity to air concerns directly with their health care providers and, at times, receive care without knowledge of their parents/guardians. The laws governing the confidentiality of minors' health care in relation to their parents/guardians vary from state to state. Keeping these factors in mind, a primary care practice may choose to mark the occasion of a patient's upcoming adolescent health supervision visit or 12th birthday by sending a letter to the adolescent and parents describing expectations for the adolescent's increasing independence in seeking and receiving health care and their practices in relation to privacy. At every visit with an adolescent, clinicians should reinforce the conditional confidentiality of their relationship. Appointment scheduling for adolescents should take into account the need to speak with both the adolescent and the parent/guardian privately. Both conversations are important, because parents and guardians may not be fully aware of their adolescents' activities or feelings, because the adolescents may be reluctant to share some concerns with their parents/guardians, and because youth and parents often differ in their ability to report on various mental health conditions (see “Algorithms for Primary Care”21). Further guidance on meeting the health care needs of adolescents is available in Bright Futures24 and from the Adolescent Health Working group.36At the time a primary care clinician identifies a child with a mental health problem, the child and family may be resistant to taking action to address the problem, perhaps because of the stigma of mental illness, conflict within the family, lack of resources, distraction by other family priorities, anger, denial, or a sense of hopelessness, possibly rooted in unsuccessful past efforts. Behavior-change science has demonstrated that people are in various stages of readiness to address a health problem: some are not even contemplating action, some are contemplating action but are ambivalent, some are ready to act, and some are already acting to create change.37 Rather than using a prescriptive approach, primary care clinicians are more effective if they assess a family's readiness to address a problem and then help them to move to the next stage of readiness at their own pace.4,21,38The practice can collaborate with a mental health professional to train clinicians in these techniques. Application of these techniques is quite manageable within the pace of a busy primary care practice, particularly if the primary care clinician is prepared with skills to bring a visit to an efficient and supportive close and to reschedule the family for additional brief sessions, if necessary.39 However, such primary care interventions are typically briefer than usual mental health outpatient services and different in content. Practice preparations to ensure appropriate scheduling, Current Procedural Terminology (CPT) coding, and billing for these sessions will help to make these activities sustainable. Guidance is available in the chapter action kit1 and in Supplemental Appendix S10.Although not a substitute for specialty care, interactive support services that assist patients and their families in managing, tracking, and working on their symptoms seem to be effective in extending the reach and success