Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Abstract

Public health and health care systems face many challenges as indicators of acuity and demand for child mental health services increase.1McMartin SE Kingsbury M Dykxhoorn J et al.Time trends in symptoms of mental illness in children and adolescents in Canada.CMAJ. 2014; 186: E672-E678Crossref PubMed Scopus (35) Google Scholar, 2Kalb LG Stapp EK Ballard ED et al.Trends in psychiatric emergency department visits among youth and young adults in the US.Pediatrics. 2019; 143e2018292Crossref Scopus (100) Google Scholar, 3Ruch DA Sheftall AH Schlagbaum P et al.Trends in suicide among youth aged 10 to 19 years in the United States, 1975 to 2016.JAMA Netw Open. 2019; 2e193886Crossref PubMed Scopus (132) Google Scholar These systems have not been designed to detect problems early and intervene with potentially preventive interventions.4Leslie LK. Mehus CJ. Hawkins JD et al.Primary health care: potential home for family-focused preventive interventions.Am J Prev Med. 2016; 17: S106-S108Abstract Full Text Full Text PDF Scopus (115) Google Scholar,5Cuijpers P Van Straten A Smit F Preventing the incidence of new cases of mental disorders: a meta-analytic review.J Nerv Ment Dis. 2005; 193: 119-125Crossref PubMed Scopus (132) Google Scholar In addition, the child mental health workforce lacks sufficient capacity as it is presently configured.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar Integration of mental health services into primary care has been promoted as one answer to these challenges7Unützer J Carlo AD Collins PY Leveraging collaborative care to improve access to mental health care on a global scale.World Psychiatry. 2020; 19: 36-37Crossref PubMed Scopus (22) Google Scholar and is endorsed by national and international organizations.8Foy JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (45) Google Scholar,9World Health Organization (WHO)Caring for Children and Adolescents With Mental Disorders: Setting WHO Directions. World Health Organization, Geneva2003Google Scholar Nearly all children have primary care visits,10Bloom B Cohen RA Freeman G Summary health statistics for U.S. children: national health interview survey, 2010. National Center for Health Statistics.Vital Health Stat. 2011; 10Google Scholar and the philosophy of pediatric primary care in the United States is oriented toward universal prevention, surveillance, and early intervention.11Jellinek M Patel BP Froehle MC Bright Futures in Practice: Mental Health – Volume I, Practice Guide. National Center for Education in Maternal and Child Health, Arlington, Va2002Google Scholar Primary care providers are seen as credible sources of psychosocial information and guidance,12Moseley KL Freed GL Goold SD Which sources of child health advice do parents follow?.Clin Pediatr (Phila). 2011; 50: 50-56Crossref PubMed Scopus (45) Google Scholar and many families express a preference for getting psychosocial care in a primary care rather than a mental health setting.13Herman PM Ingram M Rimas H et al.Patient preferences of a low-income Hispanic population for mental health services in primary care.Adm Policy Ment Health. 2016; 43: 740-749Crossref PubMed Scopus (8) Google Scholar Some of this preference comes from primary care being a more familiar and potentially less stigmatizing place to receive mental health care,14Pingitore D Snowden L Sansone RA et al.Persons with depressive symptoms and the treatments they receive: a comparison of primary care physicians and psychiatrists.Int J Psychiatry Med. 2001; 31: 41-60Crossref PubMed Scopus (55) Google Scholar a factor that may be especially salient to patients who already experience racial or ethnic stigma.15Interian A Lewis-Fernández R Dixon LB Improving treatment engagement of underserved U.S. racial-ethnic groups: a review of recent interventions.Psychiatr Serv. 2013; 64: 212-222Crossref PubMed Scopus (70) Google Scholar Incorporating mental health as part of “routine” medical care also sends a message that emotional well-being is an essential part of one's overall wellness.16McEwen B. The untapped power of allostasis promoted by healthy lifestyles.World Psychiatry. 2020; 19: 57-58Crossref PubMed Scopus (17) Google Scholar Prior to the beginning of this century, very few pediatricians worked in close coordination with mental health professionals. Despite evidence that child/youth integrated care can be effective and practical,17Asarnow JR Rozenman M Wiblin J et al.Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis.JAMA Pediatr. 2015; 169: 929-937Crossref PubMed Scopus (323) Google Scholar,18Platt 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: 242-271Crossref PubMed Scopus (21) Google Scholar still only about half of US pediatricians consider that they work in practices co-located with a behavioral health professional.19Richman EL Lombardi BM Zerden LDS Where Is Behavioral Health Integration Occurring? Mapping National Co-Location Trends Using National Provider Identifier Data. UMSPH, University of Michigan Behavioral Health Workforce Research Center. Ann Arbor, Mich2018Google Scholar Integration continues to face significant barriers, including lack of consensus on how primary care and co-located mental health professionals should share roles, the need for substantial transformation in how practices operate if they are to provide mental health care,20Sarvet B. The need for practice transformation in children's mental health care.JAACAP. 2017; 56: 460-461Google Scholar financing schemes that do not incentivize treatment in primary care or collaboration with mental health providers,21American Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (174) Google Scholar and a lack of mental health practitioners trained to work in primary care settings (especially in linguistically and culturally diverse communities).22Hails K Brill CD Chang T et al.Cross-cultural aspects of depression management in primary care.Curr Psychiatry Rep. 2012; 14: 336-344Crossref PubMed Scopus (9) Google Scholar,23Burkey MD Kaye DL Frosch E Training in integrated mental health-primary care models: a national survey of child psychiatry program directors.Acad Psychiatry. 2014; 38: 485-488Crossref PubMed Scopus (15) Google Scholar To these structural barriers, however, additional dilemmas have emerged as the field of integrated care has evolved. First, there is the realization that conceptualizing integrated care as a binary partnership between mental health and primary care does not address the high level of co-occurrence of mental health, developmental, and psychosocial problems that limit the effectiveness of mental health treatments when they are applied in isolation.24Spencer AE Baul TD Sikov J et al.The relationship between social risks and the mental health of school-age children in primary care.Acad Pediatr. 2020; 20: 208-215Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As the United States and much of the world enter into an era of unprecedented social and economic challenge related to the novel coronavirus, which has disproportionately impacted populations already experiencing limited access to mental health services, the need to expand the scope of integration will only become greater.25Yoshikawa H Aber JL Beardslee WR The effects of poverty on the mental, emotional, and behavioral health of children and youth: implications for prevention.Am Psychol. 2012; 67: 272-284Crossref PubMed Scopus (559) Google Scholar Second, there is the difficulty of translating the most widely known models of integrated care, developed in adult medicine, into pediatrics.26Katon W Unützer J Collaborative care models for depression: time to move from evidence to practice.Arch Intern Med. 2006; 166: 2304-2306Crossref PubMed Scopus (103) Google Scholar Compared to adult integrated care, child mental health integration must contend with presentations that vary significantly with age, which complicates screening and other forms of case-finding.27Costello EJ Mustillo S Erkanli A et al.Prevalence and development of psychiatric disorders in childhood and adolescence.Arch Gen Psychiatry. 2003; 60: 837-844Crossref PubMed Scopus (2759) Google Scholar Child mental health treatment relies more on brief, practical psychosocial interventions compared to easier-to-deliver medication titration.28Locher C Koechlin H Zion SR et al.Efficacy and safety of selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and placebo for common psychiatric disorders among children and adolescents: a systematic review and meta-analysis.JAMA Psychiatry. 2017; 74: 1011-1020Crossref PubMed Scopus (192) Google Scholar,29Marchette LK Weisz JR Practitioner review: empirical evolution of youth psychotherapy toward transdiagnostic approaches.J Child Psychol Psychiatry. 2017; 58: 970-984Crossref PubMed Scopus (69) Google Scholar In addition, while nearly everyone's mental health is related to that of the people they live with, children's mental health outcomes are particularly dependent on their parents’ own mental health,30Eckshtain D Marchette LK Schleider J et al.Parental depressive symptoms as a predictor of outcome in the treatment of child internalizing and externalizing problems.J Abnorm Child Psychol. 2019; 47: 459-474Crossref PubMed Scopus (16) Google Scholar and thus treatment often must include plans to address parents’ treatment needs and parent-child interactions.31Shonkoff JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (186) Google Scholar The American Academy of Pediatrics has issued a policy statement outlining what it sees as pediatric providers’ responsibilities to address parental mental health,32Earls MF Yogman MW Mattson G et al.Committee on psychosocial aspects of child and family health. Incorporating recognition and management of perinatal depression into pediatric practice.Pediatrics. 2019; 143: e20183259https://doi.org/10.1542/peds.2018-3259Crossref PubMed Scopus (105) Google Scholar but there remains little precedent for directly addressing parent mental health in pediatric primary care, despite its profound effects on children.33Young CA Burnett H Ballinger A et al.Embedded maternal mental health care in a pediatric primary care clinic: a qualitative exploration of mothers' experiences.Acad Pediatr. 2019; 19: 934-941Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar To date, integrated care has benefited from attempts at federal, state, and professional society levels to promote its implementation. With some exceptions, however, such as the Centers for Medicare and Medicaid Services’ InCK initiative, and efforts by the American Board of Pediatrics and the American Academy of Pediatrics,8Foy JM Green CM Earls MF Mental health competencies for pediatric practice.Pediatrics. 2019; 144: e20192757https://doi.org/10.1542/peds.2019-2757Crossref PubMed Scopus (45) Google Scholar,34Centers for Medicare and Medicade Services. Integrated Care for Kids (InCK) Model. Available at: https://innovation.cms.gov/innovation-models/integrated-care-for-kids-model. Accessed October 12, 2019.Google Scholar,35McMillan JA Land Jr, M Tucker AE Preparing future pediatricians to meet the behavioral and mental health needs of children.Pediatrics. 2020; 145: e20183796https://doi.org/10.1542/peds.2018-3796Crossref PubMed Google Scholar there has been a greater emphasis on doing so with care for adults.36Agency for Healthcare Research and Quality. The Academy. Integrating Behavioral Health & Primary Care. Available at: http://integrationacademy.ahrq.gov/. Accessed October 12, 2019.Google Scholar Other policy analyses have addressed how health systems as a whole, including those with integrated care components, can promote child and family well-being in general.37Bethell C Kennedy S Martinez-Vidal E Payment for Progress: Investing to Catalyze Child and Family Well-Being Using Personalized and Integrated Strategies to Address Social and Emotional Determinants of Health. AcademyHealth, Washington, DC2018Google Scholar The following recommendations focus more narrowly on integrating mental health into pediatric primary care. The recommendations are intended as a guide to policymakers, health system leaders and educators, and research funders; they address 4 goals that, based on the analysis above, we believe are central to the growth and effectiveness of pediatric integrated care.1.Transform pediatric practice to address family psychosocial needs First and foremost, policies must promote changes in the scope of pediatric primary care so that it can comprehensively address families’ psychosocial needs.38Freeman BK Coker TR Six questions for well-child care redesign.Acad Pediatr. 2018; 18: 609-619Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Multigenerational social and emotional wellness needs to be accepted as an integral part of pediatric care and these aspects of health need to be effectively assessed and treated by pediatricians and/or in collaboration with community-based services that address social determinants of health.31Shonkoff JP Fisher PA Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy.Dev Psychopathol. 2013; 25: 1635-1653Crossref PubMed Scopus (186) Google Scholar,39Shah PE Muzik M Rosenblum KL Optimizing the early parent-child relationship: windows of opportunity for parents and pediatricians.Curr Probl Pediatr Adolesc Health Care. 2011; 41: 183-187Crossref PubMed Scopus (8) Google Scholar State and federal programs have the ability to influence these transformations through regulatory changes, financial incentives, and corresponding technical assistance. Individual providers and health care organizations need the clear guidance, motivation, and knowledge of how to go about modifying their practices and building the community alliances they will need to provide truly integrated care. Requiring health care systems to report mental health-related metrics will allow state and federal authorities to optimally leverage incentives. Specific initiatives could include:a.Federal and/or state incentives for implementing “Advanced Medical Home” or “High Performing Medical Home”40North Carolina Department of Health and Human Services. Care Management-Ambulatory Mental Health Concept Paper. Available at:https://files.nc.gov/ncdhhs/documents/CareMgmt-AMH_ConceptPaper_FINAL_20180309.pdf. Accessed March 6, 2020.Google Scholar,41American Academy of Pedatrics. (n.d.). AAP agenda for children: medical home. Available at:https://www.aap.org/en-us/about-the-aap/aap-facts/AAP-Agenda-for-Children-Strategic-Plan/Pages/AAP-Agenda-for-Children-Strategic-Plan-Medical-Home.aspx. Accessed March 6, 2020.Google Scholar models that are foundations for integrated care. States can support these models by giving practices additional payments if they meet criteria for certification (see financing recommendations below). Incentives could be tailored to reward the use of integrated care to address disparities in mental health services and outcomes, as well as to reward coordination of child/youth and adult mental health services.b.The federal government could expand past policy statements regarding the detection and treatment of parental mental health problems as part of pediatric primary care.42Centers for Medicare & Medicaid Services Informational BulletinMaternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Department of Health and Human Services, CMMS, Baltimore2016Google Scholar Expansions could include that attention to parental mental health extends beyond concern for maternal depression in the perinatal period, as well as stating the appropriateness of including relevant parent mental health information in the child's medical record. These statements, coupled with increased training for pediatricians in the detection and initial assessment of parental health issues, could help to clearly include attention to parental mental health as within the scope of pediatric practice.c.The federal government (through Medicaid, Substance Abuse and Mental Health Services Administration, the Indian Health Service, and Health Resources and Services Administration) or individual states could fund programs that provide practices or health systems with the technical assistance needed to adopt pediatric integrated care, such as New York State's Collaborative Care Medicaid Program.43University of Washington AIMS Center. Collaborative Care Medicaid Program. Available at: https://aims.uw.edu/nyscc/programs/collaborative-care-medicaid-program-ccmp. Accessed March 6, 2020.Google Scholar,44Dayton L Agosti J Bernard-Pearl D et al.Integrating mental and physical health services using a socio-emotional trauma lens.Curr Probl Pediatr Adolesc Health Care. 2016; 46: 391-401Crossref PubMed Scopus (15) Google Scholar Additionally, the federal government could fund a national clearinghouse on pediatric integrated care efforts such inckmarks.org (which helps disseminate information related to the Center for Medicare and Medicaid Innovation InCK demonstration program),34Centers for Medicare and Medicade Services. Integrated Care for Kids (InCK) Model. Available at: https://innovation.cms.gov/innovation-models/integrated-care-for-kids-model. Accessed October 12, 2019.Google Scholar or expansion of the current Substance Abuse and Mental Health Services Administration-sponsored integrated care site45National Council for Behavioral Health. Center of Excellence for Integrated Healthcare Solutions. Available at: http://www.thenationalcouncil.org/integrated-health-coe/. Accessed March 6, 2020.Google Scholar to showcase exemplar efforts of individual practices/systems that have implemented integrated care (ideally representing all states since they have relatively unique population and policy environments, as well as models that work in communities with varying levels of mental health resources).d.Health Resources and Services Administration could expand and institutionalize its support so that all states could have so-called “child psychiatry access programs” that promote interprofessional collaboration and education supporting mental health service delivery in the pediatric primary care.46Sarvet BD Ravech M Straus JH Massachusetts child psychiatry access project 2.0: a case study in child psychiatry access program redesign.Child Adolesc Psychiatr Clin N Am. 2017; 26: 647-663Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,47Stein BD Kofner A Vogt WB et al.A national examination of child psychiatric telephone consultation programs' impact on children's mental health care utilization.J Am Acad Child Adolesc Psychiatry. 2019; 58: 1016-1019Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar These programs provide informal mental health consultation to primary care providers around specific patient's problems, and many currently have primary care provider training and practice transformation components which could be expanded to include helping integrated behavioral health providers (including those in schools) adopt and use evidence-based brief interventions or telepsychiatry when necessary. Coordinated with these “access programs,” states, health care organizations, and philanthropy could fund additional mental health skills training for primary care providers, taking advantage of the “access programs” ability to provide long-term, ongoing consultation and support for practice transformation.48Mazurek MO Parker RA Chan J et al.Effectiveness of the extension for community health outcomes model as applied to primary care for autism: a partial stepped-wedge randomized clinical trial.JAMA Pediatr. 2020; 174e196306Crossref PubMed Scopus (22) Google Scholare.The federal government, as with earlier programs that supported adoption of electronic medical records, could have similar programs promoting collection of patient-reported outcome measures and the ability to communicate in a “closed referral loop” with key community social program partners.49Massachusetts Food Is Medicine State PlanCenter for Health Law and Policy Innovation. Harvard Law School, Cambridge2019Google Scholar,50Huber BJ Austen JM Tobin RM et al.Overcoming barriers to rural children's mental health: an interconnected systems public health model.Adv Sch Ment Health Promot. 2016; 9: 219-241Crossref Scopus (4) Google Scholar These efforts would include 1) additional federal funding for public-domain systems such as PROMIS that could facilitate collection of family-level outcomes,51Mazefsky CA Yu L Pilkonis PA Psychometric properties of the emotion dysregulation inventory in a nationally representative sample of youth.J Clin Child Adolesc Psychol. 2020; 7: 1-13Crossref Scopus (23) Google Scholar,52Blackwell CK Wakschlag L Krogh-Jespersen S et al.Pragmatic health assessment in early childhood: the PROMIS® of developmentally based measurement for pediatric psychology.J Pediatr Psychol. 2020; 45: 311-318Crossref PubMed Scopus (2) Google Scholar and 2) funding local development of programs that facilitate communication between primary care teams and external service providers such as schools, food and housing programs, and programs that economic security.53Scheid D Yeaman B Nagykaldi Z et al.Regional Health eDecisions: A Guide to Connecting Health Information Exchange in Primary Care. AHRQ, AHRQ Publication No. 13-0018-EF. Rockville, Md2013Google Scholarf.The federal and state governments could create programs that increase their ability to hold payers accountable for the delivery of child/youth mental health care. For example, states could require that insurers and managed care organizations collect and publish statistics on out-of-network child behavioral health referrals, stratified by age, gender, ethnicity, and professional type (ie, psychiatric providers, therapists, neuropsychological testing). These statistics can be a proxy for the (in)adequacy of a network's mental health resources and the extent to which they are accessible by different populations. If states are authorizing the use of “collaborative care codes” (see below in financing), compiling statistics on the use of these codes could serve as a marker for the implementation of integrated care and potentially increased access and early intervention. Requiring additional codes that indicate the results of mental health screening in primary care can help document whether primary care is serving as an effective gateway for child/youth mental health services.54Hacker KA Penfold RB Arsenault LN et al.Behavioral health services following implementation of screening in Massachusetts Medicaid children.Pediatrics. 2014; 134: 737-746Crossref PubMed Scopus (18) Google Scholar2.Make pediatric integrated care financially feasible Second, policies must make pediatric integrated care financially feasible for individual practices and health systems, especially at a time when limitations on overall social and health care resources may reduce the cross-subsidization of mental health care by services that have a positive “margin.”55Bailit M Harguanani D Taylor E Challenge Guide: Payment Reform to Address Social Determinants of Health in Children. Bailit Health, Needham, Mass2018Google Scholar Pediatric integrated care does not produce the short-term cost-offsets potentially obtainable from adult integrated care, and psychological interventions for families with children are more time-consuming to deliver than prescribing medications for adults. Business models must take into account the investment in time it takes providers to build relationships with families (especially those who have experienced trauma or discrimination), directly support parents, collaborate with schools and other community organizations, and track a practice's population of children and youth with psychosocial needs. Financial feasibility varies from state to state and among practices with different payer mixes. Steps that could create more uniform opportunities across the country include:a.The federal government, professional organizations, academics, and advocates can help disseminate to state health financing authorities examples of which components of integrated care can currently be paid for using Medicaid and Children's Health Insurance Program funds directly or as part of negotiating managed care contracts.56Ross DC Guyer J Lam A et al.Fostering Social and Emotional Health Through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Center for the Study of Social Policy, Washington, DC2019Google Scholar,57Tyler ET Hulkower RL Kaminski JW Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Milbank Memorial Fund, New York2017Google Scholar For example, states could preferentially award managed care contracts to organizations that have strong integrated care programs, provide or pay for preventive parenting services, have demonstrated, at-scale working linkages to services addressing the social determinants of health, coordinate parental and child mental health care, or reimburse for telepsychiatry as a method for implementing integrated care.b.States can take several actions to reduce barriers to fee-for-service payment for integrated mental health services including:21American Academy of Child and Adolescent Psychiatry Committee on Healthcare Access and Economics, American Academy of Pediatrics Task Force on Mental HealthImproving mental health services in primary care. Reducing administrative and financial barriers to access and collaboration.Pediatrics. 2009; 123: 1248-1251Crossref PubMed Scopus (174) Google Scholar,55Bailit M Harguanani D Taylor E Challenge Guide: Payment Reform to Address Social Determinants of Health in Children. Bailit Health, Needham, Mass2018Google Scholar, 56Ross DC Guyer J Lam A et al.Fostering Social and Emotional Health Through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change. Center for the Study of Social Policy, Washington, DC2019Google Scholar, 57Tyler ET Hulkower RL Kaminski JW Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers. Milbank Memorial Fund, New York2017Google Scholar•Making it easier to empanel mental health providers who work in primary care settings,•Making it easier to license primary care sites as also providing mental health services,•Allowing primary care providers to refer to co-located or collaborating mental health providers without the need for authorization,•Allowing first-line mental health treatment by co-located or collaborating mental health providers of all disciplines as part of medical benefits (without additional co-pays),•Not requiring a formal mental health diagnosis for an initial series of mental health visits, and•Allowing billing for mental health care on the same day as a primary care service.c.States can expand the use of billing codes that support collaborative work so that both primary care and psychiatric providers can be paid for indirect consultation, case review, and coordination of referrals for both children and parents.58Washington State Health Care Authority. WAC 182-531-0425 Collaborative Care. Available at: https://www.hca.wa.gov/health-care-services-supports/collaborative-care. Accessed March 6, 2020.Google Scholar As part of paying for collaborative care, states can also allow billing for the services of community health workers or navigators who can link families to needed follow-up services and reinforce/deliver mental health treatments (see below in workforce).d.The federal government and private insurers could allow wider latitude for billing for parent-directed services that also have potential for impact on the child.42Centers for Medicare & Medicaid Services Informational BulletinMaternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children. Department of Health and Human Services, CMMS, Baltimore2016Google Scholar3.Develop a larger and more diverse integrated care workforce Third, policies need to encourage development of the workforce so that integrated care can be delivered at scale.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar Not only is there a general lack of child mental health workforce in most areas of the country, there is an even greater lack of providers trained to work at the interface of medicine, mental health, and community supports.6AACAP work force fact sheet. Available at:https://www.aacap.org/App_Themes/AACAP/docs/resources_for_primary_care/workforce_issues/workforce_factsheet_updated_2018.pdf. Accessed March 6, 2020.Google Scholar,23Burkey MD Kaye DL Frosch E