Child Psychiatry Access Programs Research Articles

9.7 PEDIATRIC PRIMARY CARE PROVIDER COMFORT WITH MENTAL HEALTH PRACTICES: ASSESSING REGIONS WITH TREATMENT SHORTAGES

According to the National Survey of Children’s Health (2016), nearly 50% of children with a diagnosable mental health (MH) concern do not receive treatment. Child Psychiatry Access Programs like Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) address regional shortages of MH treatment access by supporting primary care providers (PCPs) with managing their patients’ MH concerns. The purpose of the current study is to assess PCPs’ comfort with MH practices to inform expansion of BHIPP services.

9.9 UTILIZATION AND OUTCOMES OF CHILD PSYCHIATRY CONSULTATION TO PEDIATRIC PRIMARY CARE PRACTITIONERS

In the context of a national shortage of child and adolescent psychiatrists, pediatric primary care practitioners (PCPs) are managing an increasing number of patients with mental health disorders. In an effort to better support PCPs’ provision of mental health services, currently 20 states offer telephonic and face-to-face (FTF) consultations with child and adolescent psychiatrists. We sought to examine the utilization and clinical outcomes of FTF child and adolescent psychiatrist consultations available to community pediatric practices affiliated with Boston Children’s Hospital (BCH) through enrollment in the Massachusetts Child Psychiatry Access Program (MCPAP).

9.8 REFLECTING ON A DECADE OF COLLABORATIVE CARE IN NEW YORK: LESSONS LEARNED AND CUMULATIVE DATA FOR PROJECT TEACH REGIONS 1 AND 3

There are currently over 20 large-scale, statewide child psychiatry access programs across the United States. This study provides updated data on the Child and Adolescent Psychiatrists for Primary Care group Region 1 and 3 providers for Project TEACH (PT), one of the larger programs in the country. With the program reaching its 10-year mark, this would be a good time to reflect on the challenges and successes of establishing a broad-scale, pediatric collaborative care program. PT, established in 2010, is a New York State Office of Mental Health initiative to provide child mental health support to assist primary care in assessing and managing children with mild-to-moderate mental health needs. Child and Adolescent Psychiatrists for Primary Care is 1 of 2 regional providers for PT and provides service to over 80% of New York State. The program is a collaboration between 5 university-based child psychiatry divisions. PT consists of 3 broad efforts: formal education, linkage/referral assistance, and consultation support for primary care physicians. In 2016, the program was re-funded for 5 years through June 2021. A statewide coordinating center (SCC), the Massachusetts General Hospital (MGH) Psychiatry Academy, was also designated at that time. The SCC coordinates and oversees the efforts of the 2 regional providers, markets the program, maintains the website, and oversees education and evaluation.

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

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

A Systematic Review of the Methods Used to Evaluate Child Psychiatry Access Programs.

There is a well-documented gap between the need for and availability of mental health services for children nationwide. To address this gap, over 30 regional Child Psychiatry Access Programs (CPAPs) provide psychiatric consultation and other services to primary care providers. Summarize the methods used to evaluate CPAPs in the United States. PubMed, PsychInfo, CINAHL, and reference checking. A systematic literature review was conducted searching 3 databases. The search produced 307 unique articles, 278 were excluded for irrelevance, leaving 29 for data extraction. Data extracted included author(s), publication year, provider types, CPAP formats, study sample, design, outcomes examined, results, and limitations. Articles were also appraised for quality using the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide. The 29 articles evaluated 13 unique CPAPs. Most evaluations used nonexperimental observational designs (68.9%), 6.9% used quasi-experimental designs, and none used true experimental designs. Evaluations examined the following outcomes: usage of program services (82.8%), provider satisfaction (48.3%), provider comfort/confidence with managing mental health concerns (31.0%), provider practice change (24.1%), patient outcomes (13.7%), and family satisfaction (6.9%). Outcomes were measured using surveys, qualitative interviews, or insurance claims data. Review was limited to articles published in English in 3 databases or identified by reference checking. Evaluations of CPAPs have largely been descriptive in nature, focusing primarily on program usage and provider satisfaction. Few studies have examined the impact of CPAPs on patients, families, or health systems. Future studies should evaluate the broader impacts of CPAPs.

3.24 EVALUATING CHILD PSYCHIATRY ACCESS PROGRAMS: A SYSTEMATIC REVIEW

Between 13 and 20 percent of US children experience mental health problems annually. There is a well-documented gap between the need for and availability of mental health services for children nationwide. In response to this demand, more than 30 regional Child Psychiatry Access Programs (CPAPs) have been established to provide mental health consultation to primary care providers. The purpose of this review was to understand how CPAPs in the United States have been evaluated.

1.12 COLLABORATIVE MENTAL HEALTH CARE FOR ASD IN A STATEWIDE CHILD PSYCHIATRY ACCESS PROGRAM (CPAP) FOR PRIMARY CARE

Primary care providers (PCPs) play an important role in treating youth with ASD. The AAP recommends that PCPs only prescribe psychotropic medications with which they have sufficient expertise. Experts have suggested that PCPs consult with child psychiatry access programs (CPAP) for help in treating ASD. We examined calls for whom PCPs sought consultation with the Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) CPAP. We examined ASD (vs. non-ASD) differences in: 1) illness severity; 2) comorbidity; and 3) psychotropic medication use. Differences within ASD consults were examined to predict illness severity and co-management with a mental health (MH) provider.

4.7 ROLE OF CHILD PSYCHIATRY ACCESS PROGRAMS (CPAPS) IN SUICIDE SCREENING AND ASSESSMENT

The objectives of this presentation are as follows: 1) to categorize the nature of safety concerns reported to a Child Psychiatry Access Program (CPAP); and 2) to describe the rates of referrals to emergency departments (EDs) by pediatricians following consultation with a CPAP.

3.44 CHARACTERISTICS OF PROVIDERS USING A CHILD PSYCHIATRIC ACCESS PROGRAM IN MARYLAND

Despite a significant increase in outpatient visits for diagnosis and treatment of mental health disorders among youth, there is a growing gap between the need for and availability of pediatric mental health services (MHS). Child Psychiatry Access Programs (CPAPs), similar to the Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) program, have shown promise in increasing access to MHS. The purpose of this study is to describe the types of primary care clinicians (PCCs) that call BHIPP and to examine patterns of their use of BHIPP services.

3.16 EIGHT YEARS OF COLLABORATIVE CARE IN NEW YORK: CURRENT DATA FOR PROJECT TEACH, REGIONS 1 AND 3

There currently are more than 20 large-scale, statewide child psychiatry access programs across the United States. This study provides updated data for year 8 on the Child and Adolescent Psychiatry for Primary Care (CAP PC)—Regions 1 and 3 providers for Project TEACH—one of the larger programs in the country. Project TEACH, established in 2010, is a New York State Office of Mental Health initiative that provides primary care professionals with the tools they need to assess and manage children with mild-to-moderate mental health needs.

Impact of Child Psychiatry Access Programs on Mental Health Care in Pediatric Primary Care: Measuring the Parent Experience.

This study aimed to assess parents' satisfaction with the primary care provider (PCP) in the treatment of their child's mental health problems after the PCP consulted with the Massachusetts Child Psychiatry Access Program (MCPAP). It studied how parental satisfaction may vary across factors, including service utilization, parental perception of the child's illness, and parental perception of certain PCP attributes. The study analyzed 374 telephone consultations made from PCPs to MCPAP between March 2010 and June 2012. Questions in a structured telephone survey administered to parents identified the types of services participants were referred to and assessed satisfaction rates on the basis of measures reflective of the patient-doctor relationship and of illness factors. Eighty-six percent of participants expressed satisfaction with their PCP's handling of their child's mental health problems after MCPAP consultation. Participants who agreed with statements reflective of a positive patient-doctor relationship (in terms of the PCP's empathy and knowledge) exhibited higher rates of satisfaction with the PCP's role in the treatment of their child's mental health problems than those who did not agree. The most common recommendations made to families after consultation were to follow up with the child's PCP (94%) and to obtain further MCPAP consultation (78%). The survey results indicated high rates of parents' satisfaction with the PCP's handling of their child's mental health issues. Recommendations made to PCPs by MCPAP consultants aimed to strengthen the PCP's role as a mental health provider.

4.3 Update on Collaborative Care in New York: Current Data for Project Teach Regions 1 and 3

There are currently over 20 large-scale, statewide child psychiatry access programs across the United States. This study provides updated data for year 8 on CAP PC, regions 1 and 3 providers for Project TEACH, one of the largest programs in the country. Background: Project TEACH, initiated in 2010, is a New York State Office of Mental Health initiative to provide child mental health support to assist primary care in assessing and managing children with mild to moderate mental health needs. CAP PC is one of 2 regional providers for Project TEACH and provides service to over 80% of New York State. The program is a collaboration between 5 university-based child psychiatry divisions that opened in 2010. CAP PC consists of 3 broad efforts: 1) formal education; 2) linkage/referral assistance; and 3) consultation support for primary care physicians. In 2016, the program was refunded for 5 years. A statewide coordinating center (SCC), the Massachusetts General Hospital (MGH) Psychiatry Academy, was also designated. The SCC coordinates and oversees efforts of the 2 regional providers.

Massachusetts Child Psychiatry Access Program for Moms: Utilization and Quality Assessment.

To describe the utilization and quality assessment of a population-based program to help health care providers address mental health and substance use disorders among pregnant and postpartum women, the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms). The Massachusetts Child Psychiatry Access Program for Moms builds health care providers' capacity to address perinatal mental health and substance use disorders through 1) trainings and toolkits, 2) telephonic access to perinatal psychiatric consultation, and 3) facilitating referral to community resources. Clinical encounter data were collected during telephone consultations. Focus groups were conducted with health care providers and staff from enrolled practices. In-depth interviews were conducted with patients served by the practices that participated in the focus groups. Transcribed interviews were analyzed by two researchers using an iterative, interpretive process with a grounded theory framework. In the first 3.5 years, MCPAP for Moms enrolled 145 obstetric practices, conducted 145 trainings for 1,174 health care providers, and served 3,699 women. Of telephone consultations provided, 42% were with obstetric care providers-midwives and 16% with psychiatrists. Health care providers perceived that MCPAP for Moms facilitates health care providers detecting and addressing depression and women disclosing symptoms, seeking help, and initiating treatment. Obstetric practices reported that they need additional support to more proactively address and further improve depression care. The high volume of encounters, sustained utilization over 3.5 years, and qualitative themes identified from health care providers and patients demonstrate that MCPAP for Moms is a feasible, acceptable, and sustainable approach to increasing access to evidence-based treatments for perinatal mental health and substance use disorders on a population-based level.

Severity of mental health concerns in pediatric primary care and the role of child psychiatry access programs.

To describe the clinical severity of patients for whom Primary Care Providers (PCPs) requested consultation from Maryland's Child Psychiatry Access Program (CPAP), and examine the proportion and associated characteristics of severe cases being managed alone by PCPs versus co-managed with mental health specialists. Data were collected for 872 cases based on calls received between October 2012 and December 2016. Severity was measured by consultant-assigned Clinical Global Impression-Severity (CGI-S) score. The unadjusted odds of a PCP managing a case alone for select patient and provider characteristics was calculated in a sub-sample of 229 severe cases. 73.8% of cases were categorized as mild-moderate (CGI-S 1-4) and 26.3% as severe (CGI-S 5-7). 67.3% of severe cases were managed by a PCP alone; 32.8% were co-managed. The unadjusted odds of a severe case managed alone was lower for cases with greater numbers of psychotropic medications (OR 0.76, 95% CI 0.6, 0.96), prescription of antidepressants (OR 0.51, 95% CI 0.28, 0.95), or antipsychotics (OR 0.45, 95% CI 0.22, 0.94) compared to co-managed cases. PCPs manage patients with severe mental health concerns, often without assistance from specialists. CPAPs should systematically consider how to support the PCPs' role managing clinically severe cases.

20.0 Simon Wile Symposium: Super-Powered Child Psychiatry Access Programs! Adding Value From System-Wide Integration, Early Childhood Interventions, and Quality Improvement Initiatives

The goal of this year’s Simon Wile Symposium will be to examine innovative practices in child psychiatry access programs (CPAPs) that improve access to quality mental health care for children, adolescents, and families across the nation. National experts will share their experiences and perspectives in building systems to reach pediatric primary care providers (PCPs), work within and improve regional child health and mental health systems, and continually innovate beyond the core of regional telephone consultation lines.

Massachusetts Child Psychiatry Access Project 2.0: A Case Study in Child Psychiatry Access Program Redesign.

The Massachusetts Child Psychiatry Access Program is a statewide public mental health initiative designed to provide consultation, care navigation, and education to assist pediatric primary care providers in addressing mental health problems for children and families. To improve program performance, adapt to changes in the environment of pediatric primary care services, and ensure the program's long-term sustainability, program leadership in consultation with the Massachusetts Department of Mental Health embarked on a process of redesign. The redesign process is described, moving from an initial strategic assessment of program and the planning of structural and functional changes, through transition and implementation.

Telemedicine for Child Collaborative or Integrated Care.

Telemedicine with child psychiatry specialists is a useful tool for collaborative and integrated care systems. This article reviews the workforce and care process rationale for using child psychiatric telemedicine for collaborative care, and discusses practical ways to address the technical challenges that arise when using telemedicine. Different systems of using telemedicine discussed include child psychiatry access programs, collaborative and integrated care use of telephone consultations, televideo consultations, and televideo care delivery. Telemedicine can also be used for collaboratively conducted but care review requested by third-party consultations with treatment providers or care teams.

Description of a multi-university education and collaborative care child psychiatry access program: New York State's CAP PC.

Although, child mental health problems are widespread, few get adequate treatment, and there is a severe shortage of child psychiatrists. To address this public health need many states have adopted collaborative care programs to assist primary care to better assess and manage pediatric mental health concerns. This report adds to the small literature on collaborative care programs and describes one large program that covers most of New York state. CAP PC, a component program of New York State's Office of Mental Health (OMH) Project TEACH, has provided education and consultation support to primary care providers covering most of New York state since 2010. The program is uniquely a five medical school collaboration with hubs at each that share one toll free number and work together to provide education and consultation support services to PCPs. The program developed a clinical communications record to track information about all consultations which forms the basis of much of this report. 2-week surveys following consultations, annual surveys, and pre- and post-educational program evaluations have also been used to measure the success of the program. CAP PC has grown over the 6years of the program and has provided 8013 phone consultations to over 1500 PCPs. The program synergistically provided 17,523 CME credits of educational programming to 1200 PCPs. PCP users of the program report very high levels of satisfaction and self reported growth in confidence. CAP PC demonstrates that large-scale collaborative consultation models for primary care are feasible to implement, popular with PCPs, and can be sustained. The program supports increased access to child mental health services in primary care and provides child psychiatric expertise for patients who would otherwise have none.

UMass Researcher Turns Idea Into a Nationally Recognized Program

UMass Researcher Turns Idea Into a Nationally Recognized Program

Supporting Families Using a Rural Paediatric Integrated Care Model

Introduction : Children in rural areas are 20% less likely to receive mental health and behavioral interventions than those living in urban areas (Lambert, Ziller, & Lenardson, 2009). This is largely due to isolated service providers and the families’ lack of resources. To underscore the struggles of parents, it has been reported that 29.4% of parents report that pediatric behavioral health care services are hard to access and difficult to coordinate, especially in rural environments (Bronheim, Thomas, & McKay, 2007). Rural families in Maryland struggle to access social and behavioral health care services due to stigma, transportation, provider shortages, and a lack of family education regarding the need for services. There is currently a lack of accessible integrated health care services available to support pediatric patients and their families in rural Maryland. Description of Practice Change : Expanding shallow end care services within pediatric primary care offices in rural areas provides early screening, identification, brief treatment, and family care coordination for social and behavioral health conditions. The purpose of expanding these services through medical and social care integration is to increase access to care, normalize screening and treatment, and to facilitate the presence of social care in the primary care medical office. By increasing the services to families in the primary care office, wait times for screening and brief treatment are reduced, and the backlog for specialty care referrals and treatment is reduced. Increased supports available in the primary medical office increases the support families receive which reduces the struggle families have faced in the past to coordinate care for children. BHIPP was established in 2012 through a partnership between Johns Hopkins University, University of Maryland, and Salisbury University, with funding from Maryland's Behavioral Health Administration. The overreaching goal of BHIPP has been to increase the capacity of pediatric primary care providers to identify and treat social and behavioral health concerns. BHIPP serves the patients treated in pediatric offices whose ages range from birth through 22. Key stakeholders through this process have included the providers, local health departments, Departments of Social Services, Departments of Juvenile Justice, parent advocacy agencies, local school systems, and state coordinating agencies. Key Findings : Thus far, 29 student interns have made over 1950 patient contacts. The interns have reported that the model increases the parents’ receptivity to services and interventions, and empowers them in the decision making process related to their children’s behavioral health care. This most recent evaluation project is focused on measuring the patient and family experience with the interns in the host environment. The results of this research will be presented. Highlights : The innovative components of the Salisbury model include the collaboration and partnership with a Child Psychiatry Access Program (CPAP), which provides additional training and telephonic support for the integrated workers and the medical care providers, and ultimately increases the expertise of services available in the rural pediatric medical office. In-office interventions include intensive care management for families, motivational interviewing, screenings and referrals, and family skills training. By having an on-site student care provider, the parents are able to build relationships, develop trust, and are more likely to follow through with recommendations. The relationship with the physicians and families is built upon an adaptive feedback loop, where the families and student care providers work with the physicians to make decisions about what social and behavioral health services will be most beneficial. The student care providers then respond by adapting their interventions and work with patients on such topics as bullying prevention, nutrition education, boundaries and rule setting, behavioral charting and rewards, concentration exercises, and relaxation training. Families have responded favorably to the increased care supports in the medical office, which enhances their commitment to creating and sustaining a healthy family. Discussion and lessons learned : The BHIPP Salisbury model is an example of effective implementation of integrated behavioral health and social care to support families in rural settings. This largely underserved population has increased their access to social care and behavioral health services. Feedback from providers, students, and families will be shared and discussed. Conclusion : There is evidence of sustainability and transferability at it relates to growing number of patients served across the state of Maryland. The contact rate continues to increase each year as well as the number of providers who sign up to host a student. Sustainability is supported by the growth rate, publicity, and state-level funding support. Consistency in practice participation and continued growth supports the applicability of this model across host settings.