Collaborative Care Program Research Articles

Racial Disparities in Prescription of Antidepressants Among U.S. Veterans Referred to Behavioral Health Care.

Antidepressants are often prescribed in primary care to treat veterans who have depression. An evaluation of current racial disparities in integrated primary care is warranted. This study examined the association between race and prescription of antidepressants among veterans in primary care. Veterans in primary care (Black, N=4,120; White, N=4,372) who were referred from primary care to a collaborative care program completed an assessment of demographic characteristics and clinical symptoms, including of current antidepressant prescription before the referral, verified by chart review. Patient data were collected from January 1, 2015, to December 22, 2020. Logistic regression analyses were conducted to examine the relationships between patient race and both depression symptoms and antidepressant prescription. Analyses were also stratified by severity of depression symptoms to understand the results in the context of clinical guidelines. White patients were almost two times (odds ratio=1.96, 95% confidence interval [CI]=1.75–2.19, p<0.001) more likely than Black patients to receive an antidepressant prescription, after the analysis was controlled for depression symptoms, demographic characteristics, and other clinical symptoms. Among patients with severe depression, for whom prescription of antidepressants is clinically indicated, White patients were 1.87 times more likely than Black patients to receive an antidepressant prescription (95% CI=1.40–2.50, p<0.001). The findings reveal racial disparities in antidepressant prescription for veterans in primary care. Regular clinical review of antidepressant prescription is recommended to identify disparities in individual clinics. Future research should aim to identify drivers of racial disparities and provide recommendations for health care systems, providers, and patients.

Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses

BackgroundPrimary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement.MethodsOne year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts.ResultsThe results were organized into three categories: facilitators, barriers, and proposals for improvement as perceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation.ConclusionsThe INDI program is perceived as a useful, viable program for improving the management of depression in primary care. Uptake by primary care centers and health care professionals, however, was poor. The identification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation.Trial registrationClinicalTrials.gov identifier: NCT03285659; Registered 18th September, 2017.

Implementing collaborative care for major depression in a cancer center: An observational study using mixed-methods

ObjectivesTo describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center. MethodA mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years. ResultsProgram set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support. ConclusionA CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care.

Care managers' experiences in a collaborative care program for the treatment of bipolar disorder and PTSD in underserved communities

ObjectivesTo understand care managers' experiences treating primary care patients with bipolar disorder and PTSD in a telepsychiatry collaborative care (TCC) program, as part of a large pragmatic trial. MethodsWe conducted individual qualitative interviews with 12 care managers to evaluate barriers and facilitators to implementation of a previously completed TCC intervention for patients with bipolar disorder and/or PTSD. We used directed and conventional content analysis and Consolidated Framework for Implementation Research (CFIR) constructs to organize care manager experiences. ResultsParticipants described clinical and medication management support from telepsychiatrists and satisfaction with the TCC model as facilitators of success for patients with bipolar disorder and PTSD in underserved communities. Participants also described onboarding of primary care providers and clinic leadership as keys to successful team-care and credited satisfaction with providing Behavioral Activation as essential to sustained delivery of the psychotherapy component of TCC. ConclusionsParticipants described high satisfaction with TCC for patients with bipolar disorder and PTSD. Challenges included lack of clinic leadership and PCP engagement. Early and ongoing promotion of integrated care and prioritizing telepsychiatry consultation with patients, behavioral health professionals and PCPs, may improve patient care, provide ongoing training and improve workforce satisfaction.

The association between engagement in a perinatal collaborative care program and breastfeeding among people with identified mental health conditions

Untreated antenatal mental health conditions are associated with noninitiation and early discontinuation of breastfeeding. Whether interventions designed to optimize perinatal mental health can mitigate this association is unknown. This study aimed to examine whether engagement of pregnant people with mental health conditions in a perinatal mental health collaborative care program was associated with differences in breastfeeding initiation and continuation and whether any observed association was mediated by changes in depressive symptoms. This retrospective cohort study included all pregnant people who were referred antenatally by their obstetrical clinician to a perinatal collaborative care program and who delivered viable neonates between January 2017 and June 2018. Pregnant people were dichotomized by whether they engaged in collaborative care services. Breastfeeding initiation (endorsed at delivery) and continuation at the postpartum visit were compared between individuals who did and did not engage in collaborative care using bivariable and multivariable analyses. Mediation analyses were performed to determine if any observed associations were mediated by improvements or remission in depressive symptoms. During the study period, 350 eligible pregnant people were referred to the perinatal collaborative care program because of an identified mental health condition. Of these people, 264 (75.4%) engaged in collaborative care. Compared with those who did not engage in collaborative care, people who engaged in collaborative care were more likely to initiate breastfeeding (168 [95%] vs 47 [87%]; P=.046) and continue breastfeeding at the postpartum visit (92 [74%] vs 20 [53%]; P=.012). These associations persisted after controlling for potential confounders (adjusted odds ratio for initiation, 3.30; 95% confidence interval, 1.09-9.98; adjusted odds ratio for continuation, 3.08; 95% confidence interval, 1.29-7.36). Neither association was mediated by improvements or remission in depressive symptoms. Although antenatal mental health conditions are a risk factor for lack of initiation or early cessation of breastfeeding, engagement in a collaborative care program was associated with improvements in both breastfeeding initiation and continuation. This association was independent of improvement in depressive symptoms, suggesting that the benefits of perinatal collaborative care may extend beyond its psychological impact.

Feasibility and outcomes of a general practice and specialist alcohol and other drug collaborative care program in Sydney, Australia.

Alcohol and other drug (AoD) use is an important health and community issue and may be positively affected by collaborative care programs between specialist AoD services and general practice. This paper describes the feasibility, model of care and patient outcomes of a pilot general practice and specialist AoD (GP-AoD) collaborative care program, in Sydney, Australia, based on usual care data, the minimum data set, service utilisation information and the Australian Treatment Outcome Profile (ATOP), a patient-reported outcome measure. There were 367 referrals to the collaborative care program. GPs referred 210 patients, whereas the AoD service referred 157 patients. Most GP referrals (91.9%) were for AoD problems, whereas nearly half the AoD service referrals were for other issues. The primary drugs of concern in the GP group were either opioids or non-opioids (mostly alcohol). The AoD service-referred patients were primarily using opioids. An ATOP was completed for 152 patients. At the time of referral, those in the GP-referred non-opioid group were significantly less likely to be abstinent, used their primary drug of concern more days and were more likely to be employed (all P < 0.001). A second ATOP was completed for 93 patients. These data showed a significant improvement in the number of days the primary drug of concern was used (P = 0.026) and trends towards abstinence, improved quality of life and physical and psychological well-being for patients in the program. There are few studies of GP-AoD collaborative care programs and nothing in the Australian context. This study suggests that GP-AoD collaborative care programs in Australia are feasible and improve drug use.

A qualitative examination of the implementation of a perinatal collaborative care program.

To identify implementation strategies for collaborative care (CC) that are successful in the context of perinatal care. Perinatal depression is one of the most common complications of pregnancy and is associated with adverse maternal, obstetric, and neonatal outcomes. Although treating depressive symptoms reduces risks to mom and baby, barriers to accessing psychiatric treatment remain. CC has demonstrated benefit in primary care, expanding access, yet few studies have examined the implementation of CC in perinatal care which presents unique characteristics and challenges. We conducted qualitative interviews with 20 patients and 10 stakeholders from Collaborative Care Model for Perinatal Depression Support Services (COMPASS), a perinatal collaborative care (pCC) program implemented since 2017. We analyzed interview data by employing the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to organize empirically selected implementation strategies from Expert Recommendations for Implementing Change (ERIC) to create a guide for the development of pCC programs. We identified 14 implementation strategies used in the implementation of COMPASS. Strategies were varied, cutting across ERIC domains (eg, plan, educate, finance) and across EPIS contexts (eg, inner context - characteristics of the pCC program). The majority of strategies were identified by patients and staff as facilitators of pCC implementation. In addition, findings show opportunities for improving the implementation strategies used, such as optimal dissemination of educational materials for obstetric clinicians. The implementation of COMPASS can serve as a model for the process of building a pCC program. The identified strategies can support the implementation of this evidence-based practice for addressing postpartum depression.

Living With Dementia: Care Partner Needs and Outcomes of a Dementia Support Program in Primary Care.

To address the need for collaborative approaches to managing dementia in primary care, we implemented the Living with Dementia (LWD) program in a geriatric primary care clinic. This study evaluated the impact of short (≤6 months) and longer-term (7+ months) participation in LWD on care partner outcomes (i.e., self-efficacy, depression, and burden) using t-tests and examined dementia support topics discussed with care partners through the intervention using deductive content analysis. Across 20 months analyzed, 57 dyads participated in the LWD program. Short and longer-term LWD participation indicated a significant increase in self-efficacy with small effect sizes; no changes were observed in depression or burden. Dementia support topics most frequently discussed with care partners focused on care partner well-being, behavior management, and offering referrals. This early evaluation suggests a collaborative care program integrated into primary care can address needs related to caring for persons with dementia and may improve care partner self-efficacy.

The association between antenatal depression symptom trajectories and preterm birth

Antenatal depression has been associated with an increased risk of preterm birth (PTB). Whether improvement of depression mitigates the risk of PTB remains uncertain. Our objective was to evaluate whether, among pregnant people referred for mental health care, improvement in antenatal depression symptoms prior to delivery was associated with a reduction in PTB. This retrospective cohort study included all pregnant people referred to a perinatal collaborative care (CC) program for mental health care and who delivered between 2016-2021. Those referred to the CC program had access to subspecialty mental health treatment, including psychiatric consultation and psychotherapy. Depression symptoms were monitored via serial PHQ-9 screens every 2-4 weeks. Antenatal depression trajectories were determined by comparing the earliest prenatal PHQ-9 score after CC referral to the latest score before delivery. Trajectories were categorized as improved, stable, or worsened based on whether the PHQ-9 scores changed by at least one standard deviation (i.e., 5 points). Bivariable analyses were performed. A propensity score was generated using confounders that were significantly different on bivariable analyses across trajectories. This propensity score was included in multivariable models to control for imbalance across the exposure. Of the 732 pregnant people included, antenatal depression symptoms improved in 256 (35.0%), remained stable in 437 (59.7%), and worsened in 39 (5.3%) (Table 1). The incidence of preterm birth was 12.5%, 14.0%, and 30.8% in those whose depression symptoms improved, remained stable, or worsened, respectively (p=0.009, Table 2). Compared to those who remained stable or worsened, those who had an improved antenatal depression symptom trajectory had a significantly decreased odds of PTB (aOR 0.60, 95% CI 0.39-0.94). For pregnant people with mental health conditions, having an improved antenatal depression symptom trajectory is associated with decreased odds of PTB. These data can be used to inform counseling regarding management of depression during pregnancy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The Effectiveness of a Caregiver Support and Education Intervention Designed for Caregivers of Veterans

Abstract Veterans are at increased risk for dementia and multiple comorbid conditions, often making the family caregiving experience particularly challenging. The objective of this study was to examine the effectiveness of a telephone-based, collaborative dementia care program for improving caregiver (CG) outcomes in CGs of veterans with dementia. All CGs (n=107) received individual care management and were randomized to either individual intervention alone or individual plus group education and social support. CGs were on average 72.5 (+/-11.0) years old, and the majority were female, spouses/partners of the care recipient (CR), and providing care for ≥1 year. Pre-post analyses indicate that CGs experienced a significant reduction in both the frequency of CRs’ dementia-related symptoms (e.g. memory difficulties, disruptive behaviors, depressive affect) and their own distress in response to these symptoms. Our study adds to the literature on the development and evaluation of understudied CG populations, such as CGs of veterans with dementia.

Disrupting the Status Quo: The New Normal of Family Caregivers’ Service Use

Family caregivers are essential partners in chronic disease management for older adults. However, being a family caregiver can have negative mental and physical health consequences, making it important for some caregivers to rely on supportive services, either for themselves (e.g. support groups) or to get help with caregiving tasks (e.g. home care). Supportive service use by family caregivers is well documented; yet, this research has often not included specific subgroups of caregivers (e.g. the racially/ethnically, or geographically diverse). Hence, the purpose of this symposium is to share new findings from research on supportive service use in understudied caregiving populations. First, Dr. Cimarolli presents findings from a study on the types of supportive services long-distance caregivers use for themselves and the factors associated with supportive service use in this caregiver population. Then, Dr. Wyman reports findings from a survey on the use of home and community-based resources by family caregivers in a Native American community. Dr. Wright will share the results of a systematic review of self-care interventions designed for caregivers of African Americans living with dementia. Finally, Dr. Mavandadi presents the results of a study examining the effectiveness of a telephone-based, collaborative dementia care program for improving outcomes in caregivers of military veterans living with dementia. Dr. Karen Rose will discuss the implications of each of these study findings for the development and evaluation of supportive interventions for these specialized family caregiver groups.

Payors Train PCPs to Treat Mental Health in House

Payors Train PCPs to Treat Mental Health in House

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic.

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.

Technology-Assisted Collaborative Care Program for People with Diabetes and/or High Blood Pressure Attending Primary Health Care: A Feasibility Study.

The comorbidity of depression with physical chronic diseases is usually not considered in clinical guidelines. This study evaluated the feasibility of a technology-assisted collaborative care (TCC) program for depression in people with diabetes and/or high blood pressure (DM/HBP) attending a primary health care (PHC) facility in Santiago, Chile. Twenty people diagnosed with DM/HBP having a Patient Health Questionnaire-9 score ≥ 15 points were recruited. The TCC program consisted of a face-to-face, computer-assisted psychosocial intervention (CPI, five biweekly sessions), telephone monitoring (TM), and a mobile phone application for behavioral activation (CONEMO). Assessments of depressive symptoms and other health-related outcomes were made. Thirteen patients completed the CAPI, 12 received TM, and none tried CONEMO. The TCC program was potentially efficacious in treating depression, with two-thirds of participants achieving response to depression treatment 12 weeks after baseline. Decreases were observed in depressive symptoms and healthcare visits and increases in mental health-related quality of life and adherence to treatment. Patients perceived the CPI as acceptable. The TCC program was partially feasible and potentially efficacious for managing depression in people with DM/HBP. These data are valuable inputs for a future randomized clinical trial.

Factors Associated with Adherence to Follow-up Among Patients with Depressive Disorders in a Collaborative Care Program in Iran

Background: Despite effective treatments are available for depressive disorders, less than half of patients utilize them and the treatment gap is large. Objectives: This study aimed to investigate factors associated with adherence to follow-up in patients diagnosed with a depressive disorder in the collaborative care program in Tehran between May 2017 to October 2017. Methods: A retrospective cross-sectional study was performed in three community mental health centers (CMHCs) in Tehran. Results: A total of 435 cases were recruited, and their adherence to follow-up rate was 41.6%. According to multivariate regression, being visited in a particular center, having a high school or higher level of education, having a positive family history with effective treatment, taking selective serotonin reuptake inhibitors (SSRIs), experiencing a lower level of perceived mental health before the first visit, and referral to a psychiatrist could predict adherence to follow-up. Patients who had a chief complaint of typical depressive symptoms and those who were employed were less likely to be adherent to follow-up. Conclusions: More population-based studies in various settings and cultures are needed to enhance our knowledge regarding interventions necessary to deliver quality care to depressed patients.

Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes.

To examine the association between adverse childhood experiences and adverse pregnancy outcomes. This cohort study included individuals who enrolled in a perinatal collaborative mental health care program (COMPASS [the Collaborative Care Model for Perinatal Depression Support Services]) between 2017 and 2021. Participants completed psychosocial self-assessments, including an adverse childhood experiences screen. The primary exposure was adverse childhood experiences measured by the ACE (adverse childhood experience) score, which was evaluated as a dichotomized variable, with a high ACE score defined as greater than three. Secondary analyses used the ACE score as a continuous variable. Adverse pregnancy outcomes including gestational diabetes, hypertensive disorders of pregnancy, preterm birth, and small-for-gestational-age (SGA) births were abstracted from the electronic health record. Bivariable and multivariable analyses were performed, including mediation analyses. Of the 1,274 women with a completed adverse childhood experiences screen, 904 (71%) reported one or more adverse childhood experiences, and 290 (23%) reported a high ACE score (more than three adverse childhood experiences). Adverse childhood experience scores were not associated with gestational diabetes or SGA births. After controlling for potential confounders, individuals with high ACE score had 1.55-fold (95% CI 1.06-2.26) increased odds of having hypertensive disorders of pregnancy and 2.03-fold (95% CI 1.38-2.99) increased odds of preterm birth. Each point increase in ACE score was not associated with a statistically increased odds of hypertensive disorders of pregnancy (adjusted odds ratio [aOR] 1.07, 95% CI 0.99-1.15); however, each additional point on the adverse childhood experiences screen was associated with increased odds of preterm birth (aOR 1.13, 95% CI 1.05-1.22). Mediation analyses demonstrated tobacco use, chronic medical problems, and obesity each partially mediated the observed association between high ACE scores and hypertensive disorders of pregnancy. Having chronic medical comorbidities partially mediated the observed association between high ACE scores and preterm birth. One in four individuals referred to a perinatal mental health program who were pregnant or postpartum had a high ACE score. Having a high ACE score was associated with an increased risk of hypertensive disorders of pregnancy and preterm birth. These results underscore how remote events may reverberate through the life course.

PIVOTING WITH THE PANDEMIC: CHALLENGES AND SUCCESSES OF CHILD PSYCHIATRY ACCESS PROGRAMS NATIONWIDE

A nationwide shortage of behavioral healthcare services has prompted primary care providers (PCPs) to fill the gap in providing behavioral health care. Pediatric behavioral health needs have further increased during the pandemic. However, PCPs often lack specialized training and resources to meet the behavioral health needs of their patients. Child Psychiatry Access Programs (CPAPs) augment mental healthcare resources through collaborative care models based on peer-to-peer consultation, ongoing psychiatry education for PCPs, and other services. To date, CPAPs have been developed in 40 states, scaffolded by the National Network of Child Psychiatry Access Programs including 21 programs with funding from the Health Resources and Services Administration. Informed by community-engaged collaborations, CPAPs have leveraged their child behavioral health expertise in creative ways such as integration of peer specialists for families, telemedicine partnerships with Tribal Health Centers and schools, expanded child psychiatry fellowship education programs, and novel research networks. Diverse programs from 4 different states—Connecticut, Michigan, Mississippi, and Texas—will describe innovative strategies to implement and expand their programs, and lessons learned during the global pandemic. Furthermore, the discussant will provide an overview of CPAP functioning and innovation during the pandemic, including a focus on the Massachusetts program. CPAPs have leveraged mental health expertise in various states, allowing more children from rural and other underserved communities to access mental health care in their relatively low-cost primary care setting, schools, or local communities. As these collaborative care programs are all virtual, implementation has continued forward even in the face of the COVID-19 pandemic. Child and adolescent psychiatrists can partner with CPAPs in their state and with primary care providers to improve the care for children. Nationwide, CPAP programs are transforming mental health care through this model of consultation, resource/referral coordination, ongoing medical education, research, and training opportunities.

50.4 IDENTIFICATION OF EARLY CHILDHOOD DISORDERS IN STATEWIDE CONSULTATION PROGRAMS

The participants will become familiar with the evolution of the geographic reach, funding mechanisms, and logistics of a statewide consultation program serving children through age 26 years and perinatal women in the state of Michigan. The Michigan Child Collaborative Care (MC3) program is a statewide mental health consultation program connecting early childhood and perinatal specialists with primary care physicians (PCPs) across Michigan. Data related to the frequency of diagnoses, and the mechanisms to connect patients with evidence-based care, will be discussed. Data from over 12,500 service requests will be reviewed from 2012 to the present. Evolution of both the funding and geographic reach of the program will be described. Consultation programs serving young children and perinatal women improve access to specialized care, particularly in rural areas of the state, with 98% of consultations provided to patients not in care with a specialist. Programs often support patients whose symptom severity is deemed moderate to severe by consultants who provide the consultations. High rates of trauma, psychosocial strain, and complex differential diagnoses suggest the need for specialized consultations. Consultations often cross county lines, involving populations with both moderate to severe conditions. Growth of the program, while initially slow, does improve after 2 to 3 years or intensive outreach. Statewide programs provide needed care for patients without other access and may require the cooperation of state/federal and Medicaid payors to achieve sustainability.

IDENTIFYING AND ADDRESSING CHILDHOOD TRAUMA IN PRIMARY CARE

Nearly half of US children have experienced 1 or more adverse childhood experiences (ACEs). ACEs are associated with lasting physical and mental health problems. One way to prevent these outcomes is through early identification and intervention. The frequency and longevity with which families visit primary care makes it a nearly universal setting in which to screen for and help mitigate consequences of ACEs. However, primary care providers (PCPs) lack the time and training to address these concerns. Our Symposium will include 4 presentations on trauma in primary care and a discussant. Rebecca Ferro will compare clinical characteristics and treatment recommendations of patients with and without ACEs for whom PCPs sought psychiatric consultation or co-located social work services through Maryland’s Behavioral Health Integration in Pediatric Primary Care Program. Sheila Marcus, MD, will describe the frequency of trauma concerns among pediatric and perinatal patients for whom PCPs sought clinical consultation with the Michigan Collaborative Care Program. Joyce Harrison, MD, will describe the frequency and types of ACEs among young child patients for whom PCPs sought training and support through the Kennedy Krieger Institute Network for Early Childhood Tele-Education. Carol Vidal, MD, will describe findings from a survey of pediatricians and child and adolescent psychiatrists about their knowledge, attitudes, and training needs related to trauma-informed care. Larry Wissow, MD, will summarize the findings and discuss the implications for research, policy, and practice. Participants will learn about the frequency of ACEs in the context of primary care, models for supporting PCPs in meeting the mental health needs of pediatric patients with ACE histories, and PCP knowledge, attitudes, and perceived needs for training in trauma-informed care. There is a growing need for early identification and intervention for youth exposed to trauma. Primary care is an ideal setting to address ACEs, but there is a gap in knowledge, skills, and time to effectively address these concerns. This session will provide an opportunity to learn about characteristics of patients with ACEs presenting in primary care and approaches to supporting PCPs in meeting the needs of these patients.

46.2 Transition From an In-Person to a Remote Pediatric Collaborative Care Model During COVID-19: Effect on Program Efficiency and Outcomes

The COVID-19 pandemic accelerated the transition of many ambulatory services to a remote model, including integrated pediatric behavioral health. And while there exists a body of evidence around the effectiveness of pediatric integrated care, there is a dearth of research on delivering these services virtually. Beginning in March of 2020, the Northwell Pediatric Collaborative Care Program transitioned to an entirely remote model, with services delivered either via phone or telehealth. This poster will examine the effect of these changes on key measures of program efficiency and effectiveness. Looking at a cohort of care managers present before and after the model change, we compared a series of process and outcome measures during the same 6-month period (July to December) of 2019 and 2020. The core services delivered included assessment, brief therapy, collaborative medication management, and care coordination. The specific data points examined were the number of unique monthly patient contacts, the total number of patient contacts, the types of contacts provided, and the depression and anxiety improvement rates on the Patient Health Questionnaire-9A (PHQ-9A) and the Generalized Anxiety Disorder-7 (GAD-7), respectively. The number of unique monthly patient contacts rose by 72% (n = 621 vs n = 1071), while the total number of contacts rose by 86% (n = 859 vs n = 1601). Eighty-eight percent of care management contacts were delivered in person and 12% by phone in 2019, whereas 70% of contacts were by phone and 30% by telehealth in 2020. The depression improvement rate increased from 53% to 64%, while the anxiety improvement rate decreased from 63% to 57%. These results suggest that a remote model may be a viable option for some patients receiving integrated pediatric services. The number of patients served and number of contacts increased significantly, suggesting potential for greater operational efficiency, while the high proportion of phone contacts in 2020 may reflect initial challenges with telehealth connectivity and patient preference. Improvement in adolescent depression outcomes suggest that clinical effectiveness was maintained, while anxious patients seemed to have fared less well with this approach. Further examination of clinical outcomes will be necessary to best understand what works for whom and how to best use remote integrated care offerings going forward.