Massachusetts Child Psychiatry Access Project Research Articles

21.1 ACCESS MENTAL HEALTH CONNECTICUT: FAMILY-CENTERED PEDIATRIC MENTAL HEALTH CONSULTATIONS

The objective of this presentation is to review the family-centered, well-being-focused nature of the ACCESS (Access to all of Connecticut’s Children of Every Socioeconomic Status) Mental Health program and its contributions to improving mental health treatment for children in the state of Connecticut. ACCESS Mental Health Connecticut is a state-funded initiative created as a line item in the Department of Children and Families’ budget as a component of the gun-control legislation passed in the wake of the Sandy Hook school shooting. Initiated in June 2014 and modeled after the Massachusetts Child Psychiatry Access Project (MCPAP), the Connecticut model includes 3 Hubs to support mental health education and the well-being of pediatric primary care providers, and to support families regardless of insurance status. The model incorporates a team of child and adolescent psychiatrists, licensed social work clinicians, a program coordinator, and, uniquely, a peer specialist. The peer specialist is a parent with a child with mental health challenges who can support pediatric patients’ parents emotionally and practically as they attempt to process and navigate the mental health landscape. Since its inception in June 2014, the ACCESS Mental Health Hubs have provided over 36,700 consultations supporting over 7000 youth and their families. During the early months of the COVID-19 pandemic, the ACCESS Mental Health Teams initiated weekly well-being support Zoom meetings for the state’s pediatric primary care physicians (PPCPs). Now monthly, the Zoom “Clinical Conversations with ACCESS Mental Health” provides mental health education to address the PPCP’s unique needs. Hub child and adolescent psychiatrists also participate in Project ECHO (Extension of Community Healthcare Outcomes), AAP Connecticut webinars, grand rounds, and other venues. PPCP mental health education and early access to mental healthcare promises to identify, support, and treat children and families experiencing mental health challenges that have previously been unable to access services. The trusting personal relationships between the Hub teams and the PPCPs is a cherished component of the ACCESS Mental Health program service.

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

Addressing Maternal Mental Health: Progress, Challenges, and Potential Solutions

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

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

Primary Care Providers' Use of a Child Psychiatry Telephone Support Program

BackgroundThe Massachusetts Child Psychiatry Access Project (MCPAP) provides telephone support from mental health specialists to primary care providers (PCPs). Understanding PCPs' use may inform implementation of similar programs. We sought to examine PCPs' decision-making process to use or not use MCPAP when encountering mental health problems. MethodsWe analyzed data regarding calls from PCPs to MCPAP from October 1, 2010, to July 31, 2011, and interviewed 14 PCPs with frequent use (≥7 calls) and infrequent use (≤4 calls). PCPs were asked about recent patients with mental health problems, and they were asked to describe reasons for calling or not calling MCPAP. Frequent callers were asked what sustained use; infrequent callers were asked about alternative management strategies. Comparisons were made between these groups in qualitative analysis. ResultsPCPs (n = 993) made 6526 calls (mean = 6.6; median = 3). Factors influencing calling included: MCPAP's guidance is timely and tailored to individual scope of practice; MCPAP's ability to arrange therapy referrals exceeds PCPs' ability; providing a plan at point of care relieves anxious families; and MCPAP's assistance helps accommodate families' preference to keep mental health in primary care. Some infrequent callers had gained skills through MCPAP before 2010 and now called only for complex cases. Other reasons for infrequent calling: PCPs have other consultation sources, have fear of being asked to manage more than they are comfortable, or have misperceptions of MCPAP's offerings. ConclusionsMCPAP enhanced PCPs' ability to deliver mental health care consistent with families' preferences. PCPs applied knowledge gained from calls to subsequent patients. Promoting MCPAP components through outreach and tailoring guidance to PCPs' scope of practice may entice greater use.

Availability of Telephone-Based Child Psychiatry Consultation: Implications from a Survey of Pediatric Providers in Two States

Pediatric primary care providers (PCPs) play a critical role in caring for children with mental health concerns. Some states have introduced programs to support PCPs in managing these patients more independently. The Massachusetts Child Psychiatry Access Project consultation program is one example. This study compared responses from PCPs in Massachusetts (n = 73) with PCPs in Indiana (n = 33), a state without a consultation program, to vignettes about children with possible attention-deficit/hyperactivity disorder or depression. Participants from MA indicated a stronger interest in behavioral health issues and were more likely to screen patients. PCPs from IN were more likely to have completed a rotation in developmental and behavioral pediatrics during residency. IN respondents were also more likely to choose the correct diagnosis for vignettes and less likely to refer to a psychiatric provider for psychotropic medication. Results suggest greater independence for PCPs in IN.

Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms.

Perinatal depression is common and associated with poor birth, infant and child outcomes. Screening for perinatal depression alone does not improve treatment rates or patient outcomes. This paper describes the development, implementation and outcomes of a new and low-cost population-based program to help providers address perinatal depression, the Massachusetts Child Psychiatry Access Project (MCPAP) for Moms. MCPAP for Moms builds providers' capacity to address perinatal depression through (1) trainings and toolkits on depression screening, assessment and treatment; (2) telephonic access to perinatal psychiatric consultation for providers serving pregnant and postpartum women; and (3) care coordination to link women with individual psychotherapy and support groups. In the first 18months, MCPAP for Moms enrolled 87 Ob/Gyn practices, conducted 100 trainings and served 1123 women. Of telephone consultations provided, 64% were with obstetric providers/midwives and 16% were with psychiatrists. MCPAP for Moms costs $8.38 per perinatal woman per year ($0.70 per month) or $600,000 for 71,618 deliveries annually in Massachusetts. The volume of encounters, number of women served and low cost suggest that MCPAP for Moms is a feasible, acceptable and sustainable approach that can help frontline providers effectively identify and manage perinatal depression.

Point-of-Care Child Psychiatry Expertise: The Massachusetts Child Psychiatry Access Project.

Since 2005, after a pilot program, the Massachusetts Child Psychiatry Access Project (MCPAP) has provided point-of-care psychiatry expertise and referral assistance by telephone to primary care providers. We examined its adoption and use and the practice characteristics associated with different adoption timelines and use patterns. We merged data on calls to MCPAP in 2005 to 2011 with practice data (enrollment year, panel size, regional team assignment). We categorized practices' days from enrollment to first call (adoption) (0-100, 101-365, > 365 days) and quartile of call frequency (use) (annual highest, middle, and lowest quartiles of number of calls per 1000 empanelled patients). We determined associations between adoption and use and practice characteristics using multivariate models. Among 285 practices, adoption and use varied: 55% called 0 to 100 days from enrollment and 16% called >365 days from enrollment. Practices in the highest quartile of use made a mean 15.5 calls/year per 1000 patients, whereas the lowest quartile made 0.4 calls/year per 1000 patients. Adoption within 100 days was associated with enrollment during or after 2007 (odds ratio [OR] 4.09, 95% confidence interval [CI] 2.23-7.49) and assignment to the team at the pilot site (OR 4.42, 95% CI 2.16-9.04 for central Massachusetts). Highest-quartile use was associated with team assignment (OR 3.58, 95% CI 1.86-6.87 for central Massachusetts) and panel size (OR 0.10, 95% CI 0.03-0.31 for ≥ 10,000 vs < 2000 patients). Adoption and use of MCPAP varied widely. Timing of enrollment, assignment to the team from the program's pilot site, and panel size were associated with patterns of adoption and use. Findings may help other programs design effective implementation strategies.

Behavioral health care for children: the massachusetts child psychiatry access project.

Access to behavioral health care for children is essential to achieving good health care outcomes. Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children's need for behavioral health care. The Massachusetts Child Psychiatry Access Project has addressed this problem by delivering telephone child psychiatry consultations and specialized care coordination support to over 95 percent of the pediatric primary care providers in Massachusetts. Established in 2004, the project consists of six regional hubs, each of which has one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the 1.5 million children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children. Pediatric primary care providers enrolled in the project reported a dramatic improvement in their ability to meet the psychiatric needs of their patients. Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States.

Resource document on risk management and liability issues in integrated care models.

In the wake of the implementation of the Affordable Care Act, more than 30 million previously uninsured Americans will gain access to health care. Some of these individuals may never have interfaced with the behavioral health system. In response to an increasing need for behavioral health services, improved outcomes, and cost containment, there is a growing shift from independent behavioral health and primary care practices to collaborative care practice models. These new models have psychiatrists working with primary care providers (PCPs) and behavioral health providers (BHPs, typically social workers or psychologists) using a systematic approach to concurrently treat behavioral health and physical health conditions. By following this approach it allows the extension of psychiatric expertise to more patients. From early studies in the 1990’s to improve the detection and treatment of depression in elderly patients in primary care settings, to more recent work on outcomes in the management of depression in patients with multiple chronic conditions, a vast body of research has demonstrated the benefit of collaborative care models. However, as with any new treatment modality, psychiatrists may approach collaborative care models with a degree of uncertainty about liability risks. While there are several documents as well as case law addressing the potential malpractice risk of consultation in other medical specialties, a review of the literature revealed few publications offering guidelines for psychiatric consultations. Previous publications have been limited in scope by focusing on interactions between psychiatrists with non-physician treatment providers and have not addressed the potential liability exposure in the overlapping roles of the psychiatrist within an integrated care setting. However, these authors likely could not have anticipated the change in scope of practice of psychiatry in recent years. This resource document provides background information on medical malpractice cases, defines the doctor-patient relationship, and distinguishes the different forms of “split treatment” and how this applies to psychiatric consultation offered to PCPs and BHPs in primary care settings. In addition, it describes the duty of the psychiatrist across the spectrum of roles on an integrated care team and makes recommendations to reduce the risk of medical malpractice issues. Close proximity can foster a culture of cooperation and mutual education between PCPs and psychiatrists. This approach, often referred to as “co-location,” has several benefits for patients. The PCP may or may not choose to communicate with the psychiatrist about the behavioral health of patients or make referrals, but the contiguity may increase the chances of successful referral. Limitations in this model have given rise to new treatment paradigms for improving care. In integrated care settings, behavioral health specialists are incorporated into the primary care practice with the psychiatrist providing consultation to the PCP and BHP for management of a patient’s behavioral health conditions. These recommendations may be based upon an informal or “curbside” consultation request by the PCP or BHP, a review of the medical record or registry, and, less frequently, by formal evaluation of the patient in person or by televideo. There are a number of integrated care models including the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) model and Massachusetts Child Psychiatry Access Project (MCPAP). In these models of care, the psychiatry consultant’s role may include key aspects of both formal and informal consultation and varying aspects of “split treatment” (including what have traditionally been referred to as supervisory, consultative or collaborative roles for non-physicians). This resource document provides a framework for some of the issues to consider when working in practices offering integrated care, and provides practical points to consider in managing liability concerns. Keep in mind that issues regarding liability may not always be clear, particularly in specialty areas that are rapidly evolving. Where indicated, the psychiatrist should clarify the extent of their involvement clinically and the level of interaction with the patient and care team. Whether there is liability for malpractice depends upon specific circumstances surrounding each case and each state has different laws, regulations and caselaw. Finally, consulting an attorney or risk manager for guidance on specific issues is strongly encouraged.

Clinicians’ Utilization of Child Mental Health Telephone Consultation in Primary Care: Findings From Massachusetts

The authors examined utilization of the Massachusetts Child Psychiatry Access Project, a mental health telephone consultation service for primary care, hypothesizing that greater use would be related to severe psychiatric diagnoses and polypharmacy. The authors examined the association between utilization, defined as the mean number of contacts per patient during the 180 days following the initial contact (July 2008-June 2009), and characteristics of the initial contact, including consultation question, the child's primary mental health problem, psychotropic medication regimen, insurance status, and time of year. Utilization (N=4,436 initial contacts, mean=3.83 contacts) was associated with initial contacts about medication management, polypharmacy, public and private health insurance, and time of year. The child's primary mental health problem did not predict utilization. Telephone consultation services address treatment with psychotropic medications, particularly polypharmacy. Joint public-private funding should be considered for such public programs that serve privately insured children.

An Assessment of Satisfaction with Ambulatory Child Psychiatry Consultation Services to Primary Care Providers by Parents of Children with Emotional and Behavioral Needs: The Massachusetts Child Psychiatry Access Project University of Massachusetts Parent Satisfaction Study

This study evaluated parents’ experience with University of Massachusetts (UMass) Child Psychiatry Access Project (MCPAP), a consultation service to primary care providers (PCP), aimed at improving access to child psychiatry. Parent satisfaction questionnaire was sent to families referred to UMass MCPAP by their PCP, asking about their concerns leading to the referral, the satisfaction from the service provided, adequacy of the follow up plan, and outcome. Seventy-nine percent of parents agreed or strongly agreed that the services provided were offered in a timely manner. Fifty percent agreed or strongly agreed that their child’s situation improved following their contact with the services. Sixty-nine percent agreed or strongly agreed that the service met their family’s need. The results suggest moderate to high parental satisfaction with MCPAP model, but highlight ongoing challenges in making successful referrals for children’s mental health services in the community, following MCPAP recommendations.

Pediatrician-Psychiatrist Partnerships Expand Access to Mental Health Care

PEDIATRICIANS ARE OFTEN THE FIRST clinicians to see young patients with mental health conditions, but they may feel ill equipped to provide care for such patients. They may also struggle to find specialists to whom they can refer more complicated cases because many geographical areas face significant shortages of child and adolescent psychiatrists. To address these problems and expand access to mental health care, many states are creating programs that provide pediatricians with training along with real-time access to support from mental health professionals. One leader in this approach is Massachusetts, which created the Massachusetts Child Psychiatry Access Project (MCPAP) in 2005. The program provides pediatricians throughout the state with access to training and expertise from mental health specialists at academic centers nearby. Now other states, including New York, Ohio, Washington, and Nebraska, are following suit with similar programs (Gabel S and Sarvet B et al. Psychiatric Serv. 2011;62[8]:827-829).

Innovative Project Makes MH Care More Accessible in Primary Care

Innovative Project Makes MH Care More Accessible in Primary Care

Improving Access to Mental Health Care for Children: The Massachusetts Child Psychiatry Access Project

Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care. The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

Psychiatrists' Creativity Closes Rural Treatment Gap

Psychiatrists' Creativity Closes Rural Treatment Gap