Pediatric Integrated Care Research Articles

A systematic review and meta-analysis of pediatric integrated primary care for the prevention and treatment of physical and behavioral health conditions.

To evaluate the effects of behavioral health interventions delivered within pediatric integrated primary care models on clinical outcomes. We searched Medline, EMBASE, CENTRAL, PsycINFO, and SCOPUS for studies published from January 1, 1998, to September 20, 2023. We included studies that evaluated onsite behavioral health integration in pediatric primary care using a comparator condition (usual, enhanced usual care, or waitlist). Outcome data on symptom change, impairment/quality of life, health indicator, and behavior change were extracted using Covidence software. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline was followed Risk of bias analysis was conducted using the Cochrane Risk of Bias tool. We used multilevel meta-analysis to synthesize multiple outcomes nested within studies. Open Science Foundation pre-registration: #10.17605/OSF.IO/WV7XP. In total, 33 papers representing 27 studies involving 6,879 children and caregivers were included. Twenty-four studies were randomized controlled trials and three were quasi-experimental designs. Seventeen papers reported on treatment trials and 16 reported on prevention trials. We found a small overall effect size (SMD = 0.19, 95% confidence interval [0.11, 0.27]) supporting the superiority of integrated primary care to usual or enhanced usual care. Moderator analyses suggested similar effectiveness between co-located and integrated models and no statistically significant differences were found between treatment and prevention trials. Results suggest that integrated primary care is superior to usual and enhanced usual care at improving behavior, quality of life, and symptoms. Integrated primary care research needs improved standards for reporting to promote better synthesis and understanding of the literature.

Racial match: Black youth and pediatric integrated primary care.

Racial match: Black youth and pediatric integrated primary care.

Benefits of expanding behavioral health screening in a pediatric diabetes clinic to include anxiety and caregiver reports in youth 12 years and younger.

Depression and anxiety among youth with Type 1 diabetes (T1D) are associated with poor diabetes management. Further guidance regarding psychosocial screening measures would benefit pediatric integrated care clinics. The purpose of this exploratory study was to examine whether screening for anxiety, assessing caregiver reports, and screening children 12 years old and younger could identify a larger percentage of youth who may benefit from behavioral health support compared to the standard approach of only screening youth 13 and older for depression. Sixty-five youth 8-17 years old with T1D (N = 65; M = 13.2 years; 55.4% females) and their caregivers (75% mothers) completed validated self-report and proxy-report depression and anxiety screeners during routine clinic visits between 2019 and 2021. Twenty-seven youth aged 13-17 also completed a measure of diabetes-related distress. The standard approach of screening youth aged 13-17 for depression via self-report identified 25.6% of participants, whereas screening youth ages 8-17 for depression and anxiety via self- and proxy-reports identified 47.7%. Screening for depression/anxiety identified unique portions of youth independent of diabetes distress. Utilizing anxiety and proxy-report measures may identify youth likely to benefit from behavioral health support who are not identified when only a self-report depression measure is used in screening. Research should evaluate whether utilizing multiple measures and screening children under 13 years old improve detection and connection to care for youth experiencing difficulty managing diabetes. Early identification and intervention could subsequently mitigate the negative impacts of social-emotional difficulties on diabetes management. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Parent attitudes and perceptions of integrated behavioral health care delivery for pediatric patients

Introduction: Patient access to high-quality behavioral health services has been a well-documented problem that has only been further complicated by the COVID-19 pandemic, especially within the pediatric population. Although integrated models of care have demonstrated efficacy for improving access, there is little research examining parents’ preferences for key elements of integrated practice, which now include increased utilization of virtual care. Parent/caregiver perspectives are essential to understand and enhance behavioral health service delivery within an integrated model of care because they are largely responsible for initiating, facilitating, and intimately participating in their children’s behavioral health care.
 Methods and Aims: The Parent Acceptance of Pediatric Integrated Care Survey Revised (PAPICS-R) was developed by a multidisciplinary panel of integrated care experts to evaluate caregiver perceptions of behavior health care delivery models for pediatric patients. A major component of the revised survey was a focus on virtual care, which has become ubiquitous since the beginning of the Covid-19 pandemic. Eight hundred thirty-four parents from diverse backgrounds across the United States who had children under 18-years old completed the revised survey online. Survey responses were analyzed using various statistical modeling techniques. Detailed demographic data was collected and associations of demographic variables with item responses were assessed using ANOVA and Chi-square tests.
 Results: Results indicated parent support for core components of integrated care such as co-location of medical and behavioral health care, interactive communication between providers, and shared access to health records. Parents also tended to prefer to be involved in their child’s therapy and indicated acceptability of virtual behavioral health care. Significant differences in parent responses were evident across several demographic variables such as race/ethnicity, parent age, child age, number of children and parent education. Notably, patient privacy and stigma were primary concerns for certain groups. These key findings will be shared to explore how specific demographic differences affect parent integrated care perspectives and how best to address these differences in practice.
 Conclusions: Results from the PAPICS-R provide valuable insight into parent perceptions of integrated behavioral health care. Notably, parent attitudes toward the integrated model of care (including virtual healthcare delivery methods) are largely positive. The findings have directly impacted multiple key aspects of the IBH program including future format of care delivery, trainee education, program expansion, and quality improvement. These adaptations will be discussed along with broader implications.
 Future Directions: Additional data are being gathered to examine the impact of various parent demographic variables on perspectives of an integrated primary care model. We are also currently working to disseminate results from the PAPICS-R survey to health care providers and organizations as the data are expected to provide valuable insight for those looking to establish integrated pediatric primary care clinics or improve their current model of care. Applicability of implementation within a diverse range of communities and regions will be discussed.

Assessment of families'experience with care integration within an aerodigestive program.

The objective of this study was to assess if enrollment in a pediatric multidisciplinary aerodigestive program significantly impacted families' experiences with care integration. A previously validated 48-question Pediatric Integrated Care Survey (PICS) was administered in a cross-sectional manner to both new (new-ADC) and established (est-ADC) patients presenting for an outpatient Aerodigestive Center visit at Boston Children's Hospital. Survey results were grouped into the following five care coordination domains: (1) access to care, (2) care goal creation/planning, (3) family impact, (4) communication with health care providers, and (5) team functioning. Families were asked to rate their care integration experiences in the prior 12 months using yes/no and Likert-based questions. Comparisons were analyzed using logistic regression. Factor analysis was also performed. Ninety patient families were surveyed: 54 (60%) est-ADC patients and 36 (40%) new-ADC patients. Est-ADC patients reported higher levels of experience with team functioning, provider awareness of prior testing, provider communication, and access to alternative methods of communication. Self-identified non-White patients reported lower satisfaction in team functioning and provider understanding of their child's long-term care plan. No significant differences in care integration experiences before and after the onset of the coronavirus pandemic were seen. Patients enrolled in aerodigestive centers experienced improved care integration, most significantly in provider communication and team functioning. Despite these improvements, self-identified non-White families reported a lower care integration experience.

The Pediatric Integrated Care Survey (PICS) in a multidisciplinary clinic for Down syndrome.

The Pediatric Integrated Care Survey (PICS) is validated for use to measure the caregiver reported experience of integration and efficiency of all the aspects of their child. We began using the PICS survey to track changes in the patient experience, including throughout changing models of care during the COVID-19 pandemic. From February 2019 to June 2023, 62 responses from caregivers of individuals seen in the Massachusetts General Hospital Down Syndrome Program completed the PICS. Responses were scored using the standardized PICS user manual, and descriptive statistics were completed. The raw scores and composite monthly scores of the PICs were graphed in statistical process control charts. The average PICS score was 12.0 (range 2-19) out of a maximum score of 19; no shifts or trends were seen. Items with lowest scores indicated greatest opportunities for improvement related to: advice from other care team members, impact of decisions on the whole family, things causing stress or making it hard because of child's health, and offering opportunities to connect with other families. Studying the PICS in a specialty clinic for Down syndrome for the first time has established a baseline for future quality improvement work and interventions to increase care integration.

Outcomes of End-User Testing of a Care Coordination Mobile App With Families of Children With Special Health Care Needs: Simulation Study.

Care for children with special health care needs relies on a network of providers who work to address the medical, behavioral, developmental, educational, social, and economic needs of the child and their family. Family-directed, manually created visual depictions of care team composition (ie, care mapping) and detailed note-taking curated by caregivers (eg, care binders) have been shown to enhance care coordination for families of these children, but they are difficult to implement in clinical settings owing to a lack of integration with electronic health records and limited visibility of family-generated insights for care providers. Caremap is an electronic health record-integrated digital personal health record mobile app designed to integrate the benefits of care mapping and care binders. Currently, there is sparse literature describing end-user participation in the co-design of digital health tools. In this paper, we describe a project that evaluated the usability and proof of concept of the Caremap app through end-user simulation. This study aimed to conduct proof-of-concept testing of the Caremap app to coordinate care for children with special health care needs and explore early end-user engagement in simulation testing. The specific aims included engaging end users in app co-design via app simulation, evaluating the usability of the app using validated measures, and exploring user perspectives on how to make further improvements to the app. Caregivers of children with special health care needs were recruited to participate in a simulation exercise using Caremap to coordinate care for a simulated case of a child with complex medical and behavioral needs. Participants completed a postsimulation questionnaire adapted from 2 validated surveys: the Pediatric Integrated Care Survey (PICS) and the user version of the Mobile Application Rating Scale (uMARS). A key informant interview was also conducted with a liaison to Spanish-speaking families regarding app accessibility for non-English-speaking users. A Caremap simulation was successfully developed in partnership with families of children with special health care needs. Overall, 38 families recruited from 19 different US states participated in the simulation exercise and completed the survey. The average rating for the survey adapted from the PICS was 4.1 (SD 0.82) out of 5, and the average rating for the adapted uMARS survey was 4 (SD 0.83) out of 5. The highest-rated app feature was the ability to track progress toward short-term, patient- and family-defined care goals. Internet-based simulation successfully facilitated end-user engagement and feedback for a digital health care coordination app for families of children with special health care needs. The families who completed simulation with Caremap rated it highly across several domains related to care coordination. The simulation study results elucidated key areas for improvement that translated into actionable next steps in app development.

A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth

ObjectiveThis study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents. MethodFollowing routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14–22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity. ResultsFindings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in “real-life” safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care. ConclusionsThe PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.

The German pediatric integrated care survey (PICS-D): Translation, adaptation, and psychometric testing.

Integrated care models aim to strengthen the collaboration between healthcare sectors to ensure a higher quality of care for children with chronic conditions. Assessing pediatric healthcare integration through families' experiences, therefore, is essential. Our study aimed to psychometrically test the PICS-D, the first German-language integrated care questionnaire, which is based on the Pediatric Integrated Care Survey (PICS) developed in the USA. We examined construct validity using exploratory and confirmatory factor analyses (structural validity). Cronbach's α and McDonald's ω t coefficients explored reliability. Cognitive interviews assessed wording comprehension and item appropriateness. PICS-D was completed by 204 caregivers of children with chronic conditions (women = 84%; mean age = 41.4 years). Factor analyses identified 3 factors: "Team quality & communication", "Family impact", and "Access to care". The 3-factorial structure showed a satisfying fit to confirmatory classical-test-theory-based models. Due to the insufficient reliability of the third factor, we recommend using only factors 1 and 2 for scoring the PICS-D. The PICS-D is a 13-item questionnaire to assess family-reported experiences in pediatric care integration, which has good psychometric properties. It may be useful in guiding quality improvement efforts or measuring the impact of a care plan or care model.Trial registration: German Clinical Trials Register (DRKS): DRKS00018778; Trial registration date 05. December 2019-Retrospectively registered; https://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00018778.

Establishing a Valid, Reliable, and Efficient Chart Review Process for Research in Pediatric Integrated Primary Care Psychology.

Retrospective chart review is an accessible form of research that is commonly used across medical fields but is underutilized in behavioral health. As a relatively newer area of research, the field of pediatric integrated primary care (IPC) would particularly benefit from guidelines for conducting a methodologically sound chart review study. Here, we use our experiences building a chart review procedure for a pediatric IPC research project to offer strategies for optimizing reliability (consistency), validity (accuracy), and efficiency. We aim to provide guidance for conducting a chart review study in the specific setting of pediatric IPC so that researchers can apply this methodology toward generating research in this field.

Competencies for the practice of pediatric integrated primary care: A continuum of training.

Competencies for the practice of pediatric integrated primary care: A continuum of training.

Small town living: Unique ethical challenges of rural pediatric integrated primary care.

Small town living: Unique ethical challenges of rural pediatric integrated primary care.

SIMON WILE SYMPOSIUM: FOCUS ON DIVERSITY AND EQUITY THROUGH A PEDIATRIC COLLABORATIVE AND INTEGRATED CARE LENS

The goal of this year’s Simon Wile Symposium will be to focus on diversity, equity, and inclusion through the lens of pediatric collaborative and integrated care. National experts will share their experiences and perspectives in building systems to collaborate with pediatric primary care providers (PCPs), working within and improving regional child health and mental health systems to improve health equity. Given national trends of focus on systemic racism and on racial and ethnic disparities, our Center for Inclusive Child Care (CICC) committee discussed possible invitees who had developed innovative programs to target improved access to care for children in Black, Indigenous, and People of Color (BIPOC) and Latinx populations. The literature on child psychiatry access programs was also reviewed, resulting in the current Symposium submission. Presentations this year will focus on programs that are as follows: 1) evaluating the impact of social determinants on ADHD symptoms among a racially and ethnically diverse population of preschoolers in primary care settings; 2) implementing collaborative and integrated care through a Federally Qualified Health Center for a racially and ethnically diverse population of children; and 3) targeting improving health equity among racially and ethnically diverse populations including BIPOC and Latinx populations. As child and adolescent psychiatrists continue to work to address the significant child mental health needs in communities across the country, we have increasingly found child psychiatry collaborative and integrated care to be a valuable tool in helping pediatric PCPs care for children and families struggling with mental health issues. We believe that this can also be a valuable tool in improving health equity. Our speakers will share innovations in their access programs that have allowed them to reach new and underserved populations, better engage PCPs, and carefully build systems of collaborative care.

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.

34.1 Improving Equity in Child Mental Health Outcomes

The aim of this study is to investigate the impact of pediatric integrated care, including peer-to-peer family support, on outcomes for children with mental health needs in a multicultural, urban safety-net system. We conducted a prospective, quasi-experimental clinical trial comparing health service utilization and spending between children nonrandomly assigned (at the clinic level) to the intervention or to usual care. We analyzed service-use data in 30-day segments for 12 months pre-post initial evaluation. Outcome variables were mental health, pediatric, and pharmacy utilization. The main explanatory variables were treatment group, time, and their interaction. In addition, we examined within-group changes (pre-post) on standardized measures of clinical functioning. Intervention youths were more likely to: be Black or Hispanic (61% vs 43%; p < 0.001); speak Spanish or Portuguese (52% vs 32%; p < 0.001); and carry multiple mental health diagnoses at baseline (42% vs 30%; p = 0.009). Doubly robust estimation results indicated that the intervention group had a 36% larger pre-post gain in outpatient mental health utilization (+15.6 pts.; standard error [SE] = 6.7) but no difference in outpatient mental health spending compared to controls. Intervention youths had 20% pre-post reductions in ED admissions (–5.6 pts.; SE = 2.2) and outpatient PH utilization (–19.2 pts.; SE = 5.2). The control group experienced no significant changes. Within-group analyses of clinical functioning, including measures of self-harm, revealed statistically significant improvement from baseline to 6 months and again from 6 months to 12 months. Overcoming mental healthcare access barriers for children and families, often mediated by structural racism, requires new models of care. In addition to significant clinical change on longitudinal measures, for the intervention group, evidence from propensity-score–weighted analyses indicate service use changes consistent with reduced health status inequity.

Integrated care is associated with increased behavioral health access and utilization for youth in crisis.

Pediatric integrated care is well-positioned to play a substantial role in crisis intervention; however, few studies have investigated the impact of these services. We investigated differences in service utilization for youth experiencing a crisis in a large, predominantly rural health system by comparing outcomes for 171 youth who received a crisis evaluation in a primary care behavioral health (PCBH) setting to 171 youth presenting to the emergency department at the main hospital campus using a retrospective cohort study design. PCBH patients were less likely to be male, more likely to be diagnosed with an Adjustment Disorder and less likely to be diagnosed with Autism Spectrum Disorder. Youth evaluated in PCBH were more likely to receive a psychiatric admission, had a shorter latency to the next BH appointment, and had higher rates of completing at least 1 visit in the year following the evaluation. A statistically nonsignificant reduction in frequency of psychiatric admission was observed in the year after the index date, with 3 integrated care patients (vs. 18 on index date) and 5 ED patients (vs. 6 on index date) admitted. Opportunities for future research on cost-effectiveness of care and continuous improvement aligned with quadruple aim outcomes are discussed. Overall, this study is among few others investigating the potential for pediatric integrated care models to contribute to youth suicide prevention and the study demonstrated promising increases in access and engagement with timely behavioral health care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Notes from the Field: Results from the Parent Acceptance of Pediatric Integrated Care Survey.

Objective:To collect data and gain an understanding of parental satisfaction with and attitudes toward treatment in a pediatric integrated primary care (IPC) model.Data Sources:Primary data were collected across the United States over the course of a few months.Study Design:The 35-item, Parent Acceptance of Pediatric Integrated Care Survey (PAPICS) was developed by a panel of IPC experts. The survey was then distributed through the Qualtrics Panels Service with recruited participants (i.e., parents with children under 18-years-old) receiving a $4.00 incentive for their involvement.Data Collection/Extraction Methods:A single exploratory factor analysis was performed along with four factor retention tests and clinical judgment to guide factor selection. A 5-factor structure was selected.Principal Findings:Parents reported a high level of comfort with an IPC model and a favorable attitude toward child therapy, with some concerns regarding psychological stigma and privacy. Notable variation in parents’ beliefs regarding one-on-one psychological service delivery were observed.Conclusions:Results provided evidence for parental openness to an IPC model. Findings also highlighted potential fundamental misunderstandings regarding evidence-based psychological treatment methods for children and adolescents.

Strategic Implementation Planning for Integrated Behavioral Health Services in Pediatric Primary Care.

Delivering physical and behavioral health services in a single setting is associated with improved quality of care and reduced health care costs. Few health systems implementing integrated care develop conceptual models and targeted measurement strategies a priori with an eye toward adoption, implementation, sustainment, and evaluation. This is a broad challenge in the field, which can make it difficult to disentangle why implementation is or is not successful. This paper discusses strategic implementation and evaluation planning for a pediatric integrated care program in a large health system. Our team developed a logic model, which defines resources and community characteristics, program components, evaluation activities, short-term activities, and intermediate and anticipated long-term patient-, clinician-, and practice-related outcomes. The model was designed based on research and stakeholder input to support strategic implementation and evaluation of the program. For each aspect of the logic model, a measurement battery was selected. Initial implementation data and intermediate outcomes from a pilot in five practices in a 30-practice pediatric primary care network are presented to illustrate how the logic model and evaluation plan have been used to guide the iterative process of program development. A total of 4,619 office visits were completed during the two years of the pilot. Primary care clinicians were highly satisfied with the integrated primary care program and provided feedback on ways to further improve the program. Members of the primary care team and behavioral health providers rated the program as being relatively well integrated into the practices after the second year of the pilot. This logic model and evaluation plan provide a template for future projects integrating behavioral health services in non-specialty mental health settings, including pediatric primary care, and can be used broadly to provide structure to implementation and evaluation activities and promote replication of effective initiatives.

Reflections on changing times for pediatric integrated primary care during COVID-19 pandemic.

Objective: The COVID-19 pandemic has had a monumental impact on health care delivery The pediatric integrated primary care (IPC) program at MetroHealth Medical Center, 1 of the oldest such programs in the United States, has been profoundly changed by the COVID-19 pandemic of 2020 Method: This commentary provides a reflection on the early response of 1 established IPC program to the COVID-19 pandemic Results: Initial markers of successful adaptation to care delivery and training models include efforts that incorporate virtual consultation and telehealth practices Conclusions: The impact of the COVID-19 pandemic on pediatric psychology in IPC settings will largely depend on the flexibility and adaptability of workflows and training methods to meet the needs of the changing landscape (PsycInfo Database Record (c) 2021 APA, all rights reserved) Impact Statement Implications for Impact Statement-Pediatric integrated primary care (IPC) has been profoundly impacted by the COVID19 pandemic of 2020 The future success of IPC will depend on adapting models and training efforts that incorporate virtual and telehealth formats (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Nebraska Pediatric Integrated Care Training (NE-PICT) model.

Nebraska Pediatric Integrated Care Training (NE-PICT) model.