Integrated behavioral health in urban pediatric primary care: A step forward in preventative care
The integrated behavioral health model promotes accessibility and family engagement in behavioral health services and reduces barriers to care that are especially salient in urban, low-income settings.
By Billie S. Schwartz, Corinn A. Elmore, Julie A. Fiorelli, Sarah B. Backe, Tamique J. Ridgard, Paul M. Robins, Jennifer A. Mautone, and Thomas J. Power, PhD
Background
Equal access to high quality behavioral health (BH) care for children is an ongoing, unmet need in the United States. Numerous factors contribute to the underutilization of BH services, including family beliefs and access barriers (Power, Eiraldi, Clarke, Mazzuca, & Krain, 2005). It is estimated that only 25 percent of children with BH problems actually receive care, and that 50 percent of healthy children are at risk for developing serious health and mental health conditions (Kataoka, Zhang, & Wells, 2002). This is particularly true for the urban poor who are at significant risk for chronic health and mental health conditions (Van Cleave, Gortmaker, & Perrin, 2010).
Healthcare changes in response to the Affordable Care Act highlight the importance of a Patient-Centered Medical Home (Rittenhouse, Shortell, & Fisher, 2009), which emphasizes evidence-based, continuous, and integrated healthcare linked with community services (Institute of Medicine, 2001). Pediatric primary care has emerged as a major “de-facto” venue for the delivery of BH services to children; however, BH services currently offered in primary care are inadequate. Generally, primary care providers (PCPs) are not able to provide the range of BH services needed due to limitations in professional competence as well as role and time constraints (Power, Blum, Guevara, Jones, & Leslie, 2013). Therefore, mental health providers based in primary care can help improve the quality of preventative healthcare in these settings.
Integrated Behavioral Health
Integrating BH in urban primary care settings requires a shift from relatively long-term, office-based therapy to consultation and brief intervention. In the traditional “mental health model,” clinicians typically see patients for several 50-minute sessions over the course of a few months. In contrast, in an Integrated Behavioral Health (IBH) model, clinicians are consultants to patients and providers over a longer period of time. The consultation model allows rapid access to professionals providing brief, evidence-based care. This is consistent with a population-based approach promoting incremental changes in behavioral health that translates to significant prevention effects over time (Whitlock et al., 2002). Consultation typically involves brief evidence-based intervention and occurs with the medical team during routine well-child or sick visits. This integrated approach promotes higher quality of care both through direct patient contact and interprofessional education.
Training Competencies
There are emerging opportunities for psychology trainees interested in providing BH intervention in pediatric primary care settings. Trainees can participate in the development of models of care and effectiveness research to help shape the future of this service delivery. To support this, training competencies specific to primary care should be considered. In primary care, trainees will likely encounter a new approach to treatment in addition to pediatric health issues that are seldom the focus of traditional psychology training programs. Didactic instruction and case-centered discussion are needed to enhance trainees’ knowledge of evidenced-based interventions, behavior change strategies, and medical diagnoses commonly seen in primary care. Training should be general and widespread to adequately address the needs of the range of patients seen in this setting. Consistent with an integrated, interprofessional approach, didactic training should be provided by a diverse group of professionals who work within the practice (e.g., PCPs, nurses, social workers) and outside of the practice (e.g., psychologists, child psychiatrists, and other specialty medical providers).
Developing a Model of Care
The integration of behavioral health services into pediatric primary care centers at The Children’s Hospital of Philadelphia (CHOP) has been a developmental process that has evolved in response to the needs of our partners in pediatric practice, families, and trainees. Our model utilizes three modes of referral or “warm-handoff”: (a) Direct consultation with the PCP and family; (b) Screen and refer, which includes brief screening within the existing medical appointment and referral to community-based services; and (3) Assess and refer, which involves a more comprehensive assessment of patient/family concerns and concludes in referral to community-based services. In addition, IBH clinicians provide very short-term intervention (i.e., 1-3 problem-focused sessions) and in few cases, longer-term child and family therapy to address the needs of trainees to develop intervention skills while helping to meet patient needs. For patients for whom long-term, ongoing treatment is indicated, existing practices are followed (e.g., referral to a practice-based social worker, crisis center, or community-based mental health agency).
Conclusion
Although this model limits clinician availability to provide ongoing treatment, it enables BH services to be highly integrated with pediatric care. The IBH model promotes accessibility and family engagement in behavioral health services and reduces barriers to care that are especially salient in urban, low-income settings. This approach affords opportunities for providers to reach a greater number of families than standard care. Finally, the IBH approach emphasizes prevention to promote the movement of families through the help-seeking process so that children and adolescents are able to receive the necessary services as problems emerge.
References
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century . Washington, DC: The National Academies Press.
Kataoka, S., Zhang, L., & Wells, K. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance stats. American Journal of Psychiatry, 159 (9), 1548-1555.
Power, T. J., Eiraldi, R. B., Clarke, A. T., Mazzuca, L. B., & Krain, A. L. (2005). Improving mental health service ultilization for children and adolescents. School Psychology Quarterly, 20 , 187-205.
Power, T. J., Blum, N. J., Guevara, J. P., Jones, H. A., & Leslie, L. K. (2013). Coordinating mental health care across primary care and schools: ADHD as a case example. Advances in School Mental Health Promotion, 6 (1), 68-80.
Rittenhouse, D. R., Shortell, S. M., & Fisher, E. S. (2009). Primary care and accountable care–two essential elements of delivery-system reform. New England Journal of Medicine, 361 (24), 2301–2303.
Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. Journal of the American Medical Association, 301 (21) , 2252-2259.
Van Cleave, J., Gortmaker, S., Perrin, J. (2010). Dynamics of obesity and chronic health conditions among children and youth. Journal of the American Medical Association , 303 (7), 623-630.
Whitlock, E. P., Orleans, C. T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioral counseling interventions: An evidence-based approach. American Journal of Preventive Medicine , 22 (4), 267–284