The kids are not all right: How to integrate behavioral health into pediatric practices

A pediatrician and his patient
Nearly one in five children in the U.S. have a diagnosable mental health illness, according to the Centers for Disease Control and Prevention. (Getty/shironosov)

Statistics reveal a big conundrum. Nearly 1 in 5 children in the U.S. have a diagnosable mental health illness, according to the Centers for Disease Control and Prevention. Yet, only one in three pediatricians feels they have sufficient training to diagnose and treat mental health disorders.

Pediatric practices are working to come up with solutions to ensure their patients have access to the behavioral healthcare they need, including the four most common mental health issues that children struggle with—anxiety, depression, attention deficit hyperactivity disorder, and disruptive behavior disorder.

“If we only focus on the physical, we forget to treat the whole patient,” said Rebekah Phillips, R.N., practice administrator at Pediatrics 5280, PC in Centennial, Colorado. She and three other administrators talked about how they are integrating behavioral health in pediatrics at the Medical Group Management Association annual conference.

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So why is it only 20% of children with mental health illnesses receive care from a specialized mental health provider? Phillips said there are numerous barriers, including a limited number of providers in the area, such as she is up against in Colorado. Waiting lists to see those mental health providers are often long and services are costly. Even when insurance coverage can be issued, parents may be reluctant to see their child labeled with a mental health illness, she said.

Pediatric practices are looking at new models of care including coordinated care, co-located care and integrated care to ensure that behavioral health services are offered to all their patients, she said.

How it works in private practices

Pediatrics 5280 is a midsized private practice that has integrated behavioral health right into its model. In addition to 12 physicians and three physician assistants, the practice added a psychologist to its staff in January, Phillips said.

“We integrate her into every aspect of our practice,” she said.

The practice decided to integrate behavioral health services to give patients easy and speedier access to care, to reduce stigma—since children don’t have to leave the practice where see their regular pediatrician—and to allow for collaboration or a “warm handoff” between a patient’s pediatrician and the psychologist, Phillips said.

RELATED: Lessons from a payer-led behavioral health home model

Northhampton Area Pediatrics in Northhampton, Massachusetts, is another practice that has integrated behavioral health services. In addition to nine physicians and four nurse practitioners, the practice has one licensed independent clinical social worker and a licensed mental health counselor, along with two care coordinators, said Kimberly Brewer, practice administrator.

The practice had its reasons for integrating services, including increasing the rates of behavioral health screenings at well-child visits and evaluating children who screen positive for concerns to determine the need for further assessment and services. The practice also wanted to increase the rates of referral to behavioral health services for children with identified needs and decrease emergency room use for behavioral health issues.

So far, the practice is breaking even to cover the salary and benefits of its behavioral health providers, she said. Doctors are happy that they now have a place to send a child who needs behavioral services.

“The doctors love it. They just want more,” she said.

The goal is to provide patients with brief interventions, ideally providing help within five visits, she said.

“For us, it’s not meant to be long-term,” she said. Whether it is to treat anxiety or ADHD, sessions might focus on skills building with the child and teaching parents how to help, she said.

RELATED: ACHE 2017: Carolinas Health integrates behavioral health, primary care to improve diagnosis, treatment

The Northhampton practice is also piloting a telepsychiatry program with Boston Children’s Hospital that allows doctors to refer patients.

“Within five days we can get a child referred,” she said.

The fact a practice has behavioral health services can help attract new patients, Brewer said. The practice only offers its behavioral health services to its own patients, making the practice attractive to parents who want to have access to such services for their child.

Academic practices also adding mental health services

Academic practices that are part of a hospital are also integrating behavioral services, including Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. The pediatric hospital recognized that it needed to build programs around behavioral health, said Michelle DuJardin, J.D., senior director who leads the administration of the hospital’s Institute for Brain Protection Sciences. 

The 259-bed hospital now has 12 psychologists and three psychiatrists and wants to work with private practices throughout the state who can benefit from its areas of expertise, she said.

Part of the reason that Michigan Medicine in Ann Arbor, the academic medical center of the University of Michigan, decided to integrate behavioral health services is that primary care physicians had become de facto behavior health providers, said D’Ann Voss, administrative manager for pediatrics. Without available specialists, general practitioners were being forced to practice outside of their scope of work.

Too often doctors prescribed medications for mild to moderate problems and often behavioral issues persisted, leading to repeat visits. The hospital found referrals to off-site behavioral health specialists frequently had poor success.

Pediatrics is one of 20 clinical departments at the University of Michigan and now includes 17 psychologists with faculty appointments in the division of pediatric psychology. Integrated behavior health services are now offered in five of the nine pediatric primary care clinics.

Patients are offered one-hour appointments, with seven to eight scheduled per clinic day. Patients receive comprehensive evaluations for issues such as ADHD, depression, anxiety and learning problems and then are offered evidence-based treatment.

Still, there are two significant issues that face practices integrating behavioral health services:

  • Recruiting and hiring behavioral health providers: One of the challenges for practices seeking to integrate behavioral health services is finding the right people to fill those jobs. It may not be easy to find a therapist who speaks Spanish and is available after 3 p.m. when kids are out of school, Brewer said. School adjustment counselors who are experienced working with children often make good providers, she added. DuJardin said her hospital had several bartenders apply for jobs. “We really want psychologists with experience,” she said.
  • Being aware of the operational considerations when implementing integrated behavioral health: Another challenge is scheduling appointments and dealing with patient no-shows. Prime-time appointments are in the late afternoon when children are out of school. Northhampton Area Pediatrics does initial evaluations in the morning and two days a week offers behavioral health appointments until 7 p.m.

Practices may experience a higher rate of no-show appointments. “Our mental health side has twice the no-show rate of the clinical side,” Brewer said. She recommends a practice of keeping the time between the initial referral and the behavioral health appointment as short as possible.

She knows of one practice where if a parent is a no-show for one of those in-demand after-school appointments, they can’t schedule any of their next three visits during those prime-time hours.

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