Mental and behavioral health disorders among children are an important public health issue because of their prevalence, early onset, and impact on the child, family, and community throughout the lifespan.1,2 Estimates indicate approximately 15 million youths could benefit from mental health interventions; however, only 7% receive appropriate treatment.3,4 For those who receive mental and behavioral health (MBH) treatment, most takes place in primary care or pediatric settings.5,6 Opportunities exist to improve coordination of behavioral health services through integration and development of pediatric patient- centered medial homes. Integrating behavioral health services into primary and pediatric health care settings is important to increase availability and access to quality MBH care for children and adolescents. Primary care clinics are often easier to access than mental health facilities7; this is particularly true with pediatric populations that have annual or more frequent well-child visits.5 Integrated care can increase access and decrease stigma, by providing mental health services in a trusted and convenient location. Furthermore, not only can gains be made in the direct health care of children and adolescents, but also, parents and guardians can benefit from coordinated services, engagement, and education available at all levels.
Research on the outcomes of integrated or colocated pediatric services is primarily based on adult populations and only recently emerging for youth services.8 A recent meta-analysis on integrated health care for children and adolescents yielded a small to medium effect, yielding better outcomes compared with nonintegrated care.2 Less literature is available on the differing models used to implement integrated pediatric services. A systematic review was conducted on integrated behavioral health models in pediatric primary health care, and only 22 studies met inclusion criteria. Articles were further categorized into coordinated (consultation with primary care physician but not provided onsite), colocated (provided onsite with little to no coordination), and integrated (coordination with primary care physicians and provided onsite). Most of the studies, regardless of model type, demonstrated some degree of effectiveness.9 Furthermore, both the meta-analysis and review suggest further research, describing methods of integrated pediatric health care and where available demonstrating effectiveness, is needed.
The Deepwater Horizon Medical Benefits Class Action Settlement allowed collaborators to develop projects that included a variety of integrated health initiatives on the basis of expertise, community-based needs, and underserved populations. Therefore, the Mental and Behavioral Health Capacity Project (MBHCP) in Florida and Louisiana developed models of pediatric integrated health care related to community and clinic culture, location, and types of services needed. Both regions have marked health disparities,10 which are frequently greater for children and adolescents.11 In addition, because of the frequent disasters experienced on the Gulf Coast, there is increased vulnerability related to insufficient attention to youth with disaster response.12 The primary purpose of this article is to describe 2 sustainable programs focused on training and provision of integrated MBH services to meet the needs of children and adolescents. A secondary objective is to provide outcomes from a sample in Louisiana. Specifically, the hypothesis is that behavior problems and parental stress decrease after treatment following pediatric integrated health services.
The MBHCP in Florida (MBHCP-FL) and Louisiana (MBHCP-LA) developed similar, yet different, models of pediatric integrated health care; brief descriptions of these models are discussed next.
MBHCP-FL, directed by the University of West Florida School of Social Work, collaborates with Federally Qualified Health Centers (FQHCs) Escambia Community Clinics, Inc, which serves 2 pediatric clinics along the Florida Gulf Coast. MBHCP-FL contracted with each clinic to pay the salary of the (Licensed Clinical Social Workers) LCSW or Registered LCSW. The LCSW was placed in the agency and referrals come from warm handoffs from the clinic staff (doctor or nurse). The goal of being colocated is to meet the clients the first day they are in the clinic; however, if the therapist is busy, staff will leave a message to follow up with a phone call to the patient. During the first 2 years of the project, a total of 266 children received services, with 66 (25%) receiving a primary diagnosis of attention-deficit/hyperactivity disorder (ADHD). Additional diagnoses include adjustment disorder, conduct disorder, oppositional defiant disorder, and autism spectrum disorder. LCSWs and student interns provided by MBHCP-FL participate in initial evaluations and follow-up services including clinical care management, working collaboratively with the patients' pediatrician for medication prescription and addressing chronic health conditions.
MBHCP-LA provides integrated MBH care to rural FQHCs and community health care clinics that provide services across the lifespan. Most of the communities have only 1 primary care clinic, little or no access to MBH services, and were affected by the Deepwater Horizon Gulf oil spill and Hurricanes Katrina and Rita. MBHCP-LA, through the Louisiana State University Health Sciences Center (LSUHSC) Department of Psychiatry, has developed an interprofessional step care collaboration model that includes services provided by psychiatrists and psychologists with combined on-site and telepsychiatry treatment modalities.13 Patients were referred through a warm handoff from their primary care doctor or parent-referral with the first available mental health provider; after the MBH intake, the child was scheduled with a psychiatrist or psychologist, as needed on the basis of clinical evaluations. Supportive services include assessment and evaluation, consultation, behavioral psychotherapy, medication management, and education, with over 1300 child and adolescents services provided annually. As occurred in Florida, the most common pediatric diagnosis was ADHD (44%). The pediatric clinic program also includes training on behavioral health for clinic staff and health care professionals, as well as training of LSUHSC psychiatry residents, postdoctoral psychology fellows, and medical students.
For the secondary purpose of this article—research on the effectiveness of pediatric integrated care—a subsample from the Louisiana model was utilized from patients presenting at 2 FQHCs during the first 2 years of services. Sample selection was based on voluntary parental consent for research; services were provided regardless of participation. A preexperimental design was used to assess symptom change over time. Parents completed the measures using interview format at intake and via telephone at 1, 3, and 6-month follow-up intervals. Parents who completed the intake measures and at least 1 follow-up were included in the study. Of the 471 patients, 435 consented to research, and further 177 (41%) completed a follow-up and were included in the analysis. All procedures were approved by the LSUHSC Institutional Review Board.
Behavioral and emotional problems were measured using the Pediatric Symptom Checklist-17 (PSC-17).14 The PSC-17 was developed to screen for psychosocial functioning and consists of 17 items that are rated never (0), sometimes (1), and often (2). The total scale score was used, with 15 or higher suggesting the presence of significant behavioral or emotional problems; intake α = .88, 1-month α = .84, 3-month α = .88, and 6-month α = .88. A subsample (n = 93) of the parents also completed the Parenting Stress Index Short Form.15 A total parental stress score was calculated by adding the 36 items, where strongly agree (1), agree (2), not sure (3), disagree (4), and strongly disagree (5) intake α = .94, 1-month α = .95, 3-month α = .95, and 6-month α = .96.
The International Classification of Diseases (ICD) is a medical classification system developed by the World Health Organization. The revised International Classification of Diseases, Tenth Revision (ICD-10) allows for more specificity, sensitivity, accurate tracking of population health outcomes, and payment initiatives.16,17 Use of ICD-10 codes is required for all entities covered under the Health Insurance Portability and Accountability Act of 1996. Because of their importance around billing and revenue, grouped F classifications (F00-F09, F10-F19, F30-F39, F40-F48, F50-F59, F60-F69, F80-F89, and F90-F98) were used as a proxy for sustainability.
A total of 90 (51%) were male, 74 (42%) were female, and 13 (7%) were missing. The minimum age was 1 year and the maximum was 17 years (mean = 9.8; standard deviation = 4.3). Eighty-seven (49%) were white, 37 (21%) were African American, 14 (8%) identified as multiple racial/ethnic, 9 (5%) identified as Latino, 4 (2%) identified as Asian, and 1 (0.6%) identified as Native American, and 23 (13%) did not report racial or ethnic affiliations.
Child and adolescent patients presented with a variety of symptoms, with the 5 most frequently endorsed being behavior problems (50%), difficulty with concentration (40%), sadness (34%), stress (33%), and irritability (29%). Seventy-three (42%) patients received psychiatric services, 68 (39%) received psychological services, and 35 (20%) received combined treatments; the minimum number of visits was 1 and the maximum was 20 (mean = 4.2; standard deviation = 4.3). Clinicians used a combination of brief treatment types and the most frequent occurring at any visit (dichotomized yes or no) being parental education (n = 104, 59%), medication management (54%), stress management (41%), empowerment (33%), and psychodynamic (29%).
ICD-10 codes were available for all patients, and Table 1 presents the frequency and percentages of occurrence grouped by F codes. Two repeated-measures analyses of variance (ANOVA) were conducted to assess child behavior problems and parental stress over the course of treatment. Results suggest a statistically significant decrease in behavior problems and parenting stress over time (Table 2). In addition, 87% (n = 139) reported the MBH services received for their child as good, very good, or excellent. Change scores were calculated (intake − 3-month scores); exploratory analyses were conducted to assess associations with change scores and revealed a significant association among parenting stress and behavior problem change scores (r = 0.36; P < .001). A significant association was also found, suggesting that use of empowerment techniques, therapeutic process where the clinician helps the family identify and build upon their strengths to help them succeed with their presenting problems, was associated with decreased parenting stress scores (r = −0.25, P < .05). No other significant associations were shown with change scores.
The program models in Florida and Louisiana are tailored to different geographic and cultural needs. Both models allow MBH clinicians to provide services for the greatest number of patients in an efficient, time-sensitive manner without sacrificing the level of care. Preliminary evidence on the effectiveness from the Louisiana model was demonstrated by support of the hypothesis—that with brief behavioral interventions integrated into pediatric health care clinics, behavioral problems and parental stress improve over time. Improved behavior was also associated to reduction in parental stress, suggesting that improvement in family functioning can result from providing brief treatment, empowering parents, and parental education to supplement the visit.18,19 Taken together the results, including a 50% clinically significant reduction in behavior problems and 85% satisfaction with services is an important and meaningful gain for children and families in underserved communities.
In addition to efficiency and effectiveness, sustainability is an important consideration to the triple target (efficiency, effectiveness, and sustainability) in health care service systems, specifically for the pediatric patient-centered medial homes to ensure services are provided beyond the current funding.20 MBHCP-FL taught the clinics to bill for MBH services and once the agency had the billing process in place the MBHCP-FL money was removed and the individual professional became a paid clinic staff member. This process resulted in the permanent placement of 23 staff members across the panhandle of Florida. In Louisiana, FQHCs have hired social workers with collaborative training provided by MBHCP-LA and are actively working toward providing contracts for MBHCP-LA psychiatrists and psychologists. Direct billing and contracts would not be possible without training practitioners to learn the ICD-10 system, as reimbursement is often contingent on a diagnosable mental health condition that falls under the category of an F code. Most psychology and social work graduate programs teach the DiagnosticandStatistical Manualof Mental Disorders, Fifth Edition (DSM-5) for classification of disorders. Although there are similarities and overlap between ICD-10 and the DSM-5, the systems are different and ICD-10 (F codes for MBH) should also be included for didactic classification. Importantly, 100% of the cases had an ICD-10 code, which supports the success of ICD-10 code training and a marker toward sustainability in the clinics. Through training on ICD-10, billing, and contracts, both programs have managed to address the most challenging aspect to the implementation of integrated and coordinated behavioral health services within the primary care setting—noted as methods to sustain programs without reliance on grants or foundational contributions.21,22
Implications for Policy & Practice
- Pediatric models should be flexible and address a variety of integrated health initiatives on the basis of expertise, community-based needs, and underserved populations.
- Creating models that work within the existing health care systems are more sustainable and can become a part of normal clinic functioning.
- Mental and behavioral health integrated into pediatric health care clinics can be effective at improving child behavior problems.
- Other benefits included decreasing parental stress through providing brief treatment, empowering parents, and providing psychoeducation.
- Training on ICD-10 codes allows for improved billing and sustainability of behavioral health services within the primary care setting.
- Integration of pediatric primary care not only increases access to behavioral health services but also provides opportunities for preventive work and encouragement of positive parenting practices for improved family functioning.
The findings from this work are important; however, the study is not without limitations. The lack of generalizability of findings to different settings needs to be considered. Use of a preexperimental design was a limitation and would be enhanced by having a control group. Future studies would also benefit from exploration on factors contributing to the decrease in symptoms such as the moderation effect of parental stress or other types of life stressors, such as single-parent households and poverty. Furthermore, future inquiry into the contribution schools play in the pediatric primary-centered medical home, specifically regarding ADHD, and the community school-based MBHCP models in Alabama and Louisiana is needed. Although we cannot state that the symptom reductions were solely due to our services or will yield the same results in different locations, findings are promising and provide important support for the idea of increasing the availability of MBH consultation and services in primary care and pediatric clinics.23
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
integrated care; pediatric