Integrating Behavioral Health into Pediatric Primary Care
Integrating Behavioral Health
into Pediatric Primary Care
Allison Grennan, PhD
Associate Professor, Licensed Psychologist
Director of Internship Training
Munroe-Meyer Institute, UNMC
Kid’s Mental Health
1 in 5 Children with
diagnosed Mental Health
condition in 2022
Where are most kids?
Behavioral health concerns in children
highly
common and increasing
1
Physicians as De Facto
Mental Health providers
2
75% of children with mental health concerns are
seen in primary care
3
Sources: 1 – SAMSHA, 2013; 2 -
Stein et al., 2008; 3 - National Institute of Health Care Management Foundation 2009
Behavioral Health Needs
67% of individuals with a behavioral health disorder
do not receive behavioral health treatment
1
30-50% of referrals
to behavioral health from
primary care don’t make first appt
2,3
Two-thirds of primary care physicians reported
not
being able to access
outpatient behavioral health for
their patients
4
due to:
Shortages of mental health
care providers
Health plan barriers
Lack of coverage or
inadequate coverage
Sources:
1
Kessler et al., NEJM. 2005;352:515-23.
2
Fisher & Ransom, Arch Intern Med. 1997;6:324-333.
3
Hoge et al.,
JAMA. 2006;95:1023-1032.
B
H
T
a
k
e
s
t
i
m
e
…
Valleley, R. J.
Polaha, J., Begeny, J., & Evans, J. H. (2006). Running out of
time: Physician management of behavioral health concerns in rural
pediatric primary care.
Pediatrics Electronic Pages, 118,
e132-e138
.
A
n
d
M
o
n
e
y
…
Meadows, Valleley, Haack, Evans, and Thorson (2011). Physician “Costs” in Providing
Behavioral Health in Primary Care.
Clinical Pediatrics, 50
, 447-455
.
What is Integrated Care?
From: Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and
Primary Care Integration: AHRQ Publication No.13-IP001-EF. Rockville, MD
Models of Integrated Care
Primary Care Behavioral Health (PCBH)
describes how
licensed mental health providers/psychologists and primary
care providers work in collaborative environments to address
physical and behavioral health
Collaborative Care or CoCM
is a specific framework of
integrated care by the American Psychiatric Association
“Collaborative Care Model”
Adult Behavioral Health in
Primary Care
•
Anxiety
•
Pain
•
Depression
•
Substance Abuse
50% - 70% of physical complaints have no
identifiable physical cause (O’Donohue, 2003)
Children vs Adults in IPC
Focus on the
developing child
Families
play an active role in treatment
Treatment focuses on coping and
adjustment
and behavior
management
NIMH
Pediatric Integrated Care
SAMHSA: https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood-
experiences
Primary Care Behavioral Health
Model (PCBH)
Model of care that integrates behavioral health in the
primary care setting
Goal:
Optimize access to behavioral health support
across a variety of patient presentations
PCP sees patient and provides referral to the BHC
Licensed behavioral health professionals are referred
to as Behavioral Health Clinician “BHC’s”
Behavioral health assessment and treatment delivered
in the same space as the PCP’s
Child-Adolescent Behavioral
Health Concerns
Non-compliance
Excessive Tantrums
Elimination Disorders
ADHD
School Behavior Problems
& Refusal
Sleep Disorders
Learning Disabilities
Developmental Delays
Depression
Anxiety
Relationship Problems
Behavioral Health Needs
75-80%
10-15%
5%
Medical and BH
Provider in
Primary Care
Referrals and
Community Care
Specialty Care
https://www.integration.samhsa.gov/workforce/Integration_Competencies_Fi
nal.pdf
Why Integrated Care?
https://www.kumc.edu/documents/internalmed/quadruple-aim-healthcare-image.pdf
Six Reasons
Why
Behavioral Health Should be Part of
the Primary Care Medical Home
1.
High prevalence
of behavioral health problems in primary care (needing long-term
follow-up)
2.
High burden
of behavioral health
in primary care
3.
High cost
of unmet behavioral health needs
4.
Lower cost
when behavioral health needs are met
5.
Better health
outcomes
6.
Improved satisfaction
7.
Improving work life of health care providers
B
e
h
a
v
i
o
r
a
l
h
e
a
l
t
h
i
n
t
e
g
r
a
t
i
o
n
a
c
h
i
e
v
e
s
t
h
e
q
u
a
d
r
u
p
l
e
a
i
m
.
Quadruple Aim
Does it work?
Increases access
to behavioral health care.
Improves health outcomes
for patients with mental illness
and/or substance use disorders.
Improves health
behaviors such as compliance with treatment
recommendations, exercise, and diet.
Reduces overall health care costs
, thus representing the
opportunity for shared savings for primary care practices.
Why Integrated Care?
Research is finding…
http://www.jabfm.org/content/30/1/25.full?sid=f635119b-7243-4bfe-bbd2-3241c11377f4
;
https://www.ncbi.nlm.nih.gov/pubmed/28379819
;
http://medicaleconomics.modernmedicine.com/medical-
economics/content/tags/affordable-care-act/integrating-primary-care-and-mental-health-key-im?page=full
Improved Access
Valleley, R.J., Kosse, S., Schemm, A., Foster, N., Evans, J., & Polaha, J. (2007).
Integrated Care for Children in Rural
Communities: An Examination of Patient Attendance to Behavioral Health Services
. Families, Systems, & Health, 25,
323-
332
.
Valleley, Meadows, Burt, Menousek, Hembree, Evans, Gathje, Kupzyk, Sevecke, Lancaster (2020). Demonstrating the
impact of collocated behavioral health in pediatric primary care. Clinical Practice in Pediatric Psychology, 8(1), 13-24.
Provider Satisfaction
Hine, Grennan, Menousek, Robertson, Valleley, & Evans. (2016). Physician Satisfaction with Integrated Behavioral Health in
Pediatric Primary Care: Consistency Across Rural and Urban Settings.
Journal of Primary Care and Community Health.
1-5.
Physicians who have adopted an integrated model of care report strong
agreement that this type of model helps to improve factors such as:
•
Quality and continuity of care for their patients
•
time that it allows them to spend on medical issues
•
Cost
•
Follow-up
•
Confidence with identification/management of problems
•
Reduced stigma for their patients
Exciting Directions
Training
and
Supervision
in IPC
Early
evaluation and identification
for Autism
Spectrum Disorders
Trauma-Informed Care
Mid-America Mental Health
Technology and Transfer Center
Funded by the Substance Abuse and Mental Health
Services Administration
5-year grant awarded to Dr. Joseph Evans at the University
of Nebraska Medical Center
Aligns mental health systems and professional
competencies with evidence-based practices
Primary target states: Missouri, Iowa, Nebraska, and
Kansas - but available to any provider(s).
Provides free/low cost training and technical assistance on
topics leading to effective behavioral health practice
https://mhttcnetwork.org/centers/content/mid-america-
mhttc
Mid-America MHTTC
Integrating Behavioral Health into Pediatric Primary Care is crucial due to the increasing prevalence of mental health conditions among children. This integration aims to bridge the gap between primary care and mental health services, as a significant number of children with mental health concerns are first seen in primary care settings. However, challenges such as access barriers and inadequate coverage hinder the effective delivery of behavioral health services. Addressing these challenges is essential to ensure that children receive the necessary mental health support they need to thrive.
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Presentation Transcript
Integrating Behavioral Health into Pediatric Primary Care Allison Grennan, PhD Associate Professor, Licensed Psychologist Director of Internship Training Munroe-Meyer Institute, UNMC
Kids Mental Health 1 in 5 Children with diagnosed Mental Health condition in 2022
Where are most kids? Behavioral health concerns in children highly common and increasing1 Physicians as De Facto Mental Health providers2 75% of children with mental health concerns are seen in primary care3 Sources: 1 SAMSHA, 2013; 2 - Stein et al., 2008; 3 - National Institute of Health Care Management Foundation 2009
Behavioral Health Needs 67% of individuals with a behavioral health disorder do not receive behavioral health treatment1 30-50% of referrals to behavioral health from primary care don t make first appt2,3 Two-thirds of primary care physicians reported not being able to access outpatient behavioral health for their patients4 due to: Shortages of mental healthcare providers Health plan barriers Lack of coverage orinadequate coverage Sources: 1Kessler et al., NEJM. 2005;352:515-23.2Fisher & Ransom, Arch Intern Med. 1997;6:324-333. 3Hoge et al., JAMA. 2006;95:1023-1032.
BH Takes time 25 19.69 20 17 15 Medical Behavioral Medical & Behavioral 10 8.04 5 0 Average Time Spent Valleley, R. J.Polaha, J., Begeny, J., & Evans, J. H. (2006). Running out of time: Physician management of behavioral health concerns in rural pediatric primary care. Pediatrics Electronic Pages, 118, e132-e138.
And Money $20.00 $18.12 $18.00 $16.00 $14.00 $12.00 Medical Behavioral Medical & Behavioral $10.00 $7.35 $8.00 $6.00 $4.34 $4.00 $2.00 $0.00 Avg $ per Minute Meadows, Valleley, Haack, Evans, and Thorson (2011). Physician Costs in Providing Behavioral Health in Primary Care. Clinical Pediatrics, 50, 447-455.
From: Peek CJ and the National Integration Academy Council. Lexicon for Behavioral Health and Primary Care Integration: AHRQ Publication No.13-IP001-EF. Rockville, MD
Models of Integrated Care Primary Care Behavioral Health (PCBH) describes how licensed mental health providers/psychologists and primary care providers work in collaborative environments to address physical and behavioral health Collaborative Care or CoCM is a specific framework of integrated care by the American Psychiatric Association Collaborative Care Model
Adult Behavioral Health in Primary Care Anxiety Pain Depression Substance Abuse 50% - 70% of physical complaints have no identifiable physical cause (O Donohue, 2003)
Children vs Adults in IPC Focus on the developing child Families play an active role in treatment Treatment focuses on coping and adjustment and behavior management NIMH
Pediatric Integrated Care Screening Prevention Early Intervention SAMHSA: https://www.samhsa.gov/capt/practicing-effective-prevention/prevention-behavioral-health/adverse-childhood- experiences
Primary Care Behavioral Health Model (PCBH) Model of care that integrates behavioral health in the primary care setting Goal: Optimize access to behavioral health support across a variety of patient presentations PCP sees patient and provides referral to the BHC Licensed behavioral health professionals are referred to as Behavioral Health Clinician BHC s Behavioral health assessment and treatment delivered in the same space as the PCP s
Child-Adolescent Behavioral Health Concerns Sleep Disorders Learning Disabilities Developmental Delays Depression Anxiety Relationship Problems Non-compliance Excessive Tantrums Elimination Disorders ADHD School Behavior Problems & Refusal
Behavioral Health Needs 75-80% Medical and BH Provider in Primary Care Referrals and Community Care 10-15% 5% Specialty Care
Example Components of Integrated Care Screening by PCP Collaboration and Teamwork Shared practice space Coordinated assessment and treatment plan Communication (formal and informal) Timely access to behavioral health Shared office space System to share records https://www.integration.samhsa.gov/workforce/Integration_Competencies_Fi nal.pdf
Why Integrated Care? https://www.kumc.edu/documents/internalmed/quadruple-aim-healthcare-image.pdf
Six Reasons Why Behavioral Health Should be Part of the Primary Care Medical Home 1. High prevalence of behavioral health problems in primary care (needing long-term follow-up) High burden of behavioral health in primary care High cost of unmet behavioral health needs Lower cost when behavioral health needs are met Better health outcomes Improved satisfaction Improving work life of health care providers 2. 3. 4. 5. 6. 7. Quadruple Aim Behavioral health integration achieves the quadruple aim.
Why Integrated Care? Research is finding Increases access to behavioral health care. Improves health outcomes for patients with mental illness and/or substance use disorders. Improves health behaviors such as compliance with treatment recommendations, exercise, and diet. Reduces overall health care costs, thus representing the opportunity for shared savings for primary care practices. http://www.jabfm.org/content/30/1/25.full?sid=f635119b-7243-4bfe-bbd2-3241c11377f4; https://www.ncbi.nlm.nih.gov/pubmed/28379819; http://medicaleconomics.modernmedicine.com/medical- economics/content/tags/affordable-care-act/integrating-primary-care-and-mental-health-key-im?page=full
Improved Access Attended 1st appointment 100 90 80 70 85% 81% 60 50 40 30 20 10 0 2007 2020 Valleley, R.J., Kosse, S., Schemm, A., Foster, N., Evans, J., & Polaha, J. (2007). Integrated Care for Children in Rural Communities: An Examination of Patient Attendance to Behavioral Health Services. Families, Systems, & Health, 25, 323- 332. Valleley, Meadows, Burt, Menousek, Hembree, Evans, Gathje, Kupzyk, Sevecke, Lancaster (2020). Demonstrating the impact of collocated behavioral health in pediatric primary care. Clinical Practice in Pediatric Psychology, 8(1), 13-24.
Provider Satisfaction Physicians who have adopted an integrated model of care report strong agreement that this type of model helps to improve factors such as: Quality and continuity of care for their patients time that it allows them to spend on medical issues Cost Follow-up Confidence with identification/management of problems Reduced stigma for their patients Hine, Grennan, Menousek, Robertson, Valleley, & Evans. (2016). Physician Satisfaction with Integrated Behavioral Health in Pediatric Primary Care: Consistency Across Rural and Urban Settings. Journal of Primary Care and Community Health. 1-5.
Exciting Directions Training and Supervision in IPC Early evaluation and identification for Autism Spectrum Disorders Trauma-Informed Care
Mid-America Mental Health Technology and Transfer Center Funded by the Substance Abuse and Mental Health Services Administration 5-year grant awarded to Dr. Joseph Evans at the University of Nebraska Medical Center Aligns mental health systems and professional competencies with evidence-based practices Primary target states: Missouri, Iowa, Nebraska, and Kansas - but available to any provider(s). Provides free/low cost training and technical assistance on topics leading to effective behavioral health practice https://mhttcnetwork.org/centers/content/mid-america- mhttc
