You already know about the significant and growing demand for pediatric mental healthcare. According to a study in the Journal of Developmental and Behavioral Pediatrics, the children from the ages of 6 to 17 who had ever been diagnosed with either anxiety or depression increased from 5.4% in 2003 to 8.4% in 2012. However, only 20% of children with a behavioral, emotional, or mental disorder receive care from a pediatric provider specialized in their needs. Behavioral Health Integration (BHI) is a system that connects pediatricians with specialists in order to coordinate care for children and improve access for families. Here are some first steps, and things to consider as you move towards BHI in your practice.
Diagnosing and Treating BHD in the PCMH
Early intervention in pediatric Behavioral Health Disorders (BHD) is paramount to the lifelong success and wellbeing of the child. The lack of appropriate specialists such as pediatric psychiatrists, psychologists, and counselors leads many PCPs to diagnose and manage symptoms of the disorder themselves.
However, with two-thirds of pediatricians stating that they do not have sufficient training to treat children with BHD, the most prudent course of action is still to refer the child for specialized care for both simple and complex BHD, such as suicidal ideations, autism, or PTSD. While pediatricians are and will remain the front line of behavioral healthcare, according to guidelines published by the American Academy of Child & Adolescent Psychiatry, “there are a number of barriers that impede pediatricians’ capability to deliver mental health services, including insufficient time, training, knowledge of local resources, and access to specialists.” In addition, pediatricians often face pushback from insurance companies when they attempt to bill for mental health services, as billing for these codes triggers review for physicians who are not credentialed to offer them.
With BHI, services for pediatric mental care are referred directly to specialists who are trained in treating BHD, and therefore can offer tailored care in dedicated sessions, easy access at the convenience of families, and appropriate billing. Integration also offers the opportunity for crucial early intervention.
Methods of Behavioral Health Integration
There are several ways to introduce BHI into your practice. When considering these methods, keep in mind the needs of your practice, community, and access to nearby specialists.
Consulting your professional network and community is also hugely beneficial. There may be a friend of a friend who knows a counselor, or a new psychiatrist’s office across town that would be willing to work with you and your patients. There are a myriad of resources, networks, and communities available to offer help: see the list offered by the Substance Abuse and Mental Health Services and Administration as part of their collaboration with the U.S. Department of Health.
Consults (CPTs 99446-99449) allow pediatricians to speak directly via phone, email, or other method to a specialist, allowing professional conference regarding one or multiple patients. The advising specialist may desire an initial consult (CPTs 99241-99245) with the child and family, leading to further treatment or recommendations for care. Physicians may then refer the child for long-term treatment if necessary.
Check your state’s policies for programs such as the Massachusetts Child Psychiatry Access Program (MCPAP), which offers an initial consult to pediatricians in 30 minutes or less. After a consult, the specialist can refer the child for appropriate care.
Programs such as Wisconsin’s Care4Kids program and Project TEACH in New York aligns specialists with pediatricians to coordinate mental health care based on an individualized care plan for the patient, and offers resources for providers as they integrate. These state programs are also valuable resources for networking, advice, and assistance, both from other providers and professionals in public health.
Independent pediatricians may also choose to coordinate a formal or informal relationship with nearby specialists in order to guide families towards accessible care.
Telemedicine coverage varies by state, but has the benefit of providing access to mental health care to families who cannot access it because of coverage, distance, or time hurdles. Telemedicine can offer patients time over the phone or video chat with a provider or specialist to offer care, instead of in the office. See our previous post on telemedicine to learn more.
For some providers, the largest benefit to their patients is bringing BHI in-house. While providers have been inviting psychologists and other specialists in-house independently since at least 1990, formal colocation efforts are being piloted across the country in big ways thanks to public policy and independent practice initiatives.
Co-locating can mean different things depending on the practice, community, and availability of providers. For example, a provider may invite full time colocation to one or more BHD specialists, offer part time colocation with referrals to a specialist’s home office, or even hire new graduates in mental health services who can offer their services in exchange for their required supervised service hours (provided by a full time specialist). This situation is discussed at length in the June 2019 edition of The Independent Pediatrician.
How to Begin Behavioral Health Integration: Things to Consider
BHI is often a valuable asset to a pediatric practice, not only for the invaluable services it offers to patients, but for the ease of workflow for providers and families.
Patients, Families, Practice, and Community
Your first and foremost considerations should be, of course, the best care for your patients. Have you noticed an increase in the amount of BHDs you have diagnosed or treated in the past year or two? Trace the hurdles your practice and patients have to navigate to obtain adequate mental health care: insurance, location of services, and availability of specialists are three common ones.
Does your practice stand to gain from colocation or collaboration with a nearby BHD specialist? Practitioners caution that colocation with specialists, while wonderful for accessibility and collaboration between providers, does not often offer monetary gain for the practice as a whole. Collaboration can often be as effective over the phone or via regular meetings.
State Policy and Advocacy
Pediatric practices offer direct care to hundreds of families, and are therefore wonderful advocates for children as well. Review your local and state policies regarding BHI, and decide whether the programs and services available are what works best for your patients. As mentioned before, SAMHSA-HRSA is a great resource center to begin your search. Once you know what is out there, take advantage of available programs, grants, funding, or expertise.
If not enough specialized care exists for your patients, pediatricians may choose to advocate for programs and funding with their local and state policymakers to bring lasting changes to their communities. Learn more about how the AAP advocates for children’s mental health here.
Colleagues and Connections
Your professional network is a valuable resource. Whether it’s during your next conference or working lunch, network with colleagues and peers to determine whether there is another pediatrician or behavioral health specialist looking to collaborate for the benefit of patients and community.
Beyond simple collaboration opportunities, you may also find advice on billing, transportation, or other benefits to ease the access of regular behavioral health care for busy families.
There are many opportunities for providers seeking behavioral health integration, including:
- The treatment of BHDs as an essential health benefit under most insurances
- The Mental Health Parity and Addiction Equity Act of 2008, which seeks to advance equality in insurance coverage for mental and physical health
- States’ use of Medicaid, which has implemented the Medicaid Delivery System Reform Incentive Payment program to integrate children’s behavioral health into Medicaid managed care.
Early intervention of mental health care can change a child’s life for the better. Whether you decide to colocate, collaborate, or advocate, taking actionable steps towards mental healthcare access for your patients is a wonderful step towards equal access for all children.