Whether or not to add ancillary services is a question that many pediatricians contemplate. Including a mental health provider at your practice is one way to integrate additional services and improve the quality of care for your patients. Before taking the plunge there are a lot of questions to answer – how do you go about adding these services, do you hire someone or rent space, what are the logistics around billing and scheduling?
We talked to two of our clients, each with a different setup, to learn about the variety of ways you can include mental health services at your pediatric practice.
Before we dive in, some background. Prior to adding a new service, it's important to understand what to expect in terms of payment. You need to assess if it makes sense for your practice. According to Mental Health America (MHA), mental health services are regulated and funded by both the federal government and individual states.
Federal Funding of Mental Health Services
Depending on the state, the federal government matches state Medicaid and CHIP (Children's Health Insurance Program) funding. This match can be up to 50-70% of state spending. MHA says, "Medicaid is the single largest funder of mental health services in the country, which makes this support especially valuable."
The government also issues 'Mental Health Block Grants' (MHBG). This money is provided to help states create community-based mental health services.
State Funding of Mental Health Services
According to Mental Health America, all states receive mental health block grants as well as partial funding from Medicaid and CHIP, but each state has the choice to shape and fund their mental health system as they see fit. Since states have a significant amount of decision making power when it comes to mental health systems, from state to state the regulations and available services can be vastly different. One state can even vary widely from county to county.
MHA says that states have the "freedom to experiment with new or innovative services and delivery models." That means that although state mental health systems need to comply with standards set by the federal government, they have the freedom to expand beyond federal minimums and create more services and access for patients. MHA continues, "Depending on the state's political and economic climate, states will play a more or less substantial role in funding comprehensive mental health services."
One state that has expanded its mental health system is PCC's home state of Vermont. The Vermont Blueprint for Health is a "nationally recognized initiative that designs community-led strategies for improving health and well-being." The Blueprint invests in and supports many diverse programs, including bringing mental health services to Patient Centered Medical Homes (PCMH). With help from the Blueprint, services and staff can be co-located or embedded at PCMH practices. Access to these services is provided 'barrier free' to patients and practices, meaning there are no copays charged to patients, no prior authorization necessary, and no billing to complete. The referrals to services are made by the primary care providers.
Mental Health Services in Pediatric Practices
One pediatrician who added mental health services to her practice with help from the VT Blueprint for Health is PCC's client, Dr. Judy Orton of Green Mountain Pediatrics in Bennington, VT. According to Dr. Orton, because of the VT Blueprint, her practice now has a mental health provider who is a great fit. The provider offers "mindfulness work, which is effective for all ages and conditions, and works with families on skill building, limit setting, etc. The duration of treatment is limited, but if further therapy is needed after 3-4 months, she will work with the family until they are connected with an outside provider."
Dr. Orton says that having an embedded mental health provider has been very beneficial for patients. Having someone right there eliminates the frustration around lack of access, long waiting lists, and an unknown office for patients. "With an embedded person, I can do warm hand offs, and families are more willing to come back to a place where they receive 'medical' care (so there is less discomfort and less stigma)."
She continues, "Since mental health puts a summary of issues, discussion points, and plans directly into the EHR, we can discuss any immediate issues when the provider is in the office, so there is much more continuity and seamless care. If families call back in the interim to discuss things with the care manager nurse or me, we can provide better answers to their questions because of the communication (both verbal and with EHR documentation). It's true team care."
Logistically, because of help from the VT Blueprint, the practice does not have to do any billing for mental health services. The mental health provider is paid by the Blueprint, and families are not charged. The practice does take care of scheduling mental health appointments, check in and check out at the front desk, and provides an exam room and computer for EHR documentation.
Dr. Orton's advice to others is, "If someone is considering doing this, finding the right person to fit with the style of your practice is key. It reaps an abundance of rewards for families and the practice alike."
Integrating Mental Health Services Without State Funding
Shifting our focus to another pediatric practice, we talked to our client Nathan Morgan, the Business Manager at Pirate Pediatrics in Greenville, NC. Pirate Pediatrics is an example of a practice that added mental health services without state funding. Instead, they brought a pediatric psychologist on staff as an employee of the practice.
According to Nathan, "Two to three years ago we realized the lack of mental health services in our area was detrimental to our patients. It was not uncommon then, and now, for patients to wait 90-120 days for an appointment with a child psychiatrist or psychologist. Also, our providers were facing additional challenges with parents having more behavior problems and questions that needed to be addressed, but felt they did not have time to dedicate to these issues." Realizing that, they decided to bring a mental health professional on staff.
Discussing the benefits of having a mental health provider on staff, Nathan says, "You have a dedicated resource in your back pocket. Referrals are simple and easy because it's in the office and that removes any barriers to entry for the patient. It also removes any stigma for the patient and/or parent for seeking out mental health services. We provide a safe environment that the family is already familiar with."
Currently the psychologist at Pirate Pediatrics does initial ADHD visits for diagnosis and then works with the pediatrician for medication and med checks. The psychologist will continue to see the patients in an ongoing way for behavior modification. Having the psychologist there for ADHD and behavior visits allows the other providers to do more well checks and sick visits. Nathan shares, "It also provides support for our providers with an integrated model in that our providers can hand off patients without losing track of the patients' care. Another improvement is that we have seen an increase in patients, as parents are seeking out mental health services."
At Pirate Pediatrics, patients can use their insurance for mental health visits, or choose to pay out of pocket. Pirate's staff takes care of scheduling initial visits, and the mental health provider schedules her own follow ups. She codes her visits, and Pirate's billing service takes care of the rest. Nathan says, "As one of our employees she is fully integrated into the practice. There are as many ways to integrate mental health into a practice as there are days in the week. Each practice has to find the solution that meets their needs. It may also be dependent on the provider. Many mental health professionals like the flexibility that comes with renting space or contracting with a Primary Care Provider. Having our psychologist on staff and in the office allows us to provide 'warm hand offs' on a regular basis which helps our providers and leads to future visits."
To the pediatrician considering adding mental health services to their practice, Nathan says, "I would say, ask yourself what you are trying to accomplish. What problem are you trying to solve? What do you want the person to do and what credentials are you looking for? As with hiring or contracting with any provider, they need to be aligned with your practice goals and philosophy."
He continues, "Integrating mental health into our practice has been beneficial to our practice. I would encourage anyone interested in adding these services to do their homework regarding billing and coding. It can be tricky with many payers and Medicaid. Another area to investigate is the level of mental health provider (i.e LCSW, clinical psychologist, psychiatrist, etc.) as each has their own skill set. We use our psychologist with her training and skill set throughout our office. She comes in on newborn visits to meet with the parents, leads group sessions, provides education at staff meetings, works on marketing, leads our hospitality team, and other areas."
Adding mental health services to pediatric practices is an excellent way to improve the quality of care for patients. Having someone in-house increases access to care, making it more likely that patients will schedule appointments. There are a variety of ways to integrate these services – find out the strategy that works for you with PCC's ebook for pediatricians: Integrated Behavioral Health: A Guide to Expanding Access.