Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care

Abstract

ImportanceMore than 1 in 5 children in low-income families report a mental health (MH) problem, yet most face barriers accessing MH services. Integrating MH services into primary care at pediatric practices such as federally qualified health centers (FQHCs) may address these barriers.ObjectiveTo examine the association of a comprehensive MH integration model with health care utilization, psychotropic medication use, and MH follow-up care among Medicaid-enrolled children at FQHCs.Design, Setting, and ParticipantsThis retrospective cohort study used Massachusetts claims data from 2014 to 2017 to conduct difference-in-differences (DID) analyses before vs after implementation of a complete FQHC-based MH integration model. The sample included Medicaid-enrolled children aged 3 to 17 years who received primary care at 3 intervention FQHCs or 6 geographically proximal nonintervention FQHCs in Massachusetts. Data were analyzed in July 2022.ExposuresReceipt of care at an FQHC implementing the Transforming and Expanding Access to Mental Health Care in Urban Pediatrics (TEAM UP) model, which began fully integrating MH care into pediatrics in mid-2016.Main Outcomes and MeasuresUtilization outcomes included primary care visits, MH service visits, emergency department (ED) visits, inpatient admissions, and psychotropic medication use. Follow-up visits within 7 days of a MH-related ED visit or hospitalization were also examined.ResultsAmong the 20 170 unique children in the study sample, at baseline (2014), their mean (SD) age was 9.0 (4.1) years, and 4876 (51.2%) were female. In contrast to nonintervention FQHCs, TEAM UP was positively associated with primary care visits with MH diagnoses (DID, 4.35 visits per 1000 patients per quarter; 95% CI, 0.02 to 8.67 visits per 1000 patients per quarter) and MH service use (DID, 54.86 visits per 1000 patients per quarter; 95% CI, 1.29 to 108.43 visits per 1000 patients per quarter) and was negatively associated with rates of psychotropic medication use (DID, −0.4%; 95% CI −0.7% to −0.01%) and polypharmacy (DID, −0.3%; 95% CI, −0.4% to −0.1%). TEAM UP was positively associated with ED visits without MH diagnoses (DID, 9.45 visits per 1000 patients per quarter; 95% CI, 1.06 to 17.84 visits per 1000 patients per quarter), but was not significantly associated with ED visits with MH diagnoses. No statistically significant changes were observed in inpatient admissions, follow-up visits after MH ED visits, or follow-up visits after MH hospitalizations.Conclusions and RelevanceThe first 1.5 years of MH integration enhanced access to pediatric MH services while limiting the use of psychotropic medications. Additional implementation time is necessary to determine whether these changes will translate into reductions in avoidable utilization.

A vision for implementing equitable early mental health and resilience support in pediatric primary care: A transdiagnostic, developmental approach.

“…The AAP stresses that screening with validated instruments supplements developmental surveillance and should be administered anytime a concern arises from the clinician, parents, or early childhood professionals (AAP Developmental Surveillance and Screening Initiative, 2022). Valid detection is especially crucial in early childhood where developmental discernment is so challenging (Kim et al, 2023). A universal approach is of particular importance for advancing an antiracism stance that mitigates implicit biases, which are attenuated when all children routinely receive the same assessment (Allen et al, 2010; Sheldrick et al, 2022).…”

Changes Over Time in Outcomes of School-Age Children and Parents Receiving Integrated Mental Health Care in Federally Qualified Health Centers

“…22,23 Prior publications describe implementation of the key core components of the TEAM UP model. [15][16][17]24 All sites implemented enhanced screening in multiple languages for all age groups. Screening rates averaged 80%, consistently surpassing state benchmarks.…”

“… 15 Comparisons with non–TEAM UP FQHCs using claims data demonstrate that after 1.5 years of implementation, TEAM UP was associated with increases in primary care visit rates, particularly among children with mental health disorders, increases in mental health service use, decreases in psychotropic medication use, with no changes in the total cost of care, inpatient admission, or follow-up care. 16 , 17 Like other pragmatic studies of integrated care models, 18 these analyses rely on data from EMR and insurance claims databases, both of which can be analyzed without direct data collection from patients. However, a limitation of these data sources is that they do not capture important domains of patients' experience.…”

Urban Rural Differences on Accessing Patient Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders

“…14 This care could have been improved through care coordination and mental health integration. 15,16 Emergency department (ED) visits remain a persistent problem and often serve as an indicator of integrated primary care through care coordination because lacking access to a PCMH results in higher ED visits. 1,17 Lo et al 18 found that pediatric ED visits have risen between 2007 and 2016 for various reasons (MHDs 60%, deliberate self-harm 329%, substance abuse 159%, and living in rural and semirural communities 41%), whereas the volume of overall pediatric ED visits remained unchanged.…”