Five-Phase Replication of Behavioral Health Integration in Pediatric Primary Care

Abstract

BACKGROUND AND OBJECTIVES Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model. METHODS After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch. RESULTS Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged. CONCLUSIONS These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

Screening for pediatric behavioral health in primary care in rural and urban clinics.

“…Behavioral health screening has been shown to increase in integrated behavioral health care settings. Walter et al (2021) showed that when behavioral health integration was implemented in primary care clinics, universal behavioral health screening increased from 55.6% to 73.9% ( p < .001). In a systematic review of pediatric integrated care models, all studies reviewed utilized behavioral health screening measures in their integrated model (Burkhart et al, 2020).…”

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

“…Stepped Care Framework. In the stepped care model (example in Figure 3 135 ), the intensity of treatment is determined by the severity of the clinical presentation as assessed through standardized screening tools and focused symptom rating scales, and through focused clinical interview. For subclinical symptom presentations (concerning but not problematic), a range of preventive interventions can be used by the PCC and/or CM/BHC, including healthy lifestyle guidance (eg, nutrition, exercise, sleep, stress reduction) as the foundation for MH and wellness, and guided selfmanagement for patients and families who wish to learn and practice MH skills on their own with PCC/CM/BHC guidance and follow-up.…”

“…A meta-analysis of more than 13,000 patients enrolled in 31 randomized controlled trials of pediatric collaborative care 33 demonstrated modestly superior clinical outcomes for collaborative care vs usual care (overall effect size: d ¼ 0.32, p < .001). When triadic models were examined separately from other models, the effect size compared to usual care Note: From: Walter HJ, Vernacchio L, Correa ET, et al 135 was considerably larger (d ¼ 0.63, p ¼ .001). Other subgroup analyses demonstrated that effects were larger for treatment (d ¼ 0.42, p < .001) than for prevention studies (d ¼ 0.07, p ¼ .49), and for MH treatment (d ¼ 0.51, p < .001) than for substance abuse treatment studies (d ¼ 0.17, p ¼ .35).…”

“…The findings from the triadic models included in the Asarnow et al meta-analysis 33 are summarized in Table 6. [159][160][161][162][163][164][165] Also included in Table 6 52,135,[166][167][168][169][170][171] are the findings from published quality improvement projects examining broader dissemination of integrated MH care in real-world settings; these studies are important in their demonstration of increased access to MH services in community-based pediatric practices.…”

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes

“…Our education component diminished the costs of new curriculum development by adapting a previously tested, AAP competency-focused curriculum that was delivered with favorable outcomes to a large pediatric practice network in Massachusetts. [31][32][33] Our consultation component reduced the costs of on-demand CPAP-like consultation by utilizing local psychiatry resources that offered a limited schedule of consultation availability. Our care coordination component streamlined specialty BH referral by standardizing referral pathways to local psychotherapy and psychopharmacology resources, and by creating a resource directory for other BH services.…”