Empowering pediatricians to provide mental health care

By late adolescence, up to 20 percent of children will have experienced impairing levels of anxiety, depression, and/or ADHD, the most common and treatable mental health conditions. But child behavioral health specialists are in chronic short supply with long wait lists. Massachusetts, for example, has nearly 300,000 youths with at least one diagnosable psychiatric disorder — but only about 400 to 500 practicing pediatric psychiatrists.

“Nearly a decade can elapse between when a child first shows symptoms of a disorder and when it is diagnosed and treated, which has major consequences in their academic, social, and family lives,” says Heather Walter, MD, MPH, a child/adolescent psychiatrist at Boston Children’s Hospital.

Walter was first author on a five-year study at Boston Children’s that reports success with a program to bring much-needed behavioral health services directly into primary care pediatricians’ offices. Started in 2013, the program has improved children’s access to behavioral health care, with only minor increases in cost and high marks from participating pediatric practices. The study findings are reported today in Pediatrics.

“There aren’t enough child psychiatrists to offer this care alone,” says Walter. “Pediatricians are our obvious partners: They see children for years, know them well, are tuned into child development, and are highly trusted by patients and families.”

Meeting an unmet need

Boston Children’s Hospital’s Behavioral Health Integration Program (BHIP) was designed to empower primary care pediatricians to head off or, if indicated, treat most cases of anxiety, depression, and ADHD, referring only the more complex cases to specialists. The limited number of child mental health specialists can then focus on youths with more severe illness.

“If a child has schizophrenia or bipolar disorder, we’d want them to be cared for in a specialty setting,” notes Walter.

Our over-arching goal was to increase children’s access to behavioral health services, without breaking the bank.

The BHIP offered its services to primary care practices affiliated with the Pediatric Physicians’ Organization at Children’s, LLC (PPOC), on a first-come, first-serve basis. The program has three components:

• in-person and televideo education sessions with child psychiatrists and other behavioral health specialists
• on-demand consults with child psychiatrists (by phone, in person, or via telepsychiatry, in which a Boston Children’s psychiatrist can see, talk to and assess a child via a web connection)
• operational and clinical support for integrating psychotherapists into pediatric practices.

Five-year outcomes

Walter and her colleagues looked at outcomes in the first 13 PPOC practices in Greater Boston to enroll in BHIP. These practices comprised some 105 primary care pediatricians serving some 114,000 children and youth.

“Our over-arching goal was to increase children’s access to behavioral health services, without breaking the bank,” says Walter.

And it seems, so far, they’ve succeeded. The study found:

• Significantly increased visits to primary care providers for behavioral health problems
• Significantly increased psychotherapy visits in the primary care setting. From 2013-17, the proportion of all psychotherapy visits that took place in the primary care practices increased from 0.7 percent to 13.3 percent.
• Significantly increased pediatrician prescribing of medications for ADHD, anxiety, and depression in accordance with evidence-based guidelines. For instance, SSRI prescriptions for anxiety and depression (a 30-day supply) rose from 55 to 186 per 1,000 patients per year.
• High satisfaction among pediatricians and on-site psychotherapists: more than 90 percent of those surveyed said they were more able to effectively manage mild/moderate mental and behavioral health problems in the pediatric setting.
• Total ambulatory behavioral care costs rose just 8 percent, as diversion of routine care from more costly specialists helped offset the overall increase in behavioral health visits.

Providing top-quality behavioral health services in the right setting at the right time will help millions of children receive the care they need and deserve.

“We were hoping for a big dip in emergency room utilization, because that’s a big problem when mental health services are not widely available,” says Walter. “But we need more data before we can make that claim.”

The study did, however, find an overall 19 percent decrease in emergency room costs for behavioral health visits.

Although the team didn’t survey parents directly, pediatricians often reported high satisfaction among families who found the arrangement more convenient, less stigmatizing and in some cases more readily covered by insurance.

New initiatives

Based on the findings, Boston Children’s Hospital is continuing to expand and evaluate BHIP. The program currently reaches more than 70 affiliated pediatric practices in Massachusetts, an 85 percent participation rate.

Other recent and future initiatives include:

• expansion of substance abuse and addiction services (currently in 15 to 20 PPOC practices)

• family crisis intervention for suicidal adolescents (four PPOC practices)

• a pilot tele-psychiatry program (six PPOC practices)

• interactive, web-based training to reach providers far from Boston, including 34 pediatric practices in the Children’s Hospital Los Angeles Health Network

• partnership with Open Pediatrics, Boston Children’s web-based clinical training platform, planned for late 2019/early 2020. “This will allow us to expand our training to a national and international audience, which is very exciting,” says Walter.

• ongoing partnership with the state- and payer-funded Massachusetts Child Psychiatry Access Program (MCPAP), extending psychiatric consultation services to nearly all of the state’s approximately 500 pediatric practices.

“Providing top-quality behavioral health services to kids in the right setting at the right time will help millions of children receive the care they need and deserve,” says David DeMaso, MD, psychiatrist-in-chief in the Department of Psychiatry at Boston Children’s Hospital.

About the BHIP and the study

The BHIP was initially supported by Boston Children’s Hospital’s Provider-Payor Quality Initiative, a collaboration between Boston Children’s Hospital, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Tufts Health Care, and MassHealth. BHIP has received subsequent funding from MA Health Policy Commission, the Commonwealth of Massachusetts, the Children’s Hospital Los Angeles Health Network, the Sydney A. Swensrud Foundation, Nancy Adams & Schott Schoen Family, Harvard Pilgrim Health Care, SAMHSA, and the Tommy Fuss Center for Neuropsychiatric Disease Research.

The study in Pediatrics was funded by the Boston Children’s Hospital Payer Provider Quality Initiative. Glenn Focht, MD (now at Connecticut Children’s Medical Center) was the study’s senior author. Coauthors were Louis Vernacchio, MD, MSc, Emily Trudell, MD, Jonas Bromberg, PsyD, Ellen Goodman, MD, MSW, LICSW; Jessica Barton, MSW, LICSW; and Gregory Young, MD, all of Boston Children’s and the PPOC; and David DeMaso, MD.