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Bringing mental health care into pediatricians' offices works, finds 5-year study

June 11, 2019

A five-year study at Boston Children's Hospital reports success with a program it started in 2013 to bring much-needed behavioral health services directly into primary care pediatricians' offices. As reported today in Pediatrics, the program improved children's access to behavioral health care, with only minor increases in cost, and got high marks from participating pediatric practices.

Based on the findings, Boston Children's Hospital is continuing to expand and evaluate the program, which currently reaches more than 70 of its affiliated pediatric practices in Massachusetts.

Meeting an unmet need

By late adolescence, up to 20 percent of children will have experienced functionally impairing 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, says Heather Walter, MD, MPH, a child/adolescent psychiatrist at Boston Children's Hospital and first author on the paper. 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," Walter says. "There aren't enough child psychiatrists to offer this care alone, and we realized we needed partners. The obvious physician partners are pediatricians - they see children for years, know them well, are tuned into child development, and are highly trusted by patients and families."

Empowering pediatricians

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. This would free up the limited number of child mental health specialists to 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.

The program has three components:
    1) in-person and televideo education sessions with child psychiatrists and other behavioral health specialists

    2) on-demand phone, in-person and telepsychiatry consultations with child psychiatrists

    3) operational and clinical support for integrating psychotherapists into pediatric practices.
5-year outcomes

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 study in Pediatrics looked at outcomes in the first 13 PPOC practices in Greater Boston to enroll in the program. 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.

Study findings included:
  • 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 were delivered within participating 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 increased from 55 to 186 per 1000 patients per year for a 30-day supply.

  • High satisfaction among pediatricians and on-site psychotherapists: more than 90 percent of those surveyed reported an increased ability to effectively manage mild/moderate mental and behavioral health problems in the pediatric setting.

  • Total ambulatory behavioral care costs rose only 8 percent, as diversion of routine care away from specialists helped offset the increase in behavioral health visits overall.
"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 this Pediatrics study did not directly survey parents, pediatricians often reported high satisfaction among families who felt the arrangement was more convenient, less stigmatizing and in some cases more readily covered by insurance.

New initiatives

The BHIP now plans to extend the program to all of the PPOC primary care practices (current participation is 85 percent) and continue to research outcomes. Other recent and future initiatives include:
  • Expansion of substance abuse and addiction services in 15 to 20 PPOC practices

  • Family crisis intervention for suicidal adolescents in four PPOC practices

  • A pilot tele-psychiatry program (currently serving six PPOC practices), allowing a Boston Children's psychiatrist to directly see, talk to and assess a child through a remote web connection.

  • Interactive, web-based training to reach providers far from Boston -- including a partnership with 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.
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.

About Boston Children's Hospital

Boston Children's Hospital, the primary pediatric teaching affiliate of Harvard Medical School, is home to the world's largest research enterprise based at a pediatric medical center. Its discoveries have benefited both children and adults since 1869. Today, more than 3,000 scientists, including 8 members of the National Academy of Sciences, 18 members of the National Academy of Medicine and 12 Howard Hughes Medical Investigators comprise Boston Children's research community. Founded as a 20-bed hospital for children, Boston Children's is now a 415-bed comprehensive center for pediatric and adolescent health care. For more, visit our Discovery blog and follow us on social media @BostonChildrens, @BCH_Innovation, Facebook and YouTube.

Boston Children's Hospital

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