Child Health Matters: Integrating Behavioral Health Services into Pediatric Primary Care

摘要

Introduction : Pediatric primary care (PPC) is ideally suited to promote development and wellbeing through the provision of expanded services that address psychosocial risk factors and behavioral health issues in the context of a trusting relationship with familiar providers (Talmi & Fazio, 2012). There are approximately 34,000,000 routine well-child checks per year in PPC in the U. S. for patients from birth to 22 years of age, with approximately 121,000,000 visits for children under 15 years of age (American Academy of Pediatrics, 2009). Families with environmental risk factors or behavioral health problems often present to PPC before accessing services through the mental health system (American Academy of Child and Adolescent Psychiatry & AAP, 2009) and 75% of children with mental health disorders are now seen in PPC (AAP, 2010). With the help of integrated behavioral health clinicians (BHCs), PPC can identify and manage emotional conditions when they first emerge. Integrating behavioral health into primary care leads to better health outcomes and substantial cost savings (Maruish, 2000). The increasing prevalence of mental illness among children, early age of onset, and emerging evidence about effective preventative interventions make a strong case for early identification and intervention in PPC with integrated mental health services. Short Description of Practice Change Implemented : Project CLIMB (Consultation Liaison in Mental health and Behavior) provides BHC services to children and families in a high volume PPC and residency training clinic housed within a large teaching hospital in the western part of the U.S. The BHC’s provide direct consultation, screening, and treatment in addition to triaging, referring and coordinating behavioral health care with community resources (Becker Herbst et al., 2015). Families served in this clinic have access to seamless and comprehensive care that spans physical and behavioral health in the context of a medical home. Project CLIMB’s primary goals include: 1) increasing access to mental health, behavioral, and developmental services and 2) training PPC professionals to address mental health and behavioral issues emerging within the medical home. This paper aims to: 1) Describe the development, implementation, and evaluation of Project CLIMB. 2) Demonstrate the use of clinical informatics to evaluate effectiveness and outcomes. 3) Characterize behavioral health consultation services as related to demographic variables, recommendations made, number of visits, and presenting problems. Key Findings : Data were collected for five consecutive years, from January 2009 through December 2014. Clinical informatics strategies and electronic medical record abstraction include extraction of clinical flowsheets, demographics, health care utilization, and medical information. Results below are from a preliminary analysis of data collected between November 2008 and December 2013. 3,708 ethnically/racially diverse patients (20% of total patients) birth to 22-years of age (4.6 years-old, with 47% falling between birth and 3 years-old) received BHC services. Families seen in clinic were primarily covered by public insurance (85%). Most common consultation types: mental health (62%), developmental (17%), pregnancy related depression (17%), and psychopharmacology (7%). Nearly 22 % of the population experienced a family circumstance as the presenting concern, followed by 13.7% behavior problems, 10.7 % psychosocial problems, and 6.8% developmental delay. When the consultation type was developmental in nature, clinicians were more likely to refer families to developmental services in the community (X2 (1, N=1984) = 127.79, p<.001; OR = 5.92, 95% CI = 3.9, 9.0) as well as discuss preschool as a recommendation (X2 (1, N=1984) = 12.55, p<.001; OR = 8.7, 95% CI = 2.4, 31.5). Referral for parent mental health services were 12 times more likely in pregnancy-related depression consults (OR = 12.6, 95% CI = 6.9, 22.6). Consultation type significantly predicted presenting problem (p<.001) and demonstrated that the referrals and recommendations provided by BHC’s differed depending on the type of behavioral health consult (OR = 4.7, 95% CI = 1.7, 12.9). Highlights : Integrated behavioral health services were characterized by differences in frequency, presenting problems, and recommendations. Such services address mental health, behavior, and development and facilitate referrals to community resources. With psychology leadership, integrated behavioral health services were effectively developed, implemented, evaluated, and disseminated into a residency training PPC and community settings. Conclusion : Integrating mental and behavioral health services into primary care enables BHCs to identify, assess, and intervene around critical issues that affect the health and wellbeing of children and families. BHC’s positively contribute to the early detection of problems and connection to community-based s