Issue Paper n August 2009 STRATEGIES TO SUPPORT THE INTEGRATION OF MENTAL HEALTH INTO PEDIATRIC PRIMARY CARE

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1 Issue Paper August 2009 STRATEGIES TO SUPPORT THE INTEGRATION OF MENTAL HEALTH INTO PEDIATRIC PRIMARY CARE

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3 Issue Paper August 2009 TAbLE OF CONTENTS Executive Summary... 2 Sectio I... 4 Itroductio Sectio II... 6 The Childre s Metal Health Ladscape Sectio III Strategies to Improve Early Idetificatio ad Treatmet for Childre i Primary Care Sectio IV Coclusios Appedix Selected Resources o Childre s Metal Health Care Edotes

4 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care ExECUTIvE SUMMARY Oe i five childre ad adolescets i the U.S. experieces metal health problems, ad up to oe-half of all lifetime cases of metal illess begi by age fourtee. Sevety-five percet of childre with diagosed metal health disorders are ow see i the primary care settig, makig the maagemet of metal health issues a growig part of pediatric practices. The icreasig prevalece of metal illess amog childre, early age of oset, ad emergig evidece about effective prevetive itervetios make a strog case for early idetificatio ad itervetio. Pediatricias are well positioed to detect problems i a child s social ad emotioal developmet due to their cosistet presece i a child s life, but the udersupply of metal health professioals traied to treat childre, coupled with iadequate fiacig, mea that pediatricias are icreasigly relied upo ot oly to detect problems but also to provide the full spectrum of metal health services without the tools ad resources to do so effectively. This paper provides a overview of research advaces ad policy treds that support itegratio of metal health ito primary care ad explores various strategies primary care providers ad health plas ca employ to achieve more coordiated ad itegrated metal health care i the pediatric primary care settig. While focused o the pediatric practice, much of the discussio is also relevat to others who provide primary care services to childre, icludig family practitioers. The paper delieates the potetial beefits of a itegrated approach as well as the obstacles that must be overcome i order to provide childre ad their families with coordiated, seamless care that supports childre s emotioal well-beig. Recet research i metal health, eurobiology ad early childhood developmet stregthes the case for prevetio ad early itervetio. The America Academy of Pediatrics Bright Futures practice guide outlies a approach to address developmetal ad metal health eeds based o age ad stage of developmet. The three levels of itervetio ecessary to provide a full spectrum of metal health care iclude: prevetio ad health promotio, early itervetio ad treatmet. Deliverig this full rage of services may require multiple sources outside the practice but activities should be cetralized aroud the primary care provider. The fiacig ad reimbursemet of metal health services must be take ito accout whe cosiderig itegratig metal health ito primary care practice. Most private ad public isurers do ot provide reimbursemet for collaborative or itegrative care ad metal health beefits are ofte carved out, with primary care providers excluded from the etwork of providers who ca provide ad bill for metal health services. I recet years, health plas have begu to recogize the eed to itegrate physical ad metal health, ad may have brought behavioral health maagemet activities i-house. Metal health services covered by private isurers i the primary care settig geerally iclude screeig, assessmet ad/or medicatio maagemet. However, efforts to expad the cotet of pediatric care to address metal health ofte place ew demads o the provider, ad reimbursemet for the additioal time ad services required to appropriately address metal health issues are ofte lackig. Public sector fudig for metal health services is provided through a combiatio of public isurace programs, federal grats to states, commuity heath ad commuity metal health ceters, school systems, public health departmets, ad juveile justice. While Medicaid Early Periodic Screeig, Diagostic, ad Treatmet (EPSDT) provisios require that all childre be regularly screeed ad tested to idetify ay coditios requirig treatmet, icludig physical, metal, emotioal ad 2

5 Issue Paper August 2009 cogitive developmetal delays, state Medicaid programs vary widely ad oly 60 percet of Medicaid programs reimburse for screeig ad assessmet. Although barriers exist i brigig metal health ad primary care together, multiple public ad private sector efforts are uderway to promote ad ehace itegratio. Recogizig the importace of itegratig metal health services ito primary care, the federal govermet, the America Academy of Pediatrics ad private foudatios are directly supportig iitiatives to develop the evidece base, provide tools for primary care providers to implemet metal health services ad obtai appropriate reimbursemet for their services, ad pilot iovative programs supportig itegratio. I cosiderig whether ad how to itegrate metal health ito pediatric primary care, a practice must cosider what role they wish to play ad what services they will provide directly. Examiig issues related to their patiet populatio s eeds, the size of the practice, existig resources, ad the practice s skills ad iterests ca help the practice set a framework for cosiderig specific strategies for itegratio. There are three broad categories of service models primary care providers may adopt i order to provide metal health services: cosultatio, co-locatio ad collaboratio. Cosultative models allow providers, especially those workig i rural or frotier commuities, to cosult with child psychiatrists usig telemedicie or other meas. Co-locatig metal health specialists i the practice ca improve access to care, streamlie billig, ad ehace care coordiatio ad treatmet plaig. Collaborative care models build o the medical home model by establishig treatmet parterships betwee metal health ad primary care providers. This approach ofte icludes cross-discipliary case coferecig, co-maagemet of care ad some form of care coordiatio. No oe model is superior to the others the model selected depeds o the eeds of the practice. spectrum disorders ad attetio deficit-hyperactivity disorder, supportig telephoic or i-perso cosultatios with metal health professioals, ad implemetig psychopharmacology quality iitiatives to assure appropriate use of drugs ad follow-up care. Plas are also providig outreach to patiets idetified through claims or employee assistace programs. Still others are ivolved i atioal or state efforts to address policy cocers related to coverage of metal health services ad the relatioship betwee primary care ad medical home efforts. The medical home model is a promisig overarchig framework for icorporatig metal health care ito primary care due to the parterships established with the family ad the ability to coordiate care with other health care providers, icludig metal health professioals. While there are barriers to overcome, policymakers, providers ad health plas ca take a umber of steps to make itegratio a reality. Chages i both medical school educatio curricula ad cotiuig educatio ca ehace primary care capacity to provide metal health services. The eed for improved reimbursemet for metal health services i primary care could be alleviated by allowig a wider rage of providers to bill for metal health services. Icreasig fiacial support for primary care practices to adopt the models explored i this paper promises to improve dramatically the quality of care ad collaboratio amog all providers carig for the emotioal well-beig of childre. However, these models must also be evaluated to determie the extet to which they produce improved outcomes. Itegratig metal health ito primary care is a urget cocer, give the shortages of metal health providers, as is the eed to cotiue to develop the evidece base for effective prevetive ad treatmet strategies. Health plas, providers, federal agecies, researchers, ad policymakers should all be parters i achievig more coordiated, effective metal health care for childre i the primary care settig. To date, private health plas efforts to ehace metal health ad primary care collaboratio have focused primarily o adults. Some plas, however, are addressig childre s metal health by offerig traiig or dissemiatig educatioal resources, developig cliical guidelies ad other tools for more commo emotioal ad behavioral issues such as autism 3

6 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care SECTION 1: INTRODUCTION With 75 percet of childre with diagosed metal health disorders see i primary care settigs, addressig childre s metal health eeds has become a icreasigly importat cosideratio for primary care practices as well as for health plas. May pediatricias ad family practitioers are fidig that maagig metal health issues is a growig part of their practices. The icreased attetio o the medical home, ad its comprehesive approach to care, further emphasizes this role. However, the quatity ad quality of the primary care provider s iteractio with metal health professioals are variable, ad overall quality of metal health care is ueve. Private health plas ad public payers traditioally focused o defiig beefits, services, ad other arragemets related to metal health services for adults, but are ow faced with a growig awareess of the importace of addressig childre s metal health issues as well. This paper explores various strategies that ca be employed by primary care providers, with the support of health plas, to achieve coordiated ad itegrated metal health care i the pediatric primary care settig. The burgeoig iterest i addressig childre s metal health eeds reflects curret treds i research, practice ad policy. I 1999 The Surgeo Geeral s Report o Childre s Metal Health first elevated the atio s attetio to critical childre s metal health issues by focusig ot oly o diagosable metal illesses, but o the social, evirometal, emotioal ad behavioral factors that ifluece the metal health of childre ad adolescets. 1 The Presidet s New Freedom Commissio o Metal Health idetified the importace of better coordiatio betwee metal health care ad primary care ad the promotio of metal health of youg childre as importat goals for the atio i Three years later, the Istitute of Medicie issued a report further supportig the eed for the effective coordiatio of care by health, metal health ad substace abuse providers ad callig for the idetificatio of valid, age-appropriate screeig tools ad a cotiuum of evidece-based coordiatio models for childre ad youth experiecig metal health problems. 2 Despite these recommedatios ad support for better coordiatio ad itegratio of metal health care services, our delivery ad care systems remai fragmeted ad are fallig short of providig adequate prevetio ad treatmet of childre s metal disorders. Childre with metal health problems are served i multiple systems which ofte fail to commuicate, share iformatio ad resources, ad trasitio care smoothly from oe system to the ext. The result is overemphasis o expesive service providers ad reactive, crisis-orieted itervetios (sometimes resultig i the child s removal from the home, school or child care settig) ad isufficiet focus o prevetio, early idetificatio, ad timely treatmet. The potetial beefits of a better itegrated approach to delivery of metal health services iclude early idetificatio of emotioal ad behavioral problems, a coordiated approach to care, ehaced resources available to childre ad families, improved moitorig, ad a collaborative approach to crisis maagemet. 3 The impetus for itegratig metal health services ito pediatric primary care is based o several key cocers: the growig eed for metal health services for childre; the sigificat udersupply of metal health professioals traied to serve childre; policy, traiig ad other barriers that limit primary care providers abilities to provide these services; ad the iadequate fiacig of metal health services. Primary care physicias ca play a uique role i addressig metal health eeds. The followig characteristics of pediatric practice make pediatricias 1 well-suited to addressig metal health issues i childre: 1 While this paper is focused o the pediatric practice, much of the discussio is also relevat to others who provide primary care services to childre icludig family practitioers. 4

7 Issue Paper August 2009 Log-term relatioships with childre ad families; Emphasis o developmet, early itervetio ad prevetio; Chagig morbidities that reflect icreased metal ad emotioal coditios i the pediatric populatio; A summary of federal, orgaizatioal ad foudatio iitiatives supportig itegrative care; ad Cosideratios ad strategies for providers ad health plas to improve the delivery of metal health care i pediatric primary care. Experiece workig with specialists o behalf of childre with special eeds; Experiece with chroic care priciples ad providig a medical home; ad Uderstadig the access issues families may face for metal health services. 4 I this paper childre s metal health is defied broadly as the successful performace of metal fuctioig, resultig i productive activities, fulfillig relatioships with other people, ad the ability to adapt ad to chage ad to cope with adversity; metal health is idispesable to persoal well-beig, family ad iterpersoal relatioships, ad cotributio to the commuity or society. 5 This defiitio icorporates the social, emotioal ad behavioral aspects of developmet ad therefore expads the potetial scope of services from treatmet aloe to prevetio ad health promotio ad early itervetio. This perspective cosiders metal health as a itegral part of effective primary care. 6 To help i the cosideratio of appropriate strategies for pediatric primary care providers ad health plas to itegrate metal health ito pediatric primary care, this paper provides: A brief overview of the prevalece of ad risk ad protective factors for childre s metal health problems; A discussio of the curret state of prevetio, early idetificatio ad treatmet of metal health i pediatric primary care, icludig the relatioships betwee primary care ad metal health services; A review of public ad private sector fiacig of metal health services for childre ad the implicatios for itegrative approaches; 5

8 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care SECTION II: THE CHILDREN S MENTAL HEALTH LANDSCAPE Metally healthy childre ad adolescets develop the ability to experiece a rage of emotios (icludig joy, coectedess, sadess, ad ager) i appropriate ad costructive ways; possess positive self-esteem ad a respect for others; ad harbor a deep sese of security ad trust i themselves ad the world. Metally healthy childre ad adolescets are able to fuctio i developmetally appropriate ways i the cotexts of self, family, peers, school ad commuity. 7 To determie the array of metal health services that may be provided i the primary care settig, it is importat to uderstad the evidece supportig itegratio ad the policy ad programmatic cotext ifluecig primary care providers abilities to implemet itegrated services. The sectio begis with a discussio of the evidece supportig the itegratio of metal health ito primary care, orgaized aroud two primary themes: the importace of the child s age ad developmetal stage as a determiat of the types of itervetios required; ad the eed for a comprehesive approach that icludes overall metal health prevetio ad promotio, early itervetio ad treatmet. We the review curret public ad private sector efforts, icludig fiacig ad programmatic policies that ifluece approaches to itegratig metal health services withi the pediatric practice. A Age-Based Framework for Uderstadig ad Promotig Childre s Metal Health Recet research i metal health, eurobiology ad early childhood developmet stregthes the case for prevetio ad early itervetio. For example, epidemiologic surveys reveal a early age of oset for some metal health disorders, while other studies poit to a associatio betwee early symptoms ad icreased risk for metal health disorders i adulthood. 8 Moreover, recet eurobiological research idicates that from ifacy oward, childre s cogitive, emotioal ad physical developmet are liked to oe aother ad are iflueced by specific familial ad evirometal risk factors that may hider the accomplishmet of developmetal tasks. Highlighted i Neuros to Neighborhoods, this research has prompted recogitio of the importace of early developmetal screeig ad itervetios ad issuace of related aticipatory guidace for pediatricias. 9 It has also ehaced the uderstadig of the relatioship betwee cogitive ad emotioal developmet i older childre ad adolescets. Epidemiology I the U.S., up to oe i five childre ad adolescets experieces metal health problems requirig some form of metal health itervetio. 10 Of those childre, about 15 percet have mild to moderate metal health problems, ad five percet have severe emotioal disturbaces or diagosable disorders that cause sigificat impairmet of their fuctioig i the home, i school ad with peers. Strikigly, up to oe-half of all lifetime cases of metal illess begi by the age of 14 years. 11 Exhibit 1 summarizes the most commoly diagosed problems amog childre ad adolescets by age of oset. I additio to the disorders listed i Table 1, childre are also subject to metal health problems related to trauma. While post-traumatic stress disorder (PTSD) does ot geerally preset util early adulthood, oe i four childre will experiece a traumatic evet before the age of 16, ad some of those childre will develop child traumatic stress (CTS). 12 If utreated, traumatic stress ca have a damagig effect o a child s developmet ad fuctioig. 6

9 Issue Paper August 2009 TabLE 1: MoST CoMMo DEvELoPMETaL ad METaL HEaLTH PRobLEMS I CHILDRE, by age of oset Age of Oset Coditio Prevalece Preschool 1 Speech Problems 5.8% Developmetal Delay 3.2% Autism Spectrum Disorders 0.5% School-age Childre (6-17 years) 1 Learig Disabilities 11.5% Attetio Deficit-Hyperactivity Disorder (ADHD) 8.8% Behavior or Coduct Problems 6.3% School-age Childre (9-17 years) 2 Ay Axiety Disorder 16% Mood Disorders 7% 1 b lachard LT et al. Emotioal Developmet ad behavioral health of america Childre ad their families: a Report from the 2003 atioal Survey of Childre s Health. Pediatrics, 2006; 117(6): U.S. Departmet of Health ad Huma Services. Metal Health: A Report of the Surgeo Geeral. Rockville, MD: U.S. Departmet of Health ad Huma Services, Substace abuse ad Metal Health Services admiistratio, Ceter for Metal Health Services, atioal Istitutes of Health, atioal Istitute of Metal Health, Risk Factors Much progress has bee made i pipoitig the protective ad risk factors that affect the likelihood that a child or youth will develop a metal health disorder. 13 Protective factors iclude a lovig, stable family eviromet, ecoomic security, positive educatioal eviromet, coectios with schools ad a healthy commuity. Risk factors iclude a paret s chroic metal illess, materal depressio, poverty, child maltreatmet, domestic violece, paretal substace abuse ad other traumatic family disruptios such as divorce. 14 It is ow kow that early itervetio ad prevetio to mitigate risks ad ehace protective factors ca positively impact health outcomes ad school readiess ad reduce health costs. 15 The example of childhood depressio is illustrative of the importace ad potetial beefits of screeig for kow risk factors ad iterveig as soo as problems are detected. Although rare i youg childre, depressio affects betwee five ad eight percet of adolescets i a give year. 16 Oe of the three major risk factors for childhood depressio is havig a paret with a mood disorder. Materal depressio is associated with behavioral problems, ijury, ADHD, coduct disorder, violece ad atisocial behavior i childre. Whe mothers are depressed, they may ot form secure attachmets with their babies. Fortuately, there are a umber of validated, reliable screeig tools for materal depressio as well as home visitig, paretig ad treatmet programs that ca help to improve paret-child attachmet ad ameliorate the impact of materal depressio o the child. 17 Detectio of depressio i youth is ow cosidered so importat that the U.S. Prevetive Services Task Force recommeds screeig of adolescets betwee the ages of 12 ad 18 for major depressive disorder. 18 Opportuities for Primary Care Itervetio Emergig evidece about age of oset, risk factors ad effective prevetio makes a strog case for early ideti- 7

10 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care ficatio ad itervetio i the primary care settig. With traiig ad support, pediatricias are well positioed to detect problems i childre s social ad emotioal developmet as early as possible. The America Academy of Pediatrics views metal health promotio as a essetial piece of pediatric health supervisio. This is reflected with the additio of metal health as a health promotio theme i the ewest editio of the Bright Futures Guidelies. Additioally, the Bright Futures Guidelies outlies a approach to address childre s developmetal ad metal health eeds based o their age ad stage of developmet. 19 This perspective expads beyod metal illess to icorporate physical, social ad emotioal health, with a focus o prevetio ad promotio. Table 2 is based o the authors review of documets ad other advice from various orgaizatios ad experts to idetify potetial steps pediatricias may take to TabLE 2: IDETIfyIg METaL HEaLTH CoCERS I PRIMaRy CaRE: basic TaSkS by STagE of DEvELoPMET Stage of Developmet ad Developmetal Tasks Ifacy (ewbor through 11 moths): secure attachmet; emotioal regulatio; appropriate coduct Early childhood (12 moths to 4 years): see above Middle childhood (5 to 10 years): learig readig, writig, ad math; attedig ad behavig appropriately i school; empathy; gettig alog with peers; self-efficacy Adolescece (11 to 21 years): healthy physical developmet; itellectual developmet ad critical thikig skills; self-esteem; positive relatioships with peers ad family; attachmet to social istitutios Basic Tasks for the Primary Care Provider Scree for materal depressio ad other psychosocial risk factors such as domestic violece ad substace use; cosider poverty as a risk factor Observe materal-child iteractio ad assess quality of attachmet Coordiate efforts with home-based materal ad child health programs such as Healthy Start Cotiue to scree for psychosocial risk factors Coduct routie surveillace for autism spectrum disorders Idetify behavioral cocers i the home, child care settig Scree for speech, other delays, physical problems that may be coected to cocerig behavior Coordiate activities with child care providers ad early childhood programs Coduct surveillace ad targeted screeig for ADHD, axiety, depressio, coduct disorders Coordiate activities with schools ad child welfare as idicated Scree for behavioral ad emotioal issues as well as co-occurrig substace use disorders Coordiate these activities with other systems ivolved with youth such as schools, juveile justice ad child welfare 8

11 Issue Paper August 2009 icrease the child s ability to accomplish developmetal tasks associated with positive developmet ad prevetio of metal, emotioal ad behavioral problems. 20, 21, 22 These steps iclude coductig age-appropriate screeig, assessig the child s eviromet, ad coordiatig with other sectors that share resposibility for the child s developmet. From Metal Health Promotio to Treatmet: A Full Spectrum of Care The scope of primary care practice ecompasses a wide rage of activities, icludig promotig welless, prevetig illess, ad diagosig ad treatig illess whe it occurs. A similarly wide rage of activities is required for a practice to address childre s metal health eeds. This comprehesive approach must take ito accout the full rage ad itesity of social, emotioal ad behavioral problems affectig childre ad youth. Such a approach requires strategies targeted to various levels of eed ad coordiated amog the systems servig those childre. Three levels of itervetio i childre s metal health iclude: Prevetio ad health promotio: promotes optimal social ad emotioal developmet ad emotioal welless, builds resiliece i childre ad youth, ad reduces stigma related to eedig ad receivig metal health services for all childre. Early itervetio: focuses o early detectio of metal health problems ad itervetios for both childre ad their families i order to prevet or mitigate the adverse effects of emergig child metal health problems. Treatmet: psychopharmacologic ad therapeutic services for childre ad youth who are diagosed with specific metal health disorders. I additio, as pediatricias ad other primary care providers take o the role of a medical home, they are assumig greater resposibilities for the coordiatio of care for their patiets. As the health professioals who are most cosistetly preset as a child grows ad develops, pediatricias ca play a critical role i surveillace, screeig ad ogoig maagemet of childre s emotioal ad behavioral problems. As Figure 1 illustrates, carig for a child s metal health ivolves all three levels of itervetio. This full rage of services is provided by multiple sources icludig but ot limited to the primary care provider. Prevetio ad Health Promotio Systematic surveillace ad developmetal screeig help pediatric practitioers to moitor the overall well-beig of their youg patiets. Workig closely with parets ad other supportive resources to idetify cocers regardig paretig ad helpig parets to obtai treatmet for their metal health ad substace use disorders ca help prevet metal health problems i childre. Professioal associatios may exted these activities to iclude public educatio surroudig the beefits of prevetio. Early Itervetio Oe of the most importat roles of the pediatricia is to idetify medical, developmetal, emotioal ad behavioral problems i childre as early as possible ad to treat them or lik them to specialty care. The fields of metal health ad child developmet have cotributed to a proliferatio of valid, reliable measures of childre s social ad emotioal developmet, as well as measures of the quality of materal-child attachmet ad psychosocial risk factors for child metal health problems. However, use of such istrumets i primary care has bee limited. Oe recet survey of developmetal screeig foud that over 70 percet of pediatricias used cliical assessmet without a accompayig stadardized istrumet. 23 Although the effectiveess of such cliical assessmet i idetifyig emotioal ad behavioral problems requires further evaluatio, research poits to the superiority of usig stadardized istrumets rather tha relyig o cliical judgmet aloe to detect metal health issues. 24 I respose to such fidigs, the America Academy of Pediatrics has set as oe of its goals the developmet of a metal health tool kit that will iclude curret best choices i screeig tools for detectig metal health issues i childre. 25 For childre idetified as at risk for or havig mild behavioral ad emotioal problems, short-term itervetios, metal health cosultatio, ad collaboratio with child care ad other providers ca ofte address problems before they become severe. 9

12 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care figure 1. METaL HEaLTH CaRE CoTIUUM Promotio ad Prevetio Focus: No problems/ typical Early Itervetio Mild to Moderate Problems Treatmet Diagosed Metal Health Disorder Routie, systematic surveillace Targeted assessmet for Comprehesive assessmet, ad screeig positive screes diagosis, ad referral to specialist Social/emotioal skill buildig Developmetally-based paret educatio (Home visitig, early educatio) Itesive paret skills traiig Public educatio ad awareess Problem-specific educatio Metal health cosultatio Idetificatio of ad treatmet for metal health ad substace use disorders i parets Provider traiig Short term couselig ad support for childre with mild to moderate problems Care coordiatio: referral ad follow-up; likage to acillary support services Provider traiig: psychopharmacology, evidece-based treatmet Idividual, family, group therapy Therapeutic child care Medicatio maagemet Crisis itervetio, hospitalizatio Multidiscipliary treatmet plaig/ Coordiatio with specialty services Sources: 1. Illiois Childre s Metal Health Partership. Strategic Pla for Buildig a Comprehesive Childre s Metal Health System i Illiois, Chicago, IL: Illiois Childre s Metal Health Partership, Jue 30, valadeghem k ad Hess Ca. Childre s Metal Health: A Overview ad Key Cosideratios for Health Systems Stakeholders, Washigto DC: atioal Istitute for Healthcare Maagemet foudatio, february Zeah P, Stafford b, agle g, ad Rice T. addressig Social-Emotioal Developmet ad Ifat Metal Health i Early Childhood Systems. buildig State Early Childhood Comprehesive Systems Series, o. 12. Los ageles, Ca: atioal Ceter for Ifat ad Early Childhood Health Policy, Jauary Treatmet How the pediatricia maages ogoig metal health issues is depedet o a umber of factors, such as the availability of child-focused metal health specialists (icludig child psychiatrists), family ad youth prefereces, ad the severity of the metal health problem. Bright Futures recommeds that primary care providers refer to metal health specialists whe the child s fuctioig at home, i school ad with peers is impaired, ad whe the patiet is suicidal, exhibits psychosis or does ot respod to office-based treatmet. 26 However, a recet study foud that pediatricias had difficulty obtaiig outpatiet metal health services for their patiets because of health isurace barriers, such as limited provider etworks ad admiistrative requiremets, rather tha due to a lack of coverage for such treatmet. 27 The study also cited a severe shortage of child ad adolescet psychiatrists. This lack of access to outpatiet metal health services poses a further problem for pediatricias as they are faced with treatig metal health disorders ad are icreasigly prescribig psychotropic medicatios, raisig cocers about whether or ot pediatricias are adequately traied i this area. 28 For childre ad youth with severe 10

13 Issue Paper August 2009 emotioal disturbace, comprehesive care ecessitates coordiatio amog all of the providers workig i differet systems to achieve similar goals. Pediatric providers, the, eed to be aware of ad egage with schools, social service, juveile justice ad child welfare providers i their commuities to reiforce ad ehace their ow efforts. Fiacial ad Programmatic Cosideratios for Itegratig Metal Health ito Pediatric Primary Care I 2005 a estimated $14 billio was spet o childre s metal health ad substace abuse programs through private isurers ad employers, state ad local geeral reveues, ad various federal programs such as Medicaid, the Childre s Health Isurace Program (CHIP), various block grats ad categorical programs. 29 Fiacig of metal health services for childre therefore reflects a rage of policies ad practices that differetially impact the types of services available ad the ability to itegrate metal health services ito primary care. This sectio briefly reviews private ad public fiacig of primary care ad metal health services ad other public iitiatives that fiacially support itegratio of metal health ad primary care. Additioal resources ad further details o the growig umber of efforts i this area may be foud i the Appedix. Payig for Services: Private ad Public Isurace I 2007, 55 percet of childre were covered by employer-sposored plas, four percet through idividual coverage, 29 percet by Medicaid ad other public programs, ad 11 percet were uisured. 30 The recet reauthorizatio of CHIP is expected to provide coverage for a additioal four millio uisured childre by Curret losses of private coverage due to icreasig uemploymet ad greater public coverage due to expasio of public programs such as CHIP will likely icrease those covered by public programs. Earlier data idicate that amog childre with some form of health isurace, oly two percet did ot have ay metal health coverage. 32 New parity legislatio passed as part of the Emergecy Ecoomic Stabilizatio Act of 2008 may further impact available coverage ad reimbursemet for childre s metal health services as health plas providig metal health beefits will eed to address parity issues. The large umber of private plas ad the variatios i idividual state Medicaid programs create a complex array of beefit structures, regulatios ad madates, resultig i cosiderable variability i childre s primary care ad metal health beefits. Maaged care arragemets add to the cofusio facig primary care providers ad metal health providers as they develop appropriate plas to serve their patiets ad determie how to iteract with each other ad obtai reimbursemet for their services. I particular, payers that carve out metal health beefits ofte exclude primary care providers from the etwork of providers who ca deliver ad bill for metal health services. This arragemet may create a disicetive for metal health screeig ad assessmets as part of the primary care visit. 33 Additioally, most private ad public plas fail to recogize the importace of collaborative ad team efforts i the itegratio process ad therefore geerally do ot provide ay reimbursemet to support these itegrative efforts. 34 Further barriers are restrictios o billig o the same day for multiple visits ad the eed for more stadardized approaches that will permit billig for these visits. Private Isurace. Although more childre are covered uder private isurace plas tha public programs, private plas pay less tha half of the total costs of metal health services for childre i the U.S. 35 Estimates idicate that this is due to higher per-child costs for metal health services paid for by Medicaid. While recet summary data o beefits ad level of reimbursemet are ot available, metal health services covered by private isurers i the primary care settig geerally iclude screeig, assessmet ad/or medicatio maagemet. Efforts to expad the cotet of pediatric care to iclude screeig, assessmet ad related itervetios for metal health issues are placig ew demads o the pediatric primary care provider. The adequacy of reimbursemet is a obstacle to expadig the services provided durig well child visits. A recet paper by the America Academy of Pediatrics ad the America Academy of Child ad Adolescet Psychiatry highlights the various iadequacies i paymet icludig lack of coverage for may metal health services that are or 11

14 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care could be provided by pediatricias, limited coverage for certai services ad the lack of icetives for multidiscipliary approaches. 36 I recet years, health plas have begu to recogize the eed to itegrate physical ad metal health. Idicators of chages i policy ad service structure iclude health pla efforts to brig their behavioral health maagemet activities i-house ad creatio of more coordiated medical ad behavioral approaches that expad the role of primary care physicias. 37, 38 These efforts have largely focused o adults ad o the most prevalet coditios, such as depressio. Iitiatives iclude developig protocols for primary care providers to idetify ad treat commo chroic behavioral health coditios, icreasig cosultative services, ad coductig pilot programs to test differet itervetios. Efforts to address specific childre s metal health issues, primarily by larger isurers ad some locallybased health plas, are more recet. These efforts iclude reimbursemet for developmetal screeig for all childre ad coditio-specific programs focused o issues such as eatig disorders, ADHD, mild depressio ad autism. I additio, various cosultative services are targetig the icreased use of drugs to treat various coditios. Examples of some of these ew efforts are highlighted i Sectio III of the paper. Public Isurace. I the public sector, fudig for metal health services is provided through a combiatio of public isurace programs ad federal ad state iitiatives. The largest public programs, Medicaid ad CHIP, provide support for primary care ad metal health services for 29.3 millio ad 6.6 millio childre, respectively. 39 Uder both programs the federal govermet defies miimum beefits ad provides partial fudig. States are resposible for the rest of the program fudig ad may vary their beefit packages ad approaches to providig metal health services beyod the miimum beefit stadard. CHIP geerally provides more limited metal health beefits tha state Medicaid programs. 40 Both programs frequetly use maaged care arragemets to provide services, either for their overall program or for metal health beefits specifically. 41 Other public fudig is through the Departmet of Defese s TRICARE program, which covers childre of military families. TRICARE icludes HMO, PPO ad fee-for-service optios, which all vary i terms of coverage for metal health services. Medicaid covers early three out of every te [28 percet] childre with diagosed metal health problems. 42 As such, Medicaid is the major driver of childre s metal health fiscal policy ad has become the major payer of childre s metal health services, especially for childre with major metal health disorders. 43 State Medicaid programs vary greatly i their support of childre s metal health services, icludig the extet to which prevetive services are reimbursed ad the role of pediatric primary care providers i providig services directly. Aother key differece amog states relates to the Early ad Periodic Screeig, Detectio, ad Treatmet (EPSDT) program, which is a importat tool for addressig metal health uder the Medicaid program. EPSDT requires regular screeig ad testig of all Medicaid childre to idetify ay coditios requirig treatmet, icludig physical, metal, emotioal ad cogitive developmetal delays. These services are usually provided by the pediatric primary care provider ad Medicaid requires that if a eed is detected, services must be provided. While EPSDT is a potetially importat platform for supportig services, states have chose differet approaches to meet the 44, 45, screeig, treatmet ad follow-up requiremets. 46 Studies have show that oly 60 percet of Medicaid programs reimburse for the use of screeig ad assessmet tools for youg childre ad few provide reimbursemet to o-physicia providers. 47 Some states also use the Medicaid Home ad Commuity-Based waiver program i order to shift services for childre ad youth with severe emotioal disturbace from ipatiet settigs to home-based ad commuity settigs. These waivers have paved the way for childre ad youth to be served i the least restrictive settig possible. Wraparoud Milwaukee is a example of a program that bleds Medicaid waiver fudig ad state metal health, juveile justice, ad child welfare fuds to address more systematically the eeds of childre with serious metal illess. It also provides services for childre i foster care ad childre with developmetal disabilities. 48 Most states implemet some type of maaged care for childre ad adolescets i their public programs 12

15 Issue Paper August 2009 by cotractig with maaged behavioral health care orgaizatios. While carve-outs ofte expad services, beefits ad the use of evidece-based care, pediatric primary care providers are typically ot icluded i the etwork, makig it difficult to cosider strategies to itegrate metal health ito primary care. Oe example of a effort to address this barrier is Coecticut s Behavioral Health Services i Pediatric Primary Care iitiative, which was desiged to icrease access to metal health services for childre ad to itegrate metal health ad primary care explicitly. ValueOptios, the Medicaid maaged behavioral health care provider i Coecticut, provides a 25 percet icrease i reimbursemet to metal health cliics that successfully parter with pediatric practices to achieve icreased access ad itegratio. Other policy chages implemeted by states to promote itegratio of metal health ito primary care iclude reimbursemet to embed behavioral cosultats i primary care teams, creatio of a etwork of psychiatric cosultats for primary care providers, ad provider traiig for metal health assessmets. 49 While a umber of states are developig creative approaches to deliverig metal health services for publicly-isured childre, there cotiue to be sigificat barriers to addressig metal health eeds effectively i the primary care settig. Primary care providers ofte have difficulty billig for metal health services due to the eed to be certified to provide metal health services, a situatio that is further complicated by the complexities of the billig process. Little icetive exists to address itegratio through collaborative care ad team approaches sice reimbursemet policies do ot support these time-cosumig efforts ad ofte provide o or limited paymet for related care coordiatio ad case maagemet activities. 50 Other Federal ad State Support for Metal Health Services I additio to the public isurace programs, the federal govermet provides other fiacial support for childre s metal health directly ad idirectly through various block grats to states, support of delivery systems such as commuity health ad commuity metal health ceters, ad support for services through the school system. These efforts iclude: The Commuity Metal Health Block Grat program, of which a estimated $147 millio supports state programs for childre ad adolescets with severe emotioal disturbace; The Comprehesive Commuity Metal Health Services Grats for Childre ad Families, with over $104 millio i grats to localities ad states to develop systems of care; The Idividuals with Disabilities Educatioal Act (IDEA), supports metal health services for childre who have specific coditios icludig autism, developmetal delays, metal retardatio ad emotioal disorders; ad The Real Choice program from the Ceters for Medicare ad Medicaid, which icludes 21 grats for childre ad youth with serious emotioal disturbace. 51 States are also explorig broader strategies to address the rage of issues ivolved i assurig that more comprehesive approaches to addressig metal health prevetio, early itervetio ad treatmet services for childre are available. 52 Oe example is CliicPlus i New York which has bee developed to provide evidece-based early idetificatio ad itervetio for childre ad youth. The program also expads access to treatmet ad slots for home ad commuity-based waiver services. The state has helped to address reimbursemet barriers i this program by icreasig fees for assessmets ad i-home treatmet. A importat compoet of this effort is its requiremet that providers use stadardized assessmet tools ad other evidece-based practices. The state has also allocated some of its federal fuds through the Natioal Istitute of Metal Health to support a ceter that dissemiates iformatio o evidece-based practices. 53 Iitiatives Supportig Itegratio of Metal Health Services ito Pediatric Primary Care This sectio describes some of the curret efforts that go beyod simply supportig metal health services to supportig actual itegratio of metal health services ito pediatric primary care. 13

16 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care Federal Efforts Curret policy ad program efforts have attempted to improve the delivery of childre s metal health services, but these iitiatives have ot yet resulted i the systemic chages required for all pediatric practices to embrace a itegrated approach to metal health ad primary care. However, the Substace Abuse ad Metal Health Services Admiistratio (SAMHSA) ad the Health Resources ad Services Admiistratio (HRSA) cotiue to support local ad state efforts to help differet child-servig systems build collaborative relatioships that result i more itegrated, streamlied metal health care. Based o whether the primary fudig source is metal health, primary care, materal ad child health, educatio or welfare, the emphasis ad startig poit for the efforts vary. Some of these iitiatives are demostratio projects that are helpig develop the evidece base for itegratio, while others are techical assistace projects iteded to assist i the implemetatio of itegratio through the developmet of guidelies, tools ad traiig to support ehaced roles for primary care practitioers. These federal agecies also support resource ceters that serve as focal poits for iformatio ad support to practitioers ad others. More detailed iformatio is icluded i the Appedix. America Academy of Pediatrics I additio to efforts at the federal level, cosiderable activity is uderway withi the private sector amog professioal groups ad foudatios. The America Academy of Pediatrics (AAP) idetified childre s metal health as a strategic priority i A Task Force o Metal Health was formed to provide leadership ad guidace to primary care cliicias for addressig metal health cocers withi the medical home. The curret activities of the Task Force iclude idetifyig metal health competecies required for pediatric primary care cliicias, idetifyig strategies for ehacig metal health care at the commuity ad practice level, providig skill buildig ad educatioal opportuities, ad developig ew cliical tools. These tools iclude algorithms that primary care cliicias ca use to promote metal health, idetify problems, egage patiets ad their families, idetify further eeds for assessmet, ad assess care for childre with idetified problems. Primary care guidace is beig developed for learig disabilities, substace use, iattetio ad impulsive behavior, depressio, axiety, disruptive behavior ad aggressio. The AAP also has a policy statemet Idetifyig Ifats ad Youg Childre With Developmetal Disorders i the Medical Home: A Algorithm for Developmetal Surveillace ad Screeig which is focused o childre 0-3 ad provides a framework for these services, icludig idetificatio of specific screeig tools ad iformatio o how to select appropriate tools ad CPT codes to use to bill for services. 54 I additio, AAP s Task Force o Metal Health, with support from a grat from the Health Resources ad Services Admiistratio s Materal ad Child Health Bureau, has produced Strategies for System Chage i Childre s Metal Health: A Chapter Actio Kit, which describes steps state chapters ca take to promote metal health ad primary care itegratio for childre. The kit addresses a umber of areas, collaboratio with metal health professios, icludig parterig with child-servig agecies, parterig with families, ad efforts to address fiacig for services. Cotracts have bee made to select state chapters that are pursuig iovative programmig to support idividual pediatric practice efforts to itegrate metal health services. 55 Examples of promisig iitiatives sposored by two state AAP chapters are: Mississippi Chapter is assessig metal health service eeds i the Jackso area ad will prepare a resource directory based o iformatio from the State Departmet of Health ad coduct a survey usig Chapter Kit tools. They will egage primary care, metal health providers ad others to address ad implemet collaboratio, iformatio sharig ad other activities that will support better itegratio of services. Orego Chapter is workig with the Orego Coucil of Child ad Adolescet Psychiatry to address the ifrastructure ad other supports eeded for ehaced pediatric ad metal health collaboratios. Their efforts build o dialogues o metal health i primary care ad support cosultatio teams that brig child psychiatric services to pediatric practices. Fially, they expect to address the policy barriers prevetig the systems chages ecessary to sustai metal health itegratio i pediatric primary care. 14

17 Issue Paper August 2009 As more chapters egage i these types of activities, they will be able to provide resources to pediatric practices iterested i expadig their efforts to provide metal health services to their patiets. I additio, the efforts to address policy chages, icludig reimbursemet practices i their states, will help address curret barriers to providig these services. Bright Futures, ow housed withi the AAP, is the major practice guide that supports pediatric care ad icludes a specific module o metal health. Origially iitiated i 1990 with the support of the Materal ad Child Health Bureau, it was developed with cosiderable iput from health ad metal health stakeholders, icludig cosumers. The guide, recetly revised i 2008, provides specific suggestios for primary care pediatric practice ad for collaborative practice betwee primary care pediatricias ad a rage of professioals (e.g., developmetal specialists, child psychiatrists, psychologists, social workers). It covers four areas of service tailored to the child s stage of developmet: 1) screeig ad assessmet, 2) health promotio ad educatio, 3) itervetios, ad 4) care coordiatio. While the guide provides various strategies to implemet its recommeded actios, oly a estimated 38 percet of childre receive these ad other recommeded services 56, 57 for well child visits. Most recetly, AAP, workig with the America Academy of Child ad Adolescet Psychiatry, developed a joit positio paper supportig itegratio of metal health services for childre ad adolescets ito primary care ad addressig the admiistrative ad fiacial barriers to these efforts. A set of uderlyig priciples i support of itegratio activities has bee edorsed by both professioal groups ad the Natioal Busiess Group o Health. Fially, the positio paper delieates issues, barriers ad potetial solutios, icludig fiftee recommedatios for actio by purchasers, payers ad maaged behavioral health orgaizatios. 58 Foudatios Foudatios have become a importat source of iovative strategies to address childre s metal health. Gratmakers i Health reviewed the role of foudatios i this area ad highlighted a umber of efforts that focus o early childhood prevetio ad early itervetio, school-based iitiatives, ivestmets i buildig capacity, ad systems chage. 59 Amog the iitiatives that directly impact the potetial itegratio of metal health services ito pediatric primary care are: Assurig Better Child Health ad Developmet (ABCD) program, supported by the Commowealth Fud, has developed ad tested various strategies to improve the care of youg childre at risk for, or with, social or emotioal developmet delays. Grats uder this program have focused o prevetive or early itervetio services ad have provided resources to support pediatric providers use of validated screeig tools ad the itegratio of those tools ito practice through learig collaboratives, traiig ad metorig efforts. Grats have also addressed the developmet of resources for appropriate referrals to follow-up services ad promoted systems chage at the state level. The Itegrated Health Care Iitiative, sposored by the Hogg Foudatio for Metal Health, is supportig collaborative models of care that address a holistic approach to care by primary care ad metal health providers. Collaborative care models were adopted by five gratees to support the treatmet of metal health problems i the pediatric or primary care settig. These gratees iclude a public health system, commuity cliics, federally qualified health ceters, ad a o-profit pediatric practice. The evaluatio curretly uderway is expected to provide importat lessos about what is eeded to implemet collaborative models successfully. Healthy Steps, origially supported by the Commowealth Fud ad the Robert Wood Johso Foudatio, with co-sposorship from the AAP, is beig expaded with the help of a large umber of fuders. This program is desiged to support the itegratio of child developmet specialists ito primary care. Developmetal specialists embedded i primary care practices ca improve physical, emotioal ad itellectual developmet of childre by assurig the provisio of prevetive ad developmetal services. Logitudial evaluatio of the iitial fiftee sites has show major beefits i terms of paretal abilities to address issues ad practice improvemets for a modest icrease i costs

18 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care Implicatios of Public ad Private Sector Efforts for the Provisio of Childre s Metal Health Services i Pediatric Settigs The previous discussios strogly suggest that the curret eviromet provides opportuities for itegratig metal health ito primary care. Multiple efforts are uderway to address itegratio ad provide a base for explorig ew ad expaded opportuities to improve the quality of ad approaches to deliverig metal health services withi the pediatric primary care settig. Icreasig emphasis o prevetio, the eed to address body ad mid holistically, ad the growig evidece base i prevetio ad treatmet are likely to support the growth of strategies to itegrate metal health ito pediatric primary care. The examples of public ad private itegrative efforts described i this sectio illustrate some of the challeges iheret i brigig together metal health ad primary care, but also outlie strategies iteded to overcome these barriers, such as more creative approaches to reimbursemet, support for testig ew approaches, buildig the evidece base, ad developig tools to support icreased itegratio of metal health ito pediatric practice. The ext sectio addresses more specific strategies pediatric practices ad health plas might cosider to further these strategies ad highlights examples curretly beig implemeted. 16

19 Issue Paper August 2009 SECTION III: STRATEGIES TO IMPROvE EARLY IDENTIFICATION AND TREATMENT FOR CHILDREN IN PRIMARY CARE The curret eviromet for pediatric primary care providers is a complex ad challegig oe i which multiple factors ifluece their ability to meet the eeds of the childre ad families they serve. Pediatric primary care providers geerally serve as the medical home for their patiets. The AAP defies the medical home as primary care that is accessible, cotiuous, comprehesive, family-cetered, coordiated, compassioate ad culturally effective. Medical homes eable the primary care provider to address the myriad eeds of their patiets ad families i oe settig. Through the partership established with the family ad other providers, it is aticipated that the primary health care professioal will ehace family/patiet access ad coordiate specialty care, educatioal services, i ad out of home care, family support, ad other public ad private commuity services that are importat to the overall health of the child/youth ad family (Figure 2). Origially developed to address the complex set of services eeded by childre with special health care eeds, the medical home is ow recogized as the stadard of care for all childre as well as for adults. Buildig medical homes ofte icorporates the use of techology, such as electroic health records, implemetatio of care coordiatio strategies, ad likages with other resources i the commuity. As defied, medical homes provide a strog basis for itegratig metal health ito primary care practice. Issues discussed earlier regardig reimbursemet ad other fiacial issues are also a cocer whe cosiderig the medical home cocept. Although some payers are begiig to recogize ad pay for some of the additioal costs of the medical home, there is still a Figure 2. Compoets of a Medical Home a partership betwee the family ad the child s/youth s primary health care professioal Relatioships based o mutual trust ad respect Coectios to supports ad services to meet the o-medical ad medical eeds of the child/youth ad their family Respect for a family s cultural ad religious beliefs after hours ad weeked access to medical cosultatio families who feel supported i carig for their child Primary health care professioals coordiatig care with a team of other care providers Source: america academy of Pediatrics The atioal Ceter of Medical Home Iitiatives. geeral Medical Home Ifo. available at: geeral.html; accessed Jauary 8,

20 Strategies to Support the Itegratio of Metal Health ito Pediatric Primary Care cosiderable gap i support for may of the aspects of deliverig this more comprehesive model. This sectio explores a variety of strategies to improve the ability of the primary care system to address childre s metal health. First, cosideratios i defiig the practice s role ad approach to addressig metal health eeds are discussed. The, three promisig approaches to addressig metal health eeds i the primary care practice are preseted, amely cosultatio, co-locatio ad collaborative care models. Fially, the curret ad potetial roles of health plas ad other payers are reviewed. Determiig Whether ad How to Itegrate Metal Health ito A Pediatric Practice Most primary care providers maage emotioal ad behavioral problems i the cotext of well child visits, ofte without the traiig ad tools ecessary to idetify ad treat behavioral health problems. I uderserved areas they may operate without the support of metal health specialists to address eve the most severe problems. I order to address these issues, may private practices, commuity-based health ceters ad some health plas are begiig to take cocrete steps to restructure their practices to better serve childre ad adolescets with emotioal ad behavioral problems. The strategies they select for itegratig primary care ad metal health services deped i part o how comprehesive a array of services the practice would like to provide. There are may possible aswers to the questio of what specific roles pediatric primary care ca play i addressig metal health eeds. Idividual practitioers ad practices will eed to determie the role they wish to play, icludig the services they wish to provide directly. Determiig how ad how deep will reflect a umber of geeral ad specific cosideratios. Table 3 represets the key areas primary care providers may wish to assess prior to determiig how to address metal health i their patiet populatio. TabLE 3: DEvELoPIg a PRaCTICE S approach To addressig METaL HEaLTH EEDS Assessmet Area Questios Assessig the service eeds of the patiet populatio What is the patiet profile (age, demographics, isurace status, family compositio, evirometal factors ad other characteristics likely to impact the eed for metal health services ad approaches to deliverig those services)? How culturally/ethically diverse is the populatio? Are there specific problems the practice is seeig? How extesive is the use of psychopharmacological treatmets amog the patiet populatio? Are there areas that are likely to eed more emphasis give the age compositio (e.g., early developmet versus adolescet issues such as eatig disorders, depressio)? What do the aswers to these questios imply for prevetio, early itervetio ad treatmet approaches? 18

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