One in five children and adolescents will receive a behavioral or psychological diagnosis by the age of 18. That’s more than the number of women diagnosed with breast cancer (1 in 8). According to the American Academy of Child and Adolescent Psychiatry, 50 percent of pediatric office visits involve behavioral, social-emotional, or developmental issues. Seventy percent of behavioral medications are prescribed by general practitioners. However, this data predates the COVID-19 pandemic. Depressive symptoms among teens have doubled since the pandemic began, and one in three high school students is feeling sad or hopeless. Visits to the emergency department for mental health issues increased by 24 percent.
We all feel the stress and strain of offering more services that may not have been part of our medical education. How can we prepare to provide the right patient with the right care at the right time?
Our organization provides behavioral and mental health care in the home of primary care. We are a specialty pediatric medical group based in San Diego and the second largest pediatric group in the country. In our 28 branches, we care for around 270,000 patients from birth to the age of 21. 45 percent of our patients are insured through the state Medicaid program. We have successfully integrated behavioral/mental health care into our practices and made it part of our organization’s DNA. However, it wasn’t always like that. What does it take to bring about change in your organization?
1. Identify a champion
In 2015, I introduced our President/CEO and Medical Director. I outlined how I thought we could use the knowledge of our clinicians who provide behavioral/mental health care and educate those who hesitate. Fortunately, our leaders recognized the importance of this diligence and gave me the leeway to begin creating a program. I met with clinicians from across our organization and those who provide specialized mental health services in our community (developmental and behavioral pediatricians, child and adolescent psychiatrists, therapists, clinicians at local Federal Qualified Health Centers (FQHC), administrators within our organization and local people Children’s Hospital). Everyone was willing to listen to my questions, give clear directions, and become partners in caring for our mutual patients. Forming this network has been invaluable as we continue to expand the services offered within CPCMG.
2. Partner with community-based organizations
As a pediatrician, you don’t have to provide all the care your patients and families need. You need to know where to send them for further help. Just as we don’t take our patients to the operating room when they have a broken leg that requires fixation, we don’t provide the evidence-based therapy they need. We are the quarterback to help coordinate care.
We’ve partnered with a nonprofit community-based organization (CBO) in San Diego County that has been providing mental health care since 1957. Their behavioral health counseling program allows families to call directly and speak to a licensed clinician who will help them review the services available within the community and appropriate for their child’s or family’s needs. They also help families check insurance coverage. They then send this list to the family and fax it to the GP. This allows for improved communication regarding action items. A second arm of this program is a peer-to-peer phone line where pediatricians, primary care physicians, internists, OB/GYNs, nurse practitioners, and physician assistants (anyone who provides behavioral/mental health services to patients) can call and speak to a pediatric and adolescent psychiatrist or a psychiatric nurse for advice. The recommendations are sent to the calling doctor. By scanning into the electronic health record (EHR) it can be referenced when patients come back and need a reminder of the next step.
This program has been invaluable to my colleagues and myself. This means we have a partner when it comes to connecting families to the services they need. Having a Psychiatrist on Call as a backup makes trying a new skill more comfortable. In addition, our families are very grateful to have two people to help their children on the path to well-being.
3. Support open communication and provide education
Clear and direct communication is key to achieving significant change in any organization. Our Behavioral and Mental Health Committee has worked closely with our management group, front and back office staff, Information Technology (IT) department and administrators to identify potential challenges and celebrate successes. By recognizing our goals early on, we are much more likely to achieve them.
A multi-pronged approach is essential to demonstrate our physicians’ continued commitment to evidence-based care. All of our clinicians are trained in ADHD, Anxiety and Depression The Reach Institute, which includes six months of follow-up. This allowed our clinicians to have a common language and understanding of the “Big 3” behavioral/mental health diagnoses. Each newly hired employee will attend this training, paid for by our group, within the first six months of employment. Our colleagues in the specialist practice offer ongoing CMEs twice a month via Zoom, covering a variety of behavioral and mental health topics.
Key leaders from our Behavioral and Mental Health Committee visit offices to follow up with our clinicians to identify sticking points in patient care. During these sessions, we can provide direct guidance to help our doctors and staff become more familiar with this important care.
Our patients need our help. Parents and guardians turn to us about what bottle to use, how often to breastfeed, when to start feeding their children, what green poop means and how to talk to their children about difficult topics. We also need to be there to provide the best possible care around behavioral and mental health issues. We can look after the whole child.
Hilary M Bowers is a pediatrician.
