Children in the United States have a huge unmet need when it comes to mental health care, and pediatricians and other pediatric primary-care providers are often left to fill the gap. That can be a problem, said psychologist Dustin Sarver, PhD, of the University of Mississippi School of Medicine, noting that such providers aren’t always comfortable diagnosing and treating mental health conditions.
“About 1 in 5 kids will have a clinically diagnosable mental health condition, but half of those kids will not receive care from a mental health provider,” said Sarver, an associate professor of psychiatry and human behavior and pediatrics. “In rural places like Mississippi, about two thirds of the child population with an identified mental health condition are not connected to services.”
Now, a Health Resources and Services Administration (HRSA) program is providing a path for psychologists and other mental health practitioners to help pediatric primary-care providers diagnose, treat, and refer children with mental and behavioral health problems.
Launched in 2018, the Pediatric Mental Health Care Access (PMHCA) program gives grants to states to support multidisciplinary teams of mental health providers who can help their pediatric primary-care colleagues. The services offered include phone consultations, training, technical assistance, and care coordination, all designed to get children the care they need.
Sharing psychology’s expertise
Teleconsultation programs designed to help pediatric primary-care providers have a long history, said Erin Swedish, MBA, PhD, director of health integration in APA’s Office of Health and Health Care Financing. But, she said, “these programs have historically focused on psychiatric consultation.” In 2003, Massachusetts began a teleconsultation program that linked primary-care providers with child psychiatrists. By 2011, the concept had spread so widely that pediatricians and child psychiatrists created the National Network of Child Psychiatry Access Programs. HRSA’s program is similar to earlier efforts, but its broadened focus is reflected in its name.
HRSA grantees build multidisciplinary mental health teams that go beyond psychiatry to include psychologists, social workers, and counselors. “Having psychologists being a part of these teams reinforces the importance of psychology in integrated care,” said Swedish. As of publication, there are PMHCA grantees in 23 states plus the District of Columbia, with several more states in development.
Although there are variations state by state, the basic outline is the same everywhere. In Mississippi, for example, the program—known as Child Access to Mental Health and Psychiatry, or CHAMP—offers free, same-day phone consultations to the state’s pediatric primary-care providers. Since receiving an HRSA grant in 2018, the program has registered a quarter of the state’s pediatric primary-care providers in its database of participating providers and works hard to build relationships with them. “We want to make sure the providers know who we are and know they can trust us, that we’re not just 1-800-Call-a-Psychologist,” said Sarver, CHAMP’s clinical director.
Three child psychologists and a psychiatrist from the University of Mississippi Medical Center field most of the calls, which are equally divided between psychiatric and behavioral health concerns. The team also includes a psychiatric nurse practitioner, a social worker, and a counselor. With calls typically lasting about 15 minutes, the psychologists tackle questions about diagnoses and treatment planning and occasionally co-consult with the psychiatrist. Meanwhile, the psychiatrist handles calls about medication management, and the social worker draws on a large database of providers across the state to suggest resources and referrals.
Integrated primary care, in which a psychologist embeds in a primary-care office, is a wonderful model, said Sarver. “But it’s just not feasible in most communities across our state,” he said. “Our phone-based consultation helps bridge that gap, enabling some level of coordinated, collaborative integrated care through consultation.”
The Indiana Behavioral Health Access Program for Youth (Be Happy) at Indiana University’s School of Medicine also provides telephone consultation to pediatricians and other pediatric primary-care providers in its home state. “Pediatricians and other primary-care providers are oftentimes the most trusted and most available providers for kids and families, but they may need some additional resources, training, and mentorship to provide the care these kids need,” said psychologist Zachary Adams, PhD, Be Happy’s codirector and an assistant professor of psychiatry at the medical school.
Although the program’s primary constituency is pediatric primary-care providers, it is now expanding its reach to therapists. Starting in mid-2022, the Be Happy help line will also connect therapists in the community—whether in private practice, community mental health centers, or even integrated care settings—with Be Happy’s psychologists for help with challenging cases. “Maybe they have a patient where things are a little more complicated than expected, or maybe they could use some help selecting an intervention or planning how to implement a particular kind of intervention a patient might need,” said Adams. “Our consulting psychologists will be available to offer evidence-based guidance and support.”
In Maryland, an HRSA grant has allowed an existing access program called Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) to extend its teleconsulting directly to patients who need care coordination, telepsychiatry, or telecounseling. “It’s on a very short-term basis, more as a bridge to care in the community than taking over care,” explained psychologist Amie Bettencourt, PhD, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins University School of Medicine.
Educating pediatric primary-care providers is another key component of the programs. BHIPP, for instance, brings primary-care providers together in monthly online training sessions that use the Project ECHO model, a peer support program for clinicians developed at the University of New Mexico that has an “all teach, all learn” philosophy. In each session, a primary-care provider presents a case involving mental health concerns, then receives feedback from other providers and the program’s psychologists and other experts about what they should do next. A psychologist also helps write a monthly newsletter that goes out to pediatric primary-care providers around the state.
Although the psychologists involved in the PMHCA programs are typically staff members at academic medical centers, there may be ways for other psychologists to get involved, said Bettencourt. Check to see if your state is on the list of HRSA grantees and then reach out to see if its program needs help implementing training for primary-care providers or part-time phone consultation. Build relationships with pediatric primary-care providers in your area and offer to provide the same kind of teleconsulting on a more local level. And urge your state to apply for HRSA funding.
“Having psychologists involved in these access programs reinforces the role of psychology in integrated care,” said Bettencourt. “It’s really important for psychology to show how it can be a critical component of these programs.”
APA is doing its part, too, Swedish added. To help ensure the financial sustainability of these programs, APA is trying to help advocate for psychologists’ increased access to and utilization of CPT® consultation codes 99446, 99447, 99448, 99449, and 99451, which cover interprofessional consultation by phone, internet, or electronic health records.
“Billing these codes allows reimbursement for the non-face-to-face time by a psychologist for consultations when the patient is not present,” explained Swedish. “Increasing psychologists’ access to and utilization of these codes for consultant work that is not face-to-face would ensure that psychologists can be reimbursed, thus allowing for more financial stability for these programs.”
Best practices
Whether you are part of a PMHCA program or just providing informal help to pediatric primary-care providers, use these tips for making the most of pediatric phone consultations:
Confirm parents’ consent. Ask providers if they have parental consent to consult with you, even if the call is purely educational, said Sarver. “While you don’t need written permission to consult with another provider, confirming they have consent is an opportunity to educate providers about the importance of family-driven practice,” he said. “We want to make sure parents are involved, since that’s the basis of family-driven practice—that parents have a say and a voice. We want to make sure it’s done transparently.”
Be efficient. “It’s important to recognize that pediatric primary-care providers are very, very busy, especially when COVID-19 has flared up,” said Sarver. Ask providers to clearly state their question and what information they need to take action to improve the mental health care of their patients.
Gather all the relevant information. A communications framework developed in Maryland’s program helps ensure that psychologists and other teleconsultants share information effectively, said Bettencourt. Called the “Five S’s,” the framework covers assessing the patient’s safety, identifying the specific behaviors the primary-care provider is concerned about, determining the settings in which those behaviors occur, noting scary issues like past trauma, and asking the provider about screening results (Harrison, J., et al., Current Problems in Pediatric and Adolescent Health Care, Vol. 46, No. 12, 2016).
Stick to the evidence base. Don’t just wing it, said Adams. “Part of the idea here is that we’re trying to promote the implementation of best practices and research-backed approaches to mental health care,” he said. “Sometimes just starting with these well-established, tried-and-true procedures really addresses the question at hand.”
Give providers ideas for how to help children and families while they wait for specialty care. For a primary-care provider treating a depressed adolescent, that might mean seeing the patient more frequently just to check in, said Bettencourt, noting that even that small form of social connection can help. The provider can also urge the patient to get busy doing something, whether it’s taking walks or calling a friend, in the short term. Providing psychoeducation to the family to normalize the problem and explain what symptoms to expect and what treatment will look like can also help.
Be ready with referrals. “We get a fair number of calls about resources and referrals,” said Sarver. The HRSA grantees maintain databases of providers in their states to help pediatric primary-care providers connect their patients to more specialized care if needed. And thanks to the loosening of telehealth regulations during the pandemic, Sarver added, access has increased. “We can now connect people in opposite ends of the state,” he said. “A pediatric primary-care provider in the very rural, impoverished area of the Mississippi Delta may not have had access to mental health support, but with telehealth, we can match providers from other areas of the state to those underserved areas.”
Provide a takeaway that goes beyond the specific case the provider is asking about. Educate providers about the standard of care on whatever topic they’re calling about so they can apply it to the next patient who has a similar problem, said Sarver. “That increases the number of kids served,” he said. One example: Recommend that providers use screening tools like the Patient Health Questionnaire-9 and the Vanderbilt ADHD Diagnostic Rating Scale to differentiate between depression and attention-deficit/hyperactivity disorder (ADHD), then ask them to call back for help in scoring and interpreting them.
Remember you don’t have to do everything in one call. Provide “bite-sized morsels” of information, prioritizing actionable steps that will have the most immediate impact on patients’ care, said Adams. “You don’t want to give so much information that the provider is overwhelmed or more confused than they were before the call,” he said. And urge providers to call back as needed and to view you as a colleague and a mentor. “We love it when we hear back from providers about what’s working and not working,” he said.
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