Mental health concerns in children and teens are unmet needs in primary care, with providers either inconsistently screening or lacking the resources or competency to effectively address. To meet the need as a system, Cleveland Clinic Children's shifted to an integrated model of care.
One in five children between the ages of 13 and 18 has a debilitating mental disorder, according to 2015 data from The National Institute of Mental Health. Half of all lifetime cases of mental health disorders begin by age 14 and 75 percent appear by age 24. The median delay from onset of symptoms to diagnosis is nearly a decade, creating economic and quality of life issues for these patients.
At the 2016 Annual Leadership Conference, Adam Keating, M.D., section head at Wooster Family Health Center Pediatrics, and Michelle Medina, M.D., FAAP, interim chair, Department of Community and General Pediatrics at Cleveland Clinic Children's Hospital, shared how Cleveland Clinic Children's shifted to an integrated model of care to include mental and behavioral health and partnered with community mental health agencies.
According to Keating, time spent training pediatricians to handle mental health issues or getting them comfortable to care for patients with mental conditions is not proportional to the burden of disease that currently exits. "A significant portion of the pediatric practice is not prepared to deal with it," Keating says. Time, resources, knowledge, training, cost, access and the stigma of mental health disorders are barriers to care. And he says silos exist in health care organizations between physical and mental health care providers and payment structures.
To improve this, Cleveland Clinic Children's integrated its model of care to:
- Make the best use of limited resources
- Bring mental health care to the primary care physician's (PCP) office
- Decrease the stigma of receiving mental health care services
- Streamline referrals
- Raise the confidence of PCPs
"We know there are not enough resources to meet demands in systems today," Keating says. "Pediatricians can do this in their office, and it raises the confidence and competence of the PCP to treat those patients they can."
Identifying a place to start
At Cleveland Clinic Children's, Keating and Medina began the integration process by addressing gaps in the current workforce and processes. They saw an undertrained workforce, an inadequate number of mental health specialists and a cumbersome referral process. "We began where the providers were and offered small wins to get them engaged," Keating says.
Their assessment identified top areas of concern and challenges:
- Accessibility of social services
- Managing emergencies
- Comfort with initial diagnosis
- Managing family or caregiver distress and
- Knowledge about psychiatric medications.
Medina says they identified already existing quality improvement projects to serve the education needs of the integration project. They let those with the expertise create the curriculum; engaged motivated providers first, and then disseminated best practices and utilized the quality improvement infrastructure for governance and partnership identification.
Tapping into additional resources and partners
The Ohio Chapter of American Academy of Pediatrics had several existing programs that helped support training and development needs and program sustainability. The Building Mental Wellness Learning Collaborative offers online content for training and an easy way for PCPs to access information and supplement their knowledge. Parenting at Mealtime and Playtime adds strengths-based developmental guidance for parents. And Good4Growth supports surveillance and screening tools for patients and families. The integration project also tapped internal experts for webinars on specific skills and diagnoses and cross-departmental partnerships.
Cleveland Clinic Children's developed role-based standards and specific skills for all caregivers, from clinicians to team members answering the phones and scheduling the appointments. Moving from a doctor-centric to a patient-centric care model for mental health, the team identified the minimum standards regarding mental and behavioral health. These standards include empathy, comfort in managing patients, tempering initial impressions, recognizing the importance of diagnosis, and using the right words at the right time. The hospital developed a team-based workflow for pre-, during and post visits based on how the patient experiences the primary care visit.
During the first phase of the integration, the organization partnered with community mental health agencies already doing work successfully with children. They began with high-risk Medicaid populations and partnered with CareSource, a managed care Medicaid organization with case management structures in place and grant and other funding opportunities. The hospital also developed a partnership with a local community mental health agency that has 90 percent of the children in school districts embedded in its system.
A dedicated triage phone line was launched and is manned by trained clinicians with case manager support. Specialty clinic referrals were also part of the phase one integration, including ADHD, pain management, weight management, oncology and transplant services.
Working as a team
One of the key components to the integration was embedding mental health providers in primary care clinics. Psychologists, social workers, counselors and psychiatrists are all effective in this role. "We're collaborating as a team vs. just being co-located," Keating says. The stigma of receiving mental health care services is lessened in the PCP, and care is delivered in a more timely fashion. The mental health providers also provide education, case conferences and participate in informal discussions on patients. Complicated cases are streamlined and referred to specialists. The patient returns to primary care once stabilized. "Our goal is to have the right people caring for the patient at the right time," he says.
In the future, the program will move from a pilot to system wide in the hospital network. Creating a network of community mental health partners, developing measurable outcomes, developing a team approach to mental health, including care coordination and planning, and establishing behavioral health as a core role of primary care at Cleveland Clinic Children's are slated for the future. "Our ability to impact quality of life is huge," Keating says. "As an industry, we've moved beyond treating diseases like diphtheria and our goal should now be building mental wellness."
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