This model streamlines care for patients with mental and behavioral health needs and reduces costs.
By Barbara S. Saunders, D.O., F.A.A.P., and Thomas David Elkin, Ph.D.
In 2016, there were more than 700,000 children under the age of 18 in Mississippi. According to the Centers for Disease Control and Prevention, an estimated 1 in 5 children under age 18 require behavioral health care. That means approximately 144,000 children in Mississippi need behavioral health services. As the only children's hospital in the state, Children's of Mississippi and its Center for Advancement of Youth (CAY) are the organizations in the state best positioned to deliver this care.
The aim at CAY is to reduce rates of adverse events and outcomes, such as teen pregnancy, incarceration, school dropout, obesity, and substance use and abuse. The aim also includes improving graduation rates, employability, the skilled workforce and reducing costs of care. The improved access to behavioral care services starts a cascade of positive changes. Better access to care leads to earlier intervention, producing better outcomes. Better outcomes lead to a healthier, more productive, and more engaged population and decrease costs.
A high-cost, inefficient system of care
Before CAY instituted its model, children with behavioral health needs often received disjointed care and unnecessarily duplicated services. The lack of coordinated services led to longer wait times before providers saw patients; increased rates of outpatient doctor visits, psychosocial visits and hospital stays; and a higher overall cost of care.
This system wasn't working for patients and their families, or the state's budget. To improve, CAY developed a model of developmental and behavioral care that provides a more coordinated, cost-effective care delivery system.
A new way of doing things
CAY receives an average of 400 new referrals per month. In 2017, CAY received 4,593 new referrals from 80 out of 81 counties in Mississippi. To meet the high demand for developmental and behavioral care, CAY's multidisciplinary team provides services including:
- Developmental and behavioral medicine.
- Child and adolescent psychiatry.
- Behavioral therapy.
- Parent/child interaction therapy (PCIT).
- Psychological evaluation and testing.
- Speech and language therapy.
- Occupational and physical therapy.
To streamline the care process and eliminate redundancy, CAY developed a rigorous triage protocol. A triage specialist reviews every referral and uses a standardized triage process to ensure the referred child is scheduled with the most appropriate provider and for the correct type of service.
Trained staff members review each referral and puts it through the same triage protocol. This has helped provide consistency in scheduling and has led to improved provider satisfaction because the patients on their schedules are appropriate for their service line. In the future, learning algorithms will automate this process and streamline the flow of care.
Patients are initially scheduled to one of several different service lines including:
- CAY dyad (child psychologist and developmental-behavioral pediatrician).
- Medical-only assessment (developmental-behavioral pediatrician or psychiatric mental health nurse practitioner).
- Outpatient child/adolescent psychiatry assessment.
- Psychological evaluation and testing.
- Behavioral therapy within CAY (to include PCIT).
- Behavioral therapy through one of CAY's community partners.
A lower cost for better outcomes
During the first year of CAY's new model, Mississippi Medicaid spent about $1,000 per child for well-child care. The cost of care for children with behavioral disorders, such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and depression was much higher. Mississippi Medicaid spent approximately $571 million to provide behavioral care services for almost 118,500 children.
Children who used CAY for their behavioral care needs were not only seen more quickly and by the appropriate type of provider, but the care was delivered at a lower cost than behavioral care services for children with the same disorders who did not use CAY.
In a study conducted by Mississippi Medicaid, 908 CAY patients from 2016 were matched to 908 non-CAY patients from the same time. The study found CAY's interdisciplinary behavioral care model was associated with approximately $5,000 in costs avoided per child. This translates into just over $4.5 million for the study sample alone. CAY patients had fewer outpatient doctor visits, fewer psychosocial visits, and required fewer days of inpatient care.
Building on the strategic plan
In early 2018, CAY's leadership team created a strategic plan focusing on three areas:
- Quality. Be the preeminent leader in children's behavioral health care.
- Quantity. Strive to improve access to care, expand across the state, and ensure sustainability of the care model.
- Catalyst. Stay active in advocacy, transformational policy and external affairs.
As part of this plan, CAY formed partnerships and collaborations with several community and statewide entities.
Partnering with and using existing services has allowed the organization to expand its reach, better meet the behavioral care needs of the children of Mississippi and decrease the cost of care.
Barbara S. Saunders, D.O., FAAP, is associate professor, Pediatrics and division chief, Division of Child Development, and Thomas David Elkin, Ph.D., is executive director, Center for Advancement of Youth at Children's of Mississippi in Jackson, Mississippi.
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