In 2024, Akron Children’s emergency departments across 33 Ohio counties logged 4,500 behavioral health visits. At primary care clinics, more than a quarter of patients screened positive for depression.
With projections showing a 15% increase in behavioral health inpatients and a 9% rise in outpatients over the next five years, leadership recognized something had to change to keep kids out of the ED.
“Not a day went by that we didn’t get a call about a patient in need of services and how long it was taking to get them into services,” said Douglas W. Straight, LPCC-S, psychiatry and behavioral health clinical operations director at Akron Children’s.
A few years earlier, the hospital began integrating behavioral health therapists in primary care clinics, which has proved an effective way to get patients care earlier. Therapists were embedded in 14 locations, with about 4,000 behavioral health visits a year, accounting for about a quarter of the total primary care clinic visits.
But results had been lacking. Patients were screened with the PHQ-9 patient health questionnaire but not always directed to the right level of care. When they were referred, the care team didn’t follow up with them. Primary care providers were uncomfortable managing behavioral health concerns, resulting in patients landing in the ED.
“Therapists were co-located but not integrated,” said Eva Szigethy, MD, PhD, Lois C. Orr Endowed Chair of Pediatric Psychiatry and director of the behavioral service line.
In all, even with therapists at the clinics, 85% of patients who were referred to treatment never went, and only 10% who had an urgent behavioral health need could be seen within four weeks.
This reality set Szigethy on a mission. After a series of conversations with frontline staff and months of steering committee meetings, she and her team revamped the entire process with a replicable model called TABBICAT: Triage, Assessment, Brief Behavioral Interventions, Care Coordination, Tracking.
“We knew a standardized approach was the key to success,” said Szigethy, who leaned on her background in implementation science. “Our new cat was going to take us from siloed, fragmented, reactive care to more integrated, holistic, and preventive care.”
Triage
When a pediatrician identifies a behavioral need, they contact the on-site mental health therapist and care coordinator. For non-urgent cases, the coordinator schedules therapy sessions within two to four weeks. Therapists continue to see the patient for five to 12 sessions.
Psychiatrists are available as consultants and meet monthly with the embedded therapists and pediatricians to discuss cases.
For urgent referrals, a centralized team decides appropriate next steps. Care coordinators ensure families follow up on therapy visits and, when needed, connect them to higher-level care within 48 hours.
The therapists reserve two half-hour slots a week for a same-day or next-day appointment for patients in crisis.
“Those have really paid back in gold,” Szigethy said. “A very high percentage of the crisis slots were utilized and resulted in very high referral rates.”
Results: The average referral rate to Akron Children’s behavioral health providers rose from 55.8% to 87.4%. And 85% of referrals in January 2025 were seen by a behavioral health provider within two to four weeks — up from 10% before TABBICAT.
Assessment
All patients receive four assessments: PHQ‑9 for depression, GAD‑7 and SCARED Child for anxiety, and the Mood and Feelings questionnaire. These are embedded in Epic and sent through MyChart before the visit. Mental health therapists conduct a qualitative mental health diagnostic once they see the patient.
Behavioral health providers can’t close a patient encounter until they fill out the Clinical Global Impression Severity (CGI-S) and Clinical Global Impression Improvement (CG-I) assessments, which are used to track progress.
“It is a very well validated and really excellent proxy whether your primary diagnosis is improving on a Likert scale,” Szigethy said.
Results: In 2024, 96% of patients ages 12 and up received PHQ‑9 screening; 10.3% scored moderate to severe, and 80.6% of those had a documented follow‑up plan.
Brief behavioral interventions
Therapists are trained in First Approach Skills Training and Brief Strategic Family Therapy to deliver focused, time‑limited support. The hospital’s data and current literature show that brief in‑clinic interventions are best for many mild‑to‑moderate cases.
“When you’re trying to sell a new therapy to very experienced mental health therapists, it’s very important to emphasize the evidence and then give them time to try it on their own,” Szigethy said. “It is wonderful to watch therapists with high resistance become some of the biggest cheerleaders of this method.”
Teens waiting to see a therapist can use an AI‑powered chat app. Eighty-five percent of patients who were offered the app downloaded and used it, with 75% continuing to use it over time. The app tracks PHQ and GAD scores, which dropped substantially over eight weeks.
“It’s not a replacement for a therapist but a great holding tool,” Szigethy said. “Kids are really engaging.”
Results: The hospital is still tracking the effectiveness of the shorter behavioral interventions, but feedback from the therapists has been highly positive.
Care coordination
Behavioral health care coordinators support pediatric practices remotely through Epic chat, connecting patients to appropriate levels of care — whether stepping up to more intensive services or transitioning to lower levels.
They’re trained in motivational interviewing to help families overcome barriers to care and can connect them to community resources as needed.
Coordinators connect patients with therapists briefly while the patient is meeting with the pediatrician. Therapists have 16-minute blocks built into their schedules throughout the day for these “meet and greets.”
“These are so important to get over so many layers of family resistance,” Szigethy said. “It’s amazing how wonderfully this works.”
Results: In 2024, more than 1,000 families received care coordination.
Tracking
“It's important to have both process and patient tracking mechanisms; one or the other isn't enough,” Szigethy said.
She and her team track a number of key measures:
- Warm hand-offs
- Time from referral to intake
- Referrals that successfully lead to intakes
- Number of days between referral to intake
- Clinical global impression assessment scores
- PHQ-9 scores
- Social drivers of health
All this is done through data visualization software like PowerBI dashboards and Webi reports.
“We really needed to have a way to longitudinally track outcomes and get that easily in our medical record,” Szigethy said. “Clinicians can easily see if the interventions are having the intended effect.”
Expanding
Around 80% of the costs associated with TABBICAT are billable to insurance.
“I've done a lot of work with my staff about documentation to ensure the complexity of care matches what we’re billing,” Szigethy said. “It’s really important to get the DRG codes right.”
To date, 13 primary care clinics are fully integrated with the TABBICAT model. The number of behavioral health care coordinators has grown from two to six, and psychiatrists are being added to two new practices at a time.
By December 2025, the hospital plans to double the number of integrated clinics — adding 13 more sites — and increase care‑coordinator staff. And that’s good news all around.
Szigethy said, “Patients are satisfied, therapists are satisfied and feel productive, and pediatricians are jumping for joy.”
