Pediatric mental health care access programs (PMHCAs) in more than 30 states are addressing gaps in mental health care access in primary care settings. Since 2012, Johns Hopkins University School of Medicine and its local partners have implemented the Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) — providing consultation with primary care providers and resource/referral support, with a goal of expanding its range of services and geographic area over time. Amie Bettencourt, Ph.D., director of research and evaluation, has been monitoring the service utilization trends in order to guide the development and improvement of program services.

The Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP)

History: Pilot operations began in the fall of 2012, in the western and eastern regions of the state. Statewide services began in July 2013. BHIPP expanded its service array in 2019 to include telemental health services and BHIPP TeleECHO Clinics.

Key Funding: Maryland Department of Health, Behavioral Health Administration and, most recently, Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS).

Partners: University of Maryland School of Medicine, Johns Hopkins University School of Medicine, Salisbury University and Morgan State University.

Services: Phone consultation service for pediatric primary care providers, training and education, referral and resource networking, care coordination, social work services co-located in select primary care practices, telemental health services (including telepsychiatry and telecounseling).

1. You recently presented a study at the American Academy of Child and Adolescent Psychiatry (AACAP) conference (recently published in Psychiatric Services) that focuses on trends in calls to BHIPP and another pediatric mental health care access program prior to and during COVID-19. What are key takeaways from your presentation?

There was a pretty significant increase in the volume of calls in the two programs. In looking at these trends, we observed an increase in the diagnostic complexity of the patients who were the focus of these calls during COVID, but there was no change in the clinical severity of these patients. This suggests that in addition to primary care providers needing to take on more of the care of pediatric mental health problems in their practices, they were also dealing with increases in the complexity of these children’s needs. Across both programs, we also observed a specific increase in the number of calls focused on anxiety, depression and disruptive behavior problems. Our findings are consistent with other data showing a rise in ER visits for mental health problems and an increase in the prevalence of anxiety and depression during COVID — and underscores the children’s mental health emergency that was recently announced by the AAP, AACAP and the Children’s Hospital Association. It is both encouraging and disheartening: PMHCA programs are filling a need for pediatric primary care settings, but the need for access to child mental health services is more dire than ever. 

 

2. You recently published a study in Psychiatric Services about the characteristics of the providers who use BHIPP services. Could you talk about the service utilization differences between urban and rural providers?

One thing we found as part of this study was that providers in rural and semi-rural areas were more likely to call BHIPP to obtain clinical consultation with a child and adolescent psychiatrist than providers in urban and suburban areas. This suggests to us that rural providers are more willing to take on the responsibility of providing mental health care in their practices and are willing to obtain more training to get more comfortable in mental health care because they recognize that there are really no other providers that their patients can turn to in the area. On the other hand, providers in urban areas tended to call BHIPP only for resource-referral networking, as they recognize that their patients can more easily access care from mental health specialists.

Recognizing this willingness to assume the mental health care of pediatric patients — together with some other data we collected on limited comfort with certain mental health practices among rural providers — BHIPP launched TeleECHO Clinics, a web-based learning collaborative that uses the Project ECHO framework. Through synchronous virtual learning sessions, these clinics, staffed by BHIPP psychiatrists and psychologists, provide primary care clinicians with a combination of didactic and case-based education to promote their knowledge and comfort with treating pediatric mental health disorders.

3. You also recently published a study in Academic Psychiatry that describes findings from a needs assessment survey conducted with primary care providers in three rural regions of Maryland. Could you walk us through the providers’ comfort in specific mental health practices?

One of the things we looked at through this needs assessment was the provider’s comfort with a range of mental health practices, from asking families about mental health problems to providing mental health care directly in the form of pharmacological and nonpharmacological interventions. We found that the providers’ comfort levels mirrored their training. Many are comfortable with asking families about major life changes or stressors; asking families about mental health problems and using screening tools to identify those problems; and providing referrals to mental health providers. On the other hand, many are not comfortable with providing psychoeducation, prescribing medication or providing in-office mental health interventions.

4. In the same study you published in Academic Psychiatry, many providers voiced concern about long waiting periods for their patients to be seen by both child psychiatrists and child therapists. What are some ways pediatric primary care providers can assist families during the waiting periods?

For noncomplicated cases, the pediatric primary care provider can initiate medication management for ADHD, anxiety and depression. There are also some simple nonpharmacological things that the provider can do while they wait for a specialist, based on the American Academy of Pediatrics guidelines. The provider can meet with the child and family more often to check in and do some psychoeducation with the family about the nature and course of the particular mental health condition. In the case of treating mild to moderate depression, the provider can also work with the child and family to help them implement the strategy of behavioral activation — the notion that doing things that one enjoys can help improve mood. If the provider is willing to take on these interventions, BHIPP can provide training and consultation to support their efforts.

5. How can a child mental health specialist get involved to increase access to care in their area?

Pediatric Mental Health Care Access programs are growing. In fact, Health Resources & Services Association (HRSA) just funded 24 additional PMHCA programs and has a goal of expanding them to every state. Other models of integrated care are also gaining ground. These types of programs and integrated care models are helping to fill the gap between the need for and the availability of pediatric mental health services. If your state doesn’t have a PMHCA program, you could raise the issue with your state’s Department of Health and ask how you could collaborate to help lay the foundation for such a program. Alternatively, you could decide to locate your own practice strategically in under-resourced settings (e.g., rural areas) and collaborate with local primary care providers by offering services, such as: consultations, training, and referrals, which would help increase mental health care services in the area.