All hands on deck: Strengthening pediatric care through behavioral health integration to save lives

Since 1990, the global suicide rate has declined by nearly a third;1 however, in the United States the number has trended up. The statistics are staggering, particularly for children:

• The overall suicide rate rose 26% between 2007 and 2017. For children 10 to 17, during that period, the rate more than doubled.2

In Utah, the numbers are even more disconcerting:

• Suicide is the leading cause of death for children 10 and older in the state.3
• The state had the fifth-highest suicide rate in the country in 2017 for children 10 and older.4
• The youth suicide rate has more than tripled in Utah over the last decade.5

Suicide is often tied to an adverse childhood experience (ACE). According to the Centers for Disease Control and Prevention (CDC), an ACE involves “abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18.” Examples include emotional, physical and sexual abuse; physical or emotional neglect; and substance abuse, mental illness or divorce in the household. These traumatic experiences can have “negative, lasting effects on health and well-being in childhood or later in life.”6

As documented in a 2016 National Survey of Children’s Health (NSCH) study, 45% of U.S. children experience at least one ACE during their childhood.7 Consequently, combatting the effects of ACEs from an early age is important to mitigate future chronic health problems.

“These negative effects are perpetuated and magnified through the generations,” Kathy Ostler, MD, board president and physician partner, Wasatch Pediatrics, Salt Lake City, Utah, conveyed at MGMA19 | The Operations Conference, in Austin, Texas. “Like many problems in healthcare development, early intervention is critical.”

A key way for practices to do so is to employ behavioral health integration to ensure comprehensive support for patients and their parents. For Wasatch Pediatrics, which has approximately 60 providers in eight clinics, the key to its success was integrating behavioral health clinicians with primary care providers to work collaboratively with patients and families.

As Mark Davis, MHSA, FACMPE, chief executive officer, related, Wasatch is independent and physician owned and has no interest in delving into subspecialty pediatrics. However, “the one exception has been behavioral health, because as pediatricians like to say, ‘that’s part of our practice now ... behavioral health is a big part of what we do,’” Davis said.

A path to behavioral health integration

The genesis of Wasatch Pediatrics’ behavioral health integration journey began about six years ago when the practice was approached by a child psychologist/physician assistant, who was both a licensed therapist and a licensed medical provider. Ultimately, two of the clinics decided to invest in this individual.

“Almost immediately he was completely booked up for months,” Davis remarked, as the child psychologist/physician assistant handled internal referrals for such issues as ADHD, anxiety, depression and autism. “The problem was that demand was more than we could supply.”

After a year or two, Wasatch Pediatrics was able to hire nurse practitioners who were trained by the child psychologist/physician assistant in behavioral health, as well as a couple psychology externs from the local university to help provide therapy. Recognizing how valuable this care was to patients, Wasatch created a behavioral health committee composed of physicians on the board, other providers and staff members to decide how best to further expand services.

“What they decided was that we would hire a behavioral health director,” Davis said. “Someone who would be with us full time in the administration office and who could help us decide where we would want to go.”

The director — Dan Braun, LCSW — emphasized a patient-focused, team-first integrative care model, which can be very cost-effective for practices. “Some of the initial reports on pediatrics say that when we are doing this in the medical office, we’re actually saving juvenile justice, the schools — we’re saving those areas quite a bit of money because they aren’t having to provide all of these services,” Braun contended.

Integrated care models

There are three primary models in integrative behavioral health care: facilitated referral, co-location and full integration. Each has advantages and disadvantages, but all aim to provide patient-centered care for a defined population.

Facilitated referral

A good place for practices, particularly smaller ones, to start is with facilitated referral, which focuses on behavioral health screenings in a primary care setting and then facilitates referral to a specialty behavioral health setting. To share expertise and perspective, the emphasis is on coordination of care, which includes medical home duties, a Community Resource Database (CRD) and community collaboration.

According to Braun, this interaction with community partners improves visibility. “Part of my role is to go to the five counties we work in, meet as
many of the behavioral health providers as possible, then find out specific information about their practices and have that personal relationship with them,” Braun stated.

As Braun articulated, studies show that the referral follow-through rate in specialty care behavioral health is typically less than 30%, so any number above that mark would put a practice in a very good place.

Co-location

Co-location is the next step in moving toward full integration. In this model, behavioral health practitioners and primary care physicians work separately at the same location. In general, they see patients with less serious behavioral health conditions and provide traditional private practice therapy services. In addition, clinicians may work for the same or different organizations.

“They do things in the traditional behavioral health way; they see people for the duration typical in a private practice behavioral health set up or even a community behavioral health location,” Braun explained. “All of the services look incredibly similar if they were going outside your walls to specialty behavioral health, except they are inside your walls.”

Full integration

When there’s no longer a distinction between behavioral health and medical health, you have full integration. In this model, primary and behavioral health services such as brief consultations and interventions are part of the clinic flow.

“The lines have blurred; we’re both cross-trained and support each other. It’s a team-based effort,” Braun said of full integration. “It might be that they never see the behavioral health person because they are able to pass on information to the providers to support them.”

This type of care includes facilitated communication, fully shared charts and warm handoffs. On average, therapy is shorter and for patients on community behavioral health waiting lists.

Fully integrated preventive care

Full integration lends itself well to preventive care, which has become the cornerstone of pediatrics. “Now my job is to make kids the absolute healthiest they can be before going into adulthood,” Ostler affirmed.

One of the most important aspects is to be proactive in addressing mental health at an early age, and a fully integrated model makes this approach much easier.

“As we work to get to full integration, nothing has been as successful as suicide prevention,” Braun maintained. “Everyone gets around it; the lines are totally blurred at that point — what’s physical, what’s behavioral health. It’s just children’s safety and making sure their wellness is number one.”

From the front desk to medical assistants to clinicians, everyone at Wasatch Pediatrics has been trained in suicide prevention.

The importance of this is reflected in sobering data related to patients and primary care visits. Referring to research conducted by the Education Development Center (EDC), Braun stated that approximately half of patients who commit suicide saw a general practitioner during the prior month. In addition, 30% had seen a mental health practitioner during the last 30 days, and 10% visited an emergency department in the last 60 days before they died by suicide.8

To help identify suicide risk, gauge the gravity and immediacy of that risk, and determine the level of support a child needs, Wasatch Pediatrics adopted the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment. “If you’re a good neighbor, you’re going to ask when you see warning signs in your best friend,” Braun said. … “Same thing with us in the office; it doesn’t have to be just the doctor who is doing this.”

Beyond the C-SSRS, Wasatch Pediatrics employs many tools to help prevent suicide, including suicide interventions, such as behavioral health referrals, same-day behavioral health evaluation and immediate suicide precautions; providing suicide prevention handouts, including information on behavioral health crisis contacts; and phone triage.

As Braun stressed, both family and friends and clinicians can play an important role in suicide prevention: “I call what we can all do ‘screening’ and I call a clinical issue that needs to be addressed by someone who has more expertise in behavioral health an ‘assessment.’”

Whether providing screening or an assessment, behavioral health integration can go a long way in helping to identify at-risk patients and ultimately improve patient outcomes. “I believe 100% that we save lives … whether they tell you or not, it’s happened,” Braun asserted. 

Notes:

1. “Global, regional, and national burden of suicide mortality 1990 to 2016: Systematic analysis for the Global Burden of Disease Study 2016.” BMJ 2019; 364:l94. Available from: bit.ly/2SuC77P.
2. U.S. Centers for Disease Control and Prevention (CDC), Web-based Injury Statistics Query and Reporting System (WISQARS), fatal injury data, 1999-2017. Available from: bit.ly/2DNldVH.
3. Ibid.
4. Ibid.
5. Ibid.
6. Felitti VJ, et al. “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.” Am J Prev Med. 1998. May;14(4):245-258.
7. Sacks V, Murphey D. ”The prevalence of adverse childhood experiences, nationally, by state, and by race or ethnicity.” Child Trends. Available from: bit.ly/2lJRCpO.
8. “Can Suicide Be a Never Event?” Zero Suicide in Health and Behavioral Health Care. Education Development Center (EDC). 2015.