Commentary: Integrated Pediatric Primary Care: Moving From Why to How

Real-World Depression Screening Practices Among Primary Care Providers Across Patient-Level and Provider-Level Characteristics

This study examined primary care provider (PCP) alignment with guideline-based care for adolescent depression screening and identified factors associated with post-screening responses. A retrospective chart review was conducted across 17 primary care clinics. Logistical regressions were estimated across provider specialties, sociodemographic factors, and patient clinical histories. Significant differences in follow-up and identification of depression were found among patients with more severe depression presentation. Follow-up screening was also more likely to be completed among patients with private insurance and less likely to occur among Black patients. Patients with significant mental health history of a mood concern, history of being prescribed psychotropic medication, were currently on medications at the time of the screening, or had a history of an internal mental health referral had a higher predicted probability of being identified as depressed on the patient problem list.

Disparities in accessing specialty behavioral health services during the COVID-19 pandemic and why we need pediatric integrated primary care

Objective

Youth unmet behavioral health needs are at public health crisis status and have worsened since the onset of the coronavirus disease 2019 pandemic (Covid-19). Integrating behavioral health services into pediatric primary care has shown efficacy in addressing youth behavioral health needs. However, there is limited guidance on facilitating equitable access to care in this setting, including in triaging access to co-located services (i.e., onsite outpatient behavioral health services with only the behavioral health provider) or to specialty behavioral health services in other clinics within larger health systems.

Methods

A retrospective, comparative study was conducted to examine variability in access to co-located and specialty behavioral health (SBH) services for a pre-Covid-19 cohort (April 2019 to March 2020; n = 367) and a mid-Covid-19 cohort (April 2020 to March 2021; n = 328), while accounting for integrated primary care consultation services. The sample included children 1-18 years old served through a large, inner-city primary care clinic. Logistic regression models were used to examine the association between scheduled and attended co-located and SBH visits, pre- and mid-Covid-19 effects, and sociodemographic factors of race and ethnicity, language, health insurance (SES proxy), age, and sex.

Results

The majority of youth were not directly scheduled for a co-located or SBH visit but the majority of those scheduled attended their visit(s). The odds of not being directly scheduled for a co-located or SBH visit were greater for the mid-Covid-19 cohort, Black youth, and older youth. Accounting for integrated primary care consultation visits addressed these disparities, with the exception of persisting significant differences in scheduled and attended co-located and SBH visits for Black youth even while accounting for IPC consultation.

Implication

Findings from the current study highlight the effective role of integrated primary care consultation services as facilitating access to initial behavioral health services, especially given that referrals to integrated primary care co-located and SBH services within the larger health system often involve barriers to care such as longer wait-times and increased lack of referral follow through. Ongoing research and equitable program development are needed to further this work.

Integrated Behavioral Health Prevention for Infants in Pediatric Primary Care: A Mixed-Methods Pilot Study

OBJECTIVE

Pediatric primary care is a promising setting in which to deliver preventive behavioral health services to young children and their families. Integrated behavioral health care models typically emphasize treatment rather than prevention. This pilot study examined the efficacy of an integrated behavioral health preventive (IBH-P) intervention delivered by psychologists and focused on supporting parenting in low-income mothers of infants as part of well-child visits in the first 6 months of life.

METHODS

Using a mixed-methods approach that included a pilot randomized clinical trial and post-intervention qualitative interviews, 137 mothers were randomly assigned to receive IBH-P or usual care. Self-report measures of parenting, child behavior, and stress were obtained at pre- and/or post-intervention. Direct observation of mother-infant interactions was conducted at post-intervention.

RESULTS

No differences between groups were found on maternal attunement, knowledge of child development, nurturing parenting, or infant behavior. A secondary analysis on a subsample with no prior exposure to IBH-P with older siblings found that mothers in IBH-P reported increased self-efficacy relative to controls. In the qualitative interviews, mothers stated that they valued IBH-P, learning about their baby, liked the integration in primary care, and felt respected and comfortable with their provider.

CONCLUSIONS

Findings are discussed in terms of the next steps in refining IBH-P approaches to prevention in primary care.

Beyond Clinical Care: The Role of Pediatric Psychology in Supporting Postpartum Depression Screening in Primary Care

Maternal health is a critical component of optimal child health and development. Consequently, the American Academy of Pediatrics added postpartum depression (PPD) screening to their psychosocial screening guidelines in 2017. The Healthy Mothers, Healthy Children Project (HMHCP) was an interprofessional initiative aimed at preparing for, then implementing and maintaining pediatrician-completed PPD screening at 1-month well visits in a pediatric primary care clinic. Roles of pediatric psychology and rates of PPD screening were examined. Pediatric psychologists actively participated as leaders and collaborators in a variety of non-clinical roles from HMHCP preparation through maintenance. The clinic achieved high and continuously improving PPD screening rates following HMHCP implementation. Importantly, PPD screening rates were equitable across race and gender. The current study outlines feasible non-clinical roles that pediatric psychologists can fulfill in support of routine PPD screening within pediatric primary care. It also highlights associated benefits and outcomes for the clinic, providers, and patients.

Addressing Suicide Risk in Primary Care: Cost Savings Associated with Diverting Patients From Emergency Departments

INTRODUCTION

Integrating behavioral health into primary care ambulatory clinics can improve management of patients presenting with suicidality in medical practices. To date, financial outcomes associated with managing suicidality in integrated care have not been documented.

OBJECTIVE

This study sought to evaluate both course of treatment (e.g., the patient is discharged home and referred to emergency departments [EDs]) and financial outcomes (e.g., cost to medical center) for patients presenting with suicidality in integrated pediatric primary care.

METHODS

Medical record review was conducted across a 6-month period. Demographics, course of treatment, and financial data were collected. Financial data were extracted using EPSi software using a cost accounting model. We documented the amount in dollars billed to the patient/insurance company and the amount reimbursed to the medical center and then calculated net margins associated with each course of treatment.

RESULTS

Participants were 103 youth (aged 7-24 years). The results demonstrate that the integrated model of care diverted 93% of participants from the ED and that the highlighted model of care yielded cost savings for the medical center. After reimbursement, patients seen in the ED for suicide evaluations cost the medical center an average of 16 times more than patients who were managed in the primary care setting.

CONCLUSION

The results document the magnitude of cost savings associated with an integrated care model for treating high-risk youth.

Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care

STUDY OBJECTIVES

To describe the adaptation, feasibility, and initial outcomes of Sleep Well!, an intervention for early childhood insomnia and insufficient sleep, designed for families from lower-socioeconomic status backgrounds presenting to large metropolitan primary care sites.

METHODS

Fifteen caregiver-child dyads (caregivers: 92.3% mothers, 80.0% Black, 53.3% ≤ 125% US poverty level; children: 73.3% female, 86.7% Black, mean age = 3.0 years) participated in this multimethod, single-arm trial. A family advisory board of caregivers (n = 4) and a clinician advisory board of sleep experts, primary care clinicians, and psychologists (n = 13) provided intervention feedback throughout the pilot. Most adaptations were related to intervention delivery methods, with some related to sleep strategies. At postintervention, caregivers completed surveys on intervention acceptability and cultural humility (primary outcomes) and completed semistructured interviews. Caregivers also reported on child sleep pre- and postintervention.

RESULTS

Thirteen (86.6%) families completed Sleep Well! and 12 (80.0%) completed pre- and postintervention measures. Caregivers reported strong intervention acceptability and cultural humility. There were preintervention to postintervention reductions in child sleep problems, bedroom electronics, sleep onset latency, and night awakening frequency and duration. Nighttime sleep duration and overall insufficient sleep also improved. Qualitative data also showed strong intervention acceptability and perceived flexibility, with few participation barriers.

CONCLUSIONS

A brief, early childhood behavioral sleep intervention delivered in primary care with families from primarily lower-socioeconomic status backgrounds and/or racially minoritized backgrounds is feasible to implement, with strong retention rates, acceptability, and perceptions of cultural humility. Child sleep improvements are positive and warrant replication in a randomized controlled trial.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Implementing Behavioral Sleep Intervention in Urban Primary Care; URL: https://clinicaltrials.gov/ct2/show/NCT04046341; Identifier: NCT04046341.

CITATION

Williamson AA, Okoroji C, Cicalese O, et al. Sleep Well! An adapted behavioral sleep intervention implemented in urban primary care. J Clin Sleep Med. 2022;18(4):1153-1166.

Cross-Cultural Adaptation and Validation of the Brazilian Portuguese Version of an Observational Measure for Parent-Child Responsive Caregiving

Responsive caregiving is the dimension of parenting most consistently related to later child functioning in both developing and developed countries. There is a growing need for efficient, psychometrically sound and culturally appropriate measurement of this construct. This study describes the cross-cultural validation in Brazil of the Responsive Interactions for Learning (RIFL-P) measure, requiring only eight minutes for assessment and coding. The cross-cultural adaptation used a recognized seven-step procedure. The adapted version was applied to a stratified sample of 153 Brazilian mother-child (18 months) dyads. Videos of mother-child interaction were coded using the RIFL-P and a longer gold standard parenting assessment. Mothers completed a survey on child stimulation (18 months) and child outcomes were measured at 24 months. Internal consistency (α = 0.94), inter-rater reliability (r = 0.83), and intra-rater reliability (r = 0.94) were all satisfactory to high. RIFL-P scores were significantly correlated with another measurement of parenting (r's ranged from 0.32 to 0.47, p < 0.001), stimulation markers (r = 0.34, p < 0.01), and children's cognition (r = 0.29, p < 0.001), language (r = 0.28, p < 0.001), and positive behavior (r = 0.17, p < 0.05). The Brazilian Portuguese version is a valid and reliable instrument for a brief assessment of responsive caregiving.

A Systematic Review of External Validity in Pediatric Integrated Primary Care Trials

OBJECTIVE

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct a systematic review of external validity reporting in integrated primary care (IPC) interventions for mental health concerns.

METHODS

We searched Medline, CINAHL, PsycINFO, the Cochrane Center Register of Controlled Trials, and relevant literature to identify publications from 1998 to 2018 reporting on open, randomized, or quasi-randomized trials of IPC interventions that targeted child (ages 0-18 years) psychological symptoms. For each publication, we extracted the information reported in each RE-AIM domain and calculated the proportion of the total studies reviewed.

RESULTS

Thirty-nine publications describing 25 studies were included in the review. Publications rarely reported some indicators of external validity, including the representativeness of participants (12%), rate of adoption clinics or providers (16%), cost of implementation (8%), or evidence of maintenance (16%). Few studies reported on key pragmatic factors such as cost or organizational change processes related to implementation and maintenance. Strengths of some studies included comparisons of multiple active treatments, use of tailorable interventions, and implementation in "real world" settings.

CONCLUSIONS

Although IPC interventions appear efficacious under research conditions, there are significant knowledge gaps regarding the degree to which they reach and engage target recipients, what factors impact adoption and implementation of IPC interventions by clinicians, how fidelity can be maintained over time, and cost-effectiveness. Pediatric IPC researchers should embrace dissemination and implementation science methods to balance internal and external validity concerns moving forward.

Psychologists and Pediatricians in the Primary Care Sandbox: Communication is Key to Cooperative Play

Recent literature, public policy, and funding opportunities call attention to the need for better increased integration of health and mental health care services in primary care settings so as to best meet the needs of children and families. There are many benefits to such integration, but pediatric primary care providers (PCPs) face multiple barriers to identifying and managing patients with mental health difficulties. One way to address this problem is through the integration of psychologists into primary care settings who can collaborate with PCPs to provide integrated behavioral health care to youth and families. However, there are challenges to collaboration, which include differences in training, professional cultures, and expectations held by professionals from various disciplines. Effective communication is a key component in supporting interprofessional collaboration between primary care providers and psychologists working in primary care settings. This paper reviews aspects of pediatric medicine culture, critical components of communication, and strategies to improve communication. Three case examples are presented in which some of these challenges have been successfully addressed. Implications and future directions are discussed.

Comparing Two Models of Integrated Behavioral Health Programs in Pediatric Primary Care

This study examined how to design, staff, and evaluate the feasibility of 2 different models of integrated behavioral health programs in pediatric primary care across primary care sites in the Bronx, NY. Results suggest that the Behavioral Health Integration Program model of pediatric integrated care is feasible and that hiring behavioral health staff with specific training in pediatric, evidence-informed behavioral health treatments may be a critical variable in increasing outcomes such as referral rates, self-reported competency, and satisfaction.

Introduction to the Special Section: Psychology in Integrated Pediatric Primary Care

Interest in providing integrated psychological and medical services in pediatric primary care is growing rapidly. Efforts to incorporate psychological services into primary care settings are leading to new models and innovative approaches to evaluation and treatment in a variety of settings. Presently, there is a need to expand the empirical base for such work and to critically evaluate what is being done. The introduction to this special section discusses some of the background for the development of integrated care, and provides some context for the articles that follow. These articles address issues related to screening in integrated pediatric primary care, the variety of services provided in the context of integrated primary care, and outline the competencies needed for providing high-quality care in such settings. Suggestions for future research directions are provided.