The medical home and integrated behavioral health: advancing the policy agenda

Parents' Preferences for Primary Care-Based Behavioral Services and the COVID-19 Pandemic: A Mixed Method Study

OBJECTIVE

This study examined how family factors impacted parents' attitudes toward integrated behavioral health (IBH) in pediatric primary care during the COVID-19 pandemic. We hypothesized that COVID-19 impact would predict family functioning challenges, and that pre-existing familial contextual factors would predict parents' interest in IBH modalities.

METHODS

Parents of children ages 1.5-5 years (N = 301) from five primary care clinics completed a survey with measures assessing familial contextual factors (income, race and ethnicity, and parents' childhood adversity), COVID-19 impact on family relationships and wellbeing, family functioning (child behavior, parenting self-efficacy, and parent psychological functioning), and parents' preferences for behavioral support in primary care. A subsample of parents (n = 23) completed qualitative interviews to provide deeper insights into quantitative relationships.

RESULTS

Higher COVID-19 impact was significantly associated with worse parent mental health and child behavior problems, as well as lower interest in IBH virtual support options. Overall, lower SES and racial and/or ethnic minority parents both indicated greater interest in IBH modalities compared to higher SES and White parents, respectively. Qualitative interviews identified how pandemic stressors led to increases in parents' desire for behavioral support from pediatricians, with parents sharing perspectives on the nature of support they desired, including proactive communication from providers and variety and flexibility in the behavioral supports offered.

CONCLUSIONS

Findings have important implications for the provision of behavioral supports for families in primary care, underlying the need to increase parents' access to IBH services by proactively providing evidence-based resources and continuing to offer telehealth support.

Using Quality Improvement to Design Early Childhood Services Navigation in Primary Care

Enrollment in high-quality early childhood education (ECE) improves educational and health outcomes and can mitigate racial and economic disparities. Pediatricians are encouraged to promote ECE yet lack the time and knowledge to assist families effectively. In 2016, our academic primary care center hired an ECE Navigator to promote ECE and help families enroll. Our SMART aims were to increase the number of children with facilitated referrals to high-quality ECE programs from 0 to 15 per month and to confirm enrollment on a subset to achieve an enrollment rate of 50% by December 31, 2020.

Methods

We used the Institute for Healthcare Improvement's Model for Improvement. Interventions included system changes in partnership with ECE agencies (eg, interactive map of subsidized preschool options, streamlined enrollment forms), case management with families, and population-based approaches to understand families' needs and the program's overall impact. We plotted the number of monthly facilitated referrals and the percentage of referrals enrolled on run and control charts. We used standard probability-based rules to identify special causes.

Results

Facilitated referrals increased from 0 to 29 per month and remained above 15. The percentage of enrolled referrals increased from 30% to 74% in 2018, then decreased to 27% in 2020 when childcare availability declined during the pandemic.

Conclusions

Our innovative ECE partnership improved access to high-quality ECE. Interventions could be adopted in part or whole by other clinical practices or WIC offices to equitably improve early childhood experiences for low-income families and racial minorities.

The Medical Home and Mental Health Services in Children and Youth with Special Health Care Needs

BACKGROUND AND OBJECTIVES

Children and youth with special health care needs (CYSHCN) commonly experience mental health concerns, but conditions are often not identified or treated within primary care. Mental health care is often not a primary focus of pediatric primary care, but the medical home model has potential to address these concerns more adequately. The purpose of this study is to examine the relationship between the medical home and use of mental health services in CYSHCN.

METHODS

Data came from the Medical Expenditure Panel Survey years 2015-2017, a nationally representative survey of health and healthcare in US families. The study included CYSHCN ages 6-17. We compared the use of mental health services, expenditures, and psychotropic medications across CYSHCN with and without a medical home using multivariable regression.

RESULTS

45% of CYSHCN received care within a medical home. CYSHCN with and without a medical home reported similar frequency of office-based mental health visits (21.2% versus 25.2%), average expenditures for visits ($147 versus $128), and psychotropic medications (11.9% versus 15.1%). Medical home status was not associated with office-based mental health visits, use of psychotropic medications, or cost for either.

CONCLUSIONS

CYSHCN with mental health care needs face barriers to satisfactory care. Creating better connections between primary and mental health care could help to ameliorate this problem. Findings suggest the medical home, a more comprehensive primary care model, may not address mental health care needs of CYSHCN.

The Medical Home and Use of Mental and Non-mental Specialty Services Among Children with Autism Spectrum Disorder (ASD)

This study assessed the relationship between the medical home and use of health services among children with autism spectrum disorder (ASD). Data from 2016 to 2018 National Survey of Children's Health was analyzed. Outcome measures were receipt of mental and non-mental specialty care, difficulty receiving needed mental and non-mental specialty care and unmet need for mental care. Having a medical home was associated with significantly lower odds of having unmet mental health need for children with ASD ages 11-17 (OR 0.14, 95% CI 0.07-0.30) but not for those ages 3-10 (OR 0.54, 95% CI 0.21-1.43). Having a medical home was also associated with lower odds of difficulty getting needed mental health care (OR 0.38, 95% CI 0.22-0.66) as well as non-mental specialty care (OR 0.24, 95% CI 0.13-0.44).

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.

METHOD

A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.

RESULTS

The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.

CONCLUSION

Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.

Disparities in Pediatric Mental and Behavioral Health Conditions

Mental and behavioral health conditions are common among children and adolescents in the United States. The purpose of this state-of the-art review article is to describe inequities in mental and behavioral health care access and outcomes for children and adolescents, characterize mechanisms behind the inequities, and discuss strategies to decrease them. Understanding the mechanisms underlying these inequities is essential to inform strategies to mitigate these health disparities. Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional. Children and adolescents in racial, ethnic, sexual, sex, and other minority groups experience inequities in access to care and disparities in outcomes for mental and behavioral health conditions. Suicide rates are nearly twice as high in Black compared to White boys 5 to 11 years old and have been increasing disproportionately among adolescent Black girls 12 to 17 years old. Children identifying as a sexual minority have >3 times increased odds of attempting suicide compared to heterosexual peers. Adverse experiences of children living as part of a minority group, including racism and discrimination, have immediate and lasting effects on mental health. Poverty and an uneven geographic distribution of resources also contribute to inequities in access and disparities in outcomes for mental and behavioral health conditions. Strategies to address inequities in mental and behavioral health among United States children include investing in a diverse workforce of mental health professionals, improving access to school-based services, ensuring equitable access to telehealth, and conducting quality improvement with rigorous attention to equity.

Paediatric integrated care in the primary care setting: A scoping review of populations served, models used and outcomes measured

BACKGROUND

Paediatric integrated care (PIC), which involves primary care and behavioural health clinicians working together with patients and families, has been promoted as a best practice in the provision of care. In this context, behavioural health includes behavioural elements in the care of mental health and substance abuse conditions, chronic illness and physical symptoms associated with stress, and addressing health behaviours. Models of and contexts in which PIC has been applied vary, as do the outcomes and measures used to determine its value. Thus, this study seeks to better understand (1) what paediatric subpopulations are receiving integrated care, (2) which models of PIC are being studied, (3) what PIC outcomes are being explored and what measures and strategies are being used to assess those outcomes, and (4) whether the various models are resulting in positive outcomes. These questions have significant policy and clinical implications, given current national- and state-level efforts aimed at promoting integrated health care.

METHODS

This study utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews to identify relevant articles published between January 1994 and 30 June 2020. The search utilized three databases: PubMed, PsycInfo and CINAHL. A total of 28 articles met the eligibility criteria for inclusion.

RESULTS

Overall, acceptability of PIC appears to be high for patients and providers, with access, screening and engagement generally increasing. However, several gaps in the knowledge base on PIC were uncovered, and for some studies, ascertaining which models of integrated care were being implemented proved difficult.

CONCLUSION

PIC has the potential to improve access to and quality of behavioural health care, but more research is needed to understand what models of PIC prove most beneficial and which policies and conditions promote cost efficiency. Rigorous evaluation of patient outcomes, provider training, institutional buy-in and system-level changes are needed.

Association of Behavioral and Mental Health Professionals in Continuity Clinic with Resident-Reported Competence

OBJECTIVE

To assess whether residents who trained with a colocated or integrated behavioral/mental health professional (B/MHP) reported greater competence in the assessment and management of behavioral/mental health (B/MH) conditions than those who trained without an onsite B/MHP. We hypothesized that having an onsite B/MHP would be associated with greater self-reported competence, especially if integrated into clinic.

STUDY DESIGN

Cross-sectional survey of applicants for the initial American Board of Pediatrics (ABP) certifying examination. The independent variable was training in a continuity clinic with no onsite B/MHP, a colocated B/MHP, or an integrated B/MHP. Outcome variables were self-reported competence in 7 B/MH assessment skills and 9 treatment skills, summarized as 2 composite measures. Competence was rated on a 5-point scale; high competence was defined as mean scores ≥4. Logistic regression assessed relationships between independent and outcome variables adjusting for covariates including individual and residency program characteristics.

RESULTS

Of 1503 eligible respondents, 645 (42.9%) reported no onsite B/MHP, 390 (26.0%) a colocated B/MHP, and 468 (31.1%) an integrated B/MHP. In multivariable models, respondents with a colocated B/MHP reported greater levels of B/MH assessment competence (aOR 1.40, 95% CI1.06-1.86) and treatment competence (aOR 1.45, 95% CI 1.03-2.05) compared with those with no B/MHP. Respondents with an integrated B/MHP similarly reported greater odds of assessment (aOR 1.33, 95%CI 1.02-1.74) and treatment competence (aOR 1.53, 95% CI 1.10-2.13) than the reference group.

CONCLUSIONS

Although specific mechanisms were not tested, training with an onsite B/MHP within a continuity clinic may improve pediatric trainees' competence for addressing B/MH conditions.

Addressing Pediatric Developmental and Mental Health in Primary Care Using Tele-Education

This study evaluates the effectiveness of an early childhood tele-education program in preparing community pediatric clinicians to manage developmental and mental health disorders in young children. Community pediatric clinicians from rural, underserved, or school-based health center practices in the mid-Atlantic region participated in a weekly tele-education videoconference. There was a significant knowledge gain evidenced by the percentage of questions answered correctly from pre- to post- didactic exposure (P < .001). Participants reported an increase in knowledge from pre- (P < .001) and in confidence from pre- to post- participation (P < .001). Practice management changes demonstrated an encouraging trend toward managing patients in the Medical Home, as compared with immediately deferring to specialists following participation. This early childhood tele-education videoconferencing program is a promising response to the urgent need to confidently increase the role of pediatricians in the provision of care for childhood developmental and mental health disorders.

Trends and Disparities in Treatment for Co-occurring Major Depression and Substance Use Disorders Among US Adolescents From 2011 to 2019

IMPORTANCE

Major depression and substance use disorders (SUD) commonly co-occur among adolescents, yet little is known about treatment use among adolescents with both conditions. Given the reciprocal influence of these conditions on each other and low prevalence of treatment overall, current information on quantification and trends in treatment of co-occurring depression and SUD is critical toward assessing how the field is performing in reaching youth in need of these services, and among youth with sociodemographic risk factors.

OBJECTIVE

To examine temporal trends and sociodemographic disparities in the treatment of co-occurring major depression and SUD among US adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used publicly available data for adolescents aged 12 to 17 years from the annual cross-sectional surveys of the National Survey on Drug Use and Health from 2011 to 2019 to assess co-occurrence of major depressive episodes (MDE) and SUD through time and prevalence of treatment for either or both of these conditions. Data were analyzed between October 2020 and February 2021.

EXPOSURES

Survey years, adolescent age, gender, race and ethnicity, type of insurance, annual household income, family structure, and residential stability.

MAIN OUTCOMES AND MEASURES

Presence and treatment of co-occurring 12-month MDE and SUD.

RESULTS

In total, 136 262 adolescents participated in the 2011 to 2019 surveys, among whom 69 584 (51.1%) were boys and 66 678 (49.0%) were girls, 46 548 (34.1%) were aged 16 to 17 years, and 18 173 (13.8%) were Black, 28 687 (23.2%) were Hispanic, and 74 512 (53.6%) were White. From 2011 to 2019, the annual prevalence of co-occurring MDE and SUD remained stable, at between 1.4% and 1.7%. Among adolescents with co-occurring MDE and SUD, the prevalence of treatment use for MDE only increased significantly from 28.5% in 2011 to 42.5% in 2019 (odds ratio [OR], 1.07; 95% CI, 1.02-1.11; P = .005), whereas the prevalence of treatment use for SUD only decreased from 4.8% to 1.5% (OR, 0.92; 95% CI, 0.85-0.99; P = .04). Overall, the prevalence of treatment use for both conditions fluctuated between 4.5% and 11.6%, without a significant linear trend over time (OR, 0.95; 95% CI, 0.87-1.03; P = .24). Extensive disparities in treatment use were found among boys for SUD and both conditions, older adolescents for MDE, Hispanic adolescents for co-occurring conditions (adjusted OR, 0.52; 95% CI, 0.27-0.98; P = .04), and Asian, Native Hawaiian, or Pacific Islander adolescents for MDE (adjusted OR, 0.24; 95% CI, 0.10-0.58; P = .002) and co-occurring conditions (adjusted OR, 0.04; 95% CI, 0.01-0.33; P = .003). Moving households 3 or more times in the past 12 months was associated with higher odds that adolescents received treatment for both conditions (adjusted OR, 2.52; 95% CI, 1.26-5.05; P = .009).

CONCLUSIONS AND RELEVANCE

This survey study found that from 2011 to 2019, less than 12% of adolescents with major depression and SUD received treatment for both conditions from 2011 to 2019. Findings from this study call for expanded service provision for adolescents with co-occurring conditions, improved coordination between service delivery systems, and enhanced policy and funding support for adolescents with unmet treatment needs.

Child Psychiatrists and Psychologists: Enhanced Collaboration in Primary Care

Psychiatry and psychology have a long history of competition that too often interferes with the collaboration that can characterize complementary contributions to our common missions. We hope this article will inspire our disciplines to expand on this collaboration, for the sake of our children and families, our communities, our colleagues, and honestly, ourselves. We are better together than apart. This text is a blueprint for the assumptions, attitudes, skills, and advocacy that can make this partnership healthy and successful.

The Behavioral Health Consultant: Roles and Responsibilities

With the scarcity of mental health services, integration of behavioral health into pediatric primary care increases the accessibility and availability to mental health services to a broad range of patients and their families while bridging the gap of physical and mental health. Encouraging whole-person care, the role of the behavioral health consultant serves as a proactive and preventative means fostering early intervention and detection, as 50% of all lifetime mental health disorders begin by the age of 14 years.

Prolonged Emergency Department Length of Stay for US Pediatric Mental Health Visits (2005-2015)

BACKGROUND AND OBJECTIVES

Children seeking care in the emergency department (ED) for mental health conditions are at risk for prolonged length of stay (LOS). A more contemporary description of trends and visit characteristics associated with prolonged ED LOS at the national level is lacking in the literature. Our objectives were to (1) compare LOS trends for pediatric mental health versus non-mental health ED visits and (2) explore patient-level characteristics associated with prolonged LOS for mental health ED visits.

METHODS

We conducted an observational analysis of ED visits among children 6 to 17 years of age using the National Hospital Ambulatory Medical Care Survey (2005-2015). We assessed trends in rates of prolonged LOS and the association between prolonged LOS and demographic and clinical characteristics (race and ethnicity, payer type, and presence of a concurrent physical health diagnosis) using descriptive statistics and survey-weighted logistic regression.

RESULTS

From 2005 to 2015, rates of prolonged LOS for pediatric mental health ED visits increased over time from 16.3% to 24.6% (LOS >6 hours) and 5.3% to 12.7% (LOS >12 hours), in contrast to non-mental health visits for which LOS remained stable. For mental health visits, Hispanic ethnicity was associated with an almost threefold odds of LOS >12 hours (odds ratio 2.74; 95% confidence interval 1.69-4.44); there was no difference in LOS by payer type.

CONCLUSIONS

The substantial rise in prolonged LOS for mental health ED visits and disparity for Hispanic children suggest worsening and inequitable access to definitive pediatric mental health care. Policy makers and health systems should work to provide equitable and timely access to pediatric mental health care.

Developing a Structure of Essential Services for a Child and Adolescent Mental Health System

Policy Points That child and adolescent mental health services needs are frequently unmet has been known for many decades, yet few systemic solutions have been sought and fewer have been implemented at scale. Key among the barriers to improving child and adolescent mental health services has been the lack of well-organized primary mental health care. Such care is a mutual but uncoordinated responsibility of multiple disciplines and agencies. Achieving consensus on the essential structures and processes of mental health services is a feasible first step toward creating an organized system.

Timing of Co-occurring Chronic Conditions in Children With Neurologic Impairment

BACKGROUND

Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI.

METHODS

This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity.

RESULTS

The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7-3.8), 4.6 (95% CI 4.5-4.7), and 5.1 (95% CI 5.1-5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years.

CONCLUSIONS

Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Pediatric Refugee Health Care Delivery in the Community Setting: An Educational Workshop for Multidisciplinary Family-Centered Care During Resettlement

INTRODUCTION

With 70.8 million people displaced worldwide, there is an increasing need for medical professionals to provide medical care to refugees. Insufficient training on refugee health poses a barrier to effective care delivery.

METHODS

This workshop addressed common challenges in providing family-centered pediatric refugee care in community settings as well as barriers related to policy changes. Presentations covered prearrival experiences, medical screening, and trauma-based care. In small groups, participants discussed cases that featured medical, behavioral health, social, and cultural factors impacting the provision of family-centered pediatric care that was culturally respectful and included shared decision-making. After the breakout session, each small group informed the larger group of topics discussed. Facilitators identified themes and reinforced key learning points. At the workshop's conclusion, participants were guided to create their own personalized action plan.

RESULTS

This workshop was presented at two international conferences to more than 47 participants, including clinicians, nurse practitioners, pediatric residents, and medical students. Evaluations were completed by 34 individuals. Participants' overall comfort level with taking care of refugee patients increased from 3.3 to 4.0 (on a 5-point scale, p = .24) during the 3-hour version of the workshop and from 3.8 to 4.0 (p = .43) in the 1-hour version of the workshop. Mean overall ratings of the 3- and 1-hour workshop versions on conference-administered evaluations were 4.8 and 4.2, respectively, on a 5-point scale.

DISCUSSIONS

This workshop was well received and equipped participants with knowledge, tools, and strategies regarding pediatric refugee health in a community setting.

A Systematic Review of the Methods Used to Evaluate Child Psychiatry Access Programs

BACKGROUND

There is a well-documented gap between the need for and availability of mental health services for children nationwide. To address this gap, over 30 regional Child Psychiatry Access Programs (CPAPs) provide psychiatric consultation and other services to primary care providers.

OBJECTIVE

Summarize the methods used to evaluate CPAPs in the United States.

DATA SOURCES

PubMed, PsychInfo, CINAHL, and reference checking.

STUDY APPRAISAL METHODS

A systematic literature review was conducted searching 3 databases. The search produced 307 unique articles, 278 were excluded for irrelevance, leaving 29 for data extraction. Data extracted included author(s), publication year, provider types, CPAP formats, study sample, design, outcomes examined, results, and limitations. Articles were also appraised for quality using the Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide.

RESULTS

The 29 articles evaluated 13 unique CPAPs. Most evaluations used nonexperimental observational designs (68.9%), 6.9% used quasi-experimental designs, and none used true experimental designs. Evaluations examined the following outcomes: usage of program services (82.8%), provider satisfaction (48.3%), provider comfort/confidence with managing mental health concerns (31.0%), provider practice change (24.1%), patient outcomes (13.7%), and family satisfaction (6.9%). Outcomes were measured using surveys, qualitative interviews, or insurance claims data.

LIMITATIONS

Review was limited to articles published in English in 3 databases or identified by reference checking.

CONCLUSIONS

Evaluations of CPAPs have largely been descriptive in nature, focusing primarily on program usage and provider satisfaction. Few studies have examined the impact of CPAPs on patients, families, or health systems. Future studies should evaluate the broader impacts of CPAPs.

Treatment for Adolescent Depression: National Patterns, Temporal Trends, and Factors Related to Service Use Across Settings

PURPOSE

Untreated major depression can lead to various negative health and social consequences among adolescents. This study aimed to examine national patterns, temporal trends, and factors related to U.S. adolescents' mental health service use for 12-month major depression across service settings.

METHODS

Data on adolescents aged 12-17 years who received treatment for their 12-month major depression were drawn from the National Survey on Drug Use and Health, 2011-2018. Patterns, trends, and factors related to adolescents' service use in specialty mental health, educational, and general medical settings and multiple settings were examined using bivariate and multivariate logistic regression.

RESULTS

Across the survey years, service use in specialty mental health settings was the most common, followed by educational and general medical settings. A significant increase was observed in adolescents' specialty mental health service use (p < .001) over time, whereas the rates of service use in educational and general medical settings remained stable. Approximately 40% of adolescents who were treated for 12-month depression received services in multiple settings each year, with no significant change over time. Among multisetting service users, combined service use in specialty mental health and educational settings was the most common. Adolescents' age, race, gender, insurance status, family income, and school experiences significantly influenced their service use across settings.

CONCLUSIONS

Continued efforts are needed to improve service provision for adolescents with depression, especially in educational and general medical settings. Strengthened funding and policy support are warranted to expand safety-net mental health services for uninsured, low-income, and racial/ethnic minority adolescents.

A Case Study of Implementing Grant-Funded Integrated Care in a Community Mental Health Center

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care

BACKGROUND

Drug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings.

METHODS

This cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12-17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites.

RESULTS

Approximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005).

DISCUSSION

Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Primary care provider utilization and satisfaction with a health system navigation program for adolescents with behavioral health needs

Approximately 49.5% of the adolescents report a mental health disorder; only about half of the children and adolescents with mental health disorders seek treatment from a mental health professional. Stigma and poor access to behavioral health providers are leading barriers to care. A large ambulatory health system implemented a BH navigation program to facilitate referrals from primary care physicians (PCPs), including pediatricians and family physicians, to BH providers. We studied PCP adoption of BH navigation services over a 4-year period, from July 2014 to June 2018. We retrieved operational data regarding service utilization, patient information from electronic health records and PCP information from administrative data, and surveyed PCPs for their appraisals of navigation services. Four thousand five hundred and fifty-five referrals were made for 3,912 patients from 290 PCPs (71% of PCPs in the health system). Depression (39%), anxiety (25%), and attention-deficit hyperactivity disorder (7%) were the most frequent reasons for referral. Referrals increased dramatically in the first half of the study period and decreased afterwards. Ninety-one percent of the PCPs agreed or strongly agreed that navigation enhanced their clinical care at 12-month survey. More than 90% of the PCPs rated the referral process, communication with navigation staff, and the overall experience as above average or excellent at 12 months. There was a decrease in these evaluation indicators after 2.5 years. The initial high referral volume reflects a need for BH navigation services. However, challenges remain to maintain positive PCP assessment in the face of such demand.

Nurse-Led Forensic Services for Foreign-Born Torture or Abuse Survivors Seeking Legal Immigration Relief: Results of a Feasibility and Acceptability Study

BACKGROUND

In 2017, a team of forensic nurses in Maryland launched the first known nurse-led and managed service delivery program designed to meet the unique medicoforensic needs of immigrant survivors, including asylum seekers, in their community. The expanded suite of services involved conducting forensic physical evaluations, which included medicolegal history-taking, head-to-toe forensic physical assessment, photodocumentation, and presentation of related findings in the form of written affidavits for use in applications for legal reliefs in immigration court (e.g., asylum, T or U visas, Convention Against Torture).

METHODS

Case-based data for patients served as part of the program (n = 8), and semistructured interview data were collected from key service delivery stakeholders (n = 5) to assess the feasibility and acceptability of this pilot program.

RESULTS

Eight asylum-seeking patients received medicoforensic nursing services between May 2017 and December 2018. Key benefits of services to clients included accessibility to timely, trauma-informed care by a professional nurse at no cost and with flexible scheduling. Furthermore, the skill sets required to conduct forensic physical evaluations were found to align with sexual assault and forensic nursing scope of practice.

CONCLUSION

Forensic nurses are well positioned to fill current service delivery gaps to meet the medicolegal needs of this vulnerable population in civil court proceedings. Recommendations of this study may be used by other forensic nurse teams to inform the design and implementation of initiatives to expand the core services of a forensic nursing program to include asylum and immigration-specific medicolegal care.

The effects of integrating behavioral health into primary care for low-income children

OBJECTIVE

To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs.

DATA SOURCES

2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan.

STUDY DESIGN

We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis.

PRINCIPAL FINDINGS

After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost.

CONCLUSIONS

Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.

Advancing the Agenda in Pediatric Mental Health Education

BACKGROUND AND OBJECTIVES

There is an urgent need to advance mental health (MH) education and/or training in pediatric residency programs, yet no consensus on how to achieve this. We created an operational framework from ideas provided by a diverse group of stakeholders on how to advance MH education.

METHODS

Concept-mapping methodology was used, which involves brainstorming ideas by completing a focus prompt, sorting ideas into groups, and rating them for importance and feasibility. Multidimensional scaling and hierarchical cluster analysis grouped ideas into clusters. Average importance and feasibility were calculated for each statement and cluster and compared statistically in each cluster and between subgroups.

RESULTS

Ninety-nine ideas were generated. Sorted ideas yielded a 7-cluster concept map: (1) modalities for MH training, (2) prioritization of MH, (3) systems-based practice, (4) self-awareness and/or relationship building, (5) training in clinical assessment of patients, (6) training in treatment, and (7) diagnosis-specific skills. Two hundred and sixteen participants rated ideas for importance and 209 for feasibility. Four clusters had a statistically significant difference between their importance and feasibility ratings (P < .001). Suburban and rural area respondents (versus urban) rated clusters higher in importance and feasibility (P < .004), trainees rated all clusters higher in feasibility than practicing clinicians, and MH professionals rated prioritization of MH higher in feasibility (3.42 vs 2.98; P < .001).

CONCLUSIONS

This comprehensive set of ideas, especially those rated highly in both importance and feasibility, should inform curricular and policy initiatives. Differences between importance and feasibility may explain why there has been little progress in this field.

Clinical Tools Working at Home with Immigrants and Refugees

At a time of evolving demographics and turbulent policy changes, pediatric providers have a critical role in the care of all children, regardless of where the child or parent was born. Pediatric providers can facilitate access to high-quality care and critical community-based resources for immigrant children and families. In this article, we delineate the primary domains for clinical care and offer clinical tools to achieve the provision of accessible, comprehensive, high-quality care within a family-centered medical home.

Interdisciplinary Perspectives on an Integrated Behavioral Health Model of Psychiatry in Pediatric Primary Care: A Community-Based Participatory Research Study

Integrated behavioral health services have positive outcomes for patients and providers, but little is known about providers' perspectives on implementing these services. This community-based participatory research collaboration with a Federally Qualified Health Center examined provider perspectives on implementing a collaborative psychiatry consultation program in pediatric primary care. We interviewed providers (N = 14) from psychiatry, social work, primary care, and psychology regarding their experiences implementing the program, and their recommendations for its sustainability. Providers described interdisciplinary integration arising from the program, with accompanying benefits (e.g., increased access to care for patients with complex diagnostic profiles, increased learning and role satisfaction among providers), and challenges (e.g., increased burden on primary care providers, potential patient discomfort with team-based care). Our results highlight the complexities of implementing collaborative psychiatry consultation in pediatric primary care, and suggest the importance of supporting primary care providers and patients within this context.

The Primary Care Behavioral Health (PCBH) Model: An Overview and Operational Definition

The Primary Care Behavioral Health (PCBH) model is a prominent approach to the integration of behavioral health services into primary care settings. Implementation of the PCBH model has grown over the past two decades, yet research and training efforts have been slowed by inconsistent terminology and lack of a concise, operationalized definition of the model and its key components. This article provides the first concise operationalized definition of the PCBH model, developed from examination of multiple published resources and consultation with nationally recognized PCBH model experts. The definition frames the model as a team-based approach to managing biopsychosocial issues that present in primary care, with the over-arching goal of improving primary care in general. The article provides a description of the key components and strategies used in the model, the rationale for those strategies, a brief comparison of this model to other integration approaches, a focused summary of PCBH model outcomes, and an overview of common challenges to implementing the model.

I Get By With A Little Help From My Friends: Models of Psychological Intervention in Pediatric Primary Care

The pediatric primary care setting is ideal for addressing children's and adolescents' mental health needs. As a result of extensive training in health promotion, consultation, assessment, and treatment of psychological disorders, psychologists are uniquely positioned to support primary care pediatricians in this endeavor. This paper provides a review of models of psychology interventions in pediatric primary care including: care delivery, scope of practice, implementation and recent research. It concludes with a case example and recommendations.

Pediatric integrated behavioral health service delivery models: Using a federal framework to assess levels of integration

OBJECTIVE

To assess the level of integration of pediatric integrated behavioral health service delivery models (IBHSDM) since it has not been well established.

DATA SOURCES

A systematic review of journal databases (e.g., PubMed) and Google searches was used to identify publications.

STUDY SELECTION

Studies were included if they examined children who were treated in an IBHSDM.

DATA EXTRACTION

The authors extracted data from studies and assessed them for level of integration using a federal conceptual framework.

DATA SYNTHESIS

Guided by PRISMA standards, the authors identified 40 journal articles that described 32 integrated delivery models. Five models (15.6%) were rated at integration level 1 or 2 (coordinated care), eight models (25%) were rated level 3 and five models (15.6%) were rated level 4 (co-located care), and fourteen models (43.8%) were rated level 5 or 6 (integrated care).

CONCLUSIONS

In general, it is assumed that more completely integrated care will result in higher quality care and reduced costs. Thirteen of the models described (40.6%) had levels of integration of 3 or lower that may be too low to produce desired effects on quality and cost. Future research should address potential barriers that impede the development of models with higher degrees of integration.

What's known about implementing co-located paediatric integrated care: a scoping review

Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.

Adverse Childhood Experiences Are Associated with Unmet Healthcare Needs among Children with Autism Spectrum Disorder

OBJECTIVE

To explore associations between level of adverse childhood experiences (ACEs) and unmet healthcare needs among children with autism spectrum disorder (ASD) using a population-based sample.

STUDY DESIGN

Cross-sectional data from the 2011-2012 National Survey of Child Health were analyzed to estimate prevalence of unmet healthcare needs among children with ASD, aged 2-17 years (ASD = 1624; estimated population = 1 174 871). Multivariate Poisson and logistic regression models were used to estimate the relationship between reported ACEs and unmet healthcare needs among children with ASD.

RESULTS

After we adjusted for all other variables, children with ASD who experienced 1-2 ACEs and 3+ ACEs were associated with 1.78 (P < .05) and 2.53 (P < .01) times the incidence rate of unmet healthcare needs in comparison with children without ACEs. Compared with children who experienced 0 ACEs, the adjusted odds of any unmet healthcare need were 2.34 (P < .01) and 2.66 (P < .01) for children with 1-2 ACEs and 3 + ACEs, respectively.

CONCLUSION

Although limited to cross-sectional data, our study provides compelling evidence on the link between ACEs and unmet healthcare needs among children with ASD. It advances understanding of risk factors in the child and community context that contribute to health disparities and negatively impact healthcare access and use in this population.

Enhancing Early Childhood Mental Health Primary Care Services: Evaluation of MA Project LAUNCH

Objectives The purpose of this study was to evaluate the efficacy of an innovative early childhood mental health intervention, Massachusetts Project LAUNCH. Early childhood mental health clinicians and family partners (paraprofessionals with lived experience) were embedded within community pediatric medical homes. Methods A longitudinal study design was used to test the hypotheses that (1) children who received services would experience decreased social, emotional and behavioral problems over time and (2) caregivers' stress and depressive symptoms would decrease over time. Families who were enrolled in services and who consented to participate in the evaluation study were included in analyses (N = 225). Individual growth models were used to test longitudinal effects among MA LAUNCH participants (children and caregivers) over three time points using screening tools. Results Analyses showed that LAUNCH children who scored in age-specific clinically significant ranges of social, emotional and behavioral problems at Time 1 scored in the normal range on average by Time 3. Caregivers' stress and depressive symptoms also declined across the three time points. Results support hypotheses that the LAUNCH intervention improved social and emotional health for children and caregivers. Conclusions for Practice This study led to sustainability efforts, an expansion of the model to three additional communities across the state and development of an online toolkit for other communities interested in implementation.

Brief, Rapid Response, Parenting Interventions Within Primary Care Settings

Opportunities created by the Patient Protection and Affordable Care Act along with the increased prevalence of pediatric behavioral and mental health concerns provide new challenges for pediatric health care providers. To address these matters, providers need to change the manner by which they provide health care to families. A novel approach is providing brief, rapid response, evidence-based parenting interventions within the pediatric primary care setting. Family-focused parenting programs support the American Academy of Pediatrics recommendations of improving mental health via supports in pediatric primary care to maximize the social and psychological well-being of families. A considerable body of research indicates that parenting interventions reduce the severity and frequency of disruptive behavior disorders in children and provide support to parent by bolstering parental resilience and improving overall family functioning. Providing these services within the pediatric primary care setting addresses the need for fully integrated health services that are family-centered and easily accessible.

Disparities in Self-reported Access to Patient-centered Medical Home Care for Children With Special Health Care Needs

BACKGROUND

Efforts to transform primary care have been underway for over a decade. Yet, we lack understanding of the progress made in scaling up this care model nationwide and on whether patient-centered medical home (PCMH) has benefited every group of children with special health care needs (CSHCNs).

OBJECTIVE

The main objective of this study was to examine variation in caregiver service experience concordant with PCMH care over time and by child characteristics.

RESEARCH DESIGN

This was a cross-sectional pooled data analysis using the 2003-2012 Medical Expenditures Panel Survey data for CSHCNs, aged 5-17 years. Logistic regressions were implemented, accounting for child and parent sociodemographic, child's health insurance, and contextual characteristics. PCMH concordant care and each component were constructed as binary variables and child functional impairment was measured with the Columbia Impairment Scale.

RESULTS

Thirty-one percent of children reported medical home concordant care; comprehensive (83%) and compassionate (82%) care were most prevalent, and the least common were accessible care (59%) and patient-centered care (60%). PCMH concordant care significantly increased nationwide between 2003 and 2012, but disparities remained based on child needs and sociodemographic characteristics. Multivariate regressions showed variation across medical home components.

CONCLUSIONS

Despite increased parent perception of care that is concordant with medical home care over time, disparities remain among high-need CSHCNs. Future research may focus on better understanding how clinical settings tailor this care model, particularly on providing increased access and patient-centered care, to better serve children at the highest need.

Development and Evaluation of Two Integrated Care Models for Children Using a Partnered Formative Evaluation Approach

Objective

To describe the development and evaluation of two integrated care models using a partnered formative evaluation approach across a private foundation, clinic leaders, providers and staff, and a university-based research center.

Design

Retrospective cohort study using multiple data sources.

Setting

Two federal qualified health care centers serving low-income children and families in Chicago.

Participants

Private foundation, clinic and academic partners.

Interventions

Development of two integrated care models and partnered evaluation design.

Main Outcome Measures

Accomplishments and early lessons learned.

Results

Together, the foundation-clinic-academic partners worked to include best practices in two integrated care models for children while developing the evaluation design. A shared data collection approach, which empowered the clinic partners to collect data using a web-based tool for a prospective longitudinal cohort study, was also created.

Conclusion

Across three formative evaluation stages, the foundation, clinic, and academic partners continued to reach beyond their respective traditional roles of project oversight, clinical service, and research as adjustments were collectively made to accommodate barriers and unanticipated events. Together, an innovative shared data collection approach was developed that extends partnered research to include data collection being led by the clinic partners and supported by the technical resources of a university-based research center.

Comparing primary care pediatricians' perceptions of clinics with and without integrated behavioral health

Objective: The purpose of this study was to investigate primary care pediatrician (PCP) perceptions of prevalence of, time spent in, and satisfaction with behavioral health services across clinics with and without on-site behavioral health providers (BHPs). Methods: A cross-sectional survey design was used to examine satisfaction across sites. Data were collected on PCP perceptions of behavioral health services among 60 pediatricians within two academic medical systems. Results: PCPs perceived behavioral health issues are prevalent and a time-consuming aspect of medical appointments and preferred to have on-site BHPs over off-site referral sources. Compared to sites without an on-site BHP, sites with on-site BHPs were more satisfied with behavioral health service availability and resources, felt they spent more time addressing medical concerns, and spent less time providing anticipatory guidance. Discussion: Study limitations included questions surrounding the validity of survey items to accurately assess PCP perceptions, lack of rigorous experimental design, and reliance on self-report data.

Patient-Centered Medical Home Care for Adolescents in Need of Mental Health Treatment

PURPOSE

The patient-centered medical home (PCMH) has emerged as an optimal primary care model for all youth; however, little is known about the extent to which adolescents in need of mental health (MH) treatment receive care consistent with the PCMH. This study assessed (1) 10-year trends in PCMH care among U.S. adolescents according to MH need and (2) variations in PCMH care and its subcomponents among adolescents with MH need, by individual and family characteristics.

METHODS

This was a secondary analysis of Medical Expenditure Panel Survey data (2004-2013). The sample included adolescents aged 12-17 years with ≥1 office-based visits in the past year (N = 18,717). Questions assessing a usual source of care and care that is accessible, comprehensive, family-centered, and compassionate were used to define PCMH care. For adolescents with MH needs, multivariable logistic regression was used to describe the association between PCMH care and sample characteristics.

RESULTS

Fifty percent of adolescents experienced PCMH care, with little change between 2004 and 2013. Adolescents with MH need (N = 3,794) had significantly lower odds of experiencing PCMH care compared with those without MH need (odds ratio, .78; 95% confidence interval, .69-.87). Among adolescents with MH needs, being uninsured and living with a parent who did not graduate high school were negatively associated with PCMH care, whereas parental usual source of care was positively associated (odds ratio, 1.69; 95% confidence interval, 1.28-2.22).

CONCLUSIONS

Increasing care accessibility, integrating MH services into primary care settings, and targeting socioeconomically disadvantaged subgroups could improve rates of PCMH care among adolescents with MH needs.

Integrating Psychological Screening Into Medical Care for Youth With Abdominal Pain

BACKGROUND

Pediatric functional abdominal pain disorders are common, costly, and disabling. Clinical anxiety is highly prevalent and is associated with increased pain and functional disability. Thus, a psychological screening process is recommended but is infrequently used in current practice.

METHODS

A screening process for patient-reported anxiety (Screen for Child Anxiety and Related Disorders), functional disability (Functional Disability Inventory), and pain levels was implemented in a large gastroenterology division within a major medical center. Quality improvement methods and traditional analytic approaches were used to test the feasibility and outcomes of routine screening in patients ages 8 to 18 with abdominal pain.

RESULTS

Screening rates increased from <1% to >80%. A total of 1291 patients who reported having abdominal pain completed the screening during the first 6 months. Clinically significant anxiety (43.1%), at least moderate disability (45%), and elevated pain (61.5%) were common in children with abdominal pain. The presence of clinically significant anxiety corresponded with higher pain and pain-related disability. Twenty-one percent of youth had clinical elevations in all 3 areas. In such instances, medical providers received an automated prompt to tailor care, including to consider a psychological referral. After the project implementation, psychological referral rates increased from 8.3 per 1000 patients to 15.2 per 1000 patients.

CONCLUSIONS

Systematic screening for anxiety, pain, and pain-related disability as a routine part of medical care can be reliably implemented with clinically meaningful results. Future directions include examining the role of anxiety over the long-term and reducing clinician burden.

Primary Care Providers' Use of a Child Psychiatry Telephone Support Program

BACKGROUND

The Massachusetts Child Psychiatry Access Project (MCPAP) provides telephone support from mental health specialists to primary care providers (PCPs). Understanding PCPs' use may inform implementation of similar programs. We sought to examine PCPs' decision-making process to use or not use MCPAP when encountering mental health problems.

METHODS

We analyzed data regarding calls from PCPs to MCPAP from October 1, 2010, to July 31, 2011, and interviewed 14 PCPs with frequent use (≥7 calls) and infrequent use (≤4 calls). PCPs were asked about recent patients with mental health problems, and they were asked to describe reasons for calling or not calling MCPAP. Frequent callers were asked what sustained use; infrequent callers were asked about alternative management strategies. Comparisons were made between these groups in qualitative analysis.

RESULTS

PCPs (n = 993) made 6526 calls (mean = 6.6; median = 3). Factors influencing calling included: MCPAP's guidance is timely and tailored to individual scope of practice; MCPAP's ability to arrange therapy referrals exceeds PCPs' ability; providing a plan at point of care relieves anxious families; and MCPAP's assistance helps accommodate families' preference to keep mental health in primary care. Some infrequent callers had gained skills through MCPAP before 2010 and now called only for complex cases. Other reasons for infrequent calling: PCPs have other consultation sources, have fear of being asked to manage more than they are comfortable, or have misperceptions of MCPAP's offerings.

CONCLUSIONS

MCPAP enhanced PCPs' ability to deliver mental health care consistent with families' preferences. PCPs applied knowledge gained from calls to subsequent patients. Promoting MCPAP components through outreach and tailoring guidance to PCPs' scope of practice may entice greater use.

Parental Adverse Childhood Experiences and Offspring Development at 2 Years of Age

OBJECTIVES

The study objective was to determine if maternal and paternal exposure to adverse childhood experiences (ACEs) have a significant association with negative offspring development at 24 months of age in a suburban pediatric primary care population.

METHODS

A retrospective cohort study was conducted of 311 mother-child and 122 father-child dyads who attended a large pediatric primary care practice. Children were born from October 2012 to June 2014, and data were collected at the 2-, 4-, and 24-month well-child visits. Multivariable Poisson regression with robust error variance was used to model the relationship between self-reported parental ACEs and the outcomes of suspected developmental delay at 24 months and eligibility for early intervention services.

RESULTS

For each additional maternal ACE, there was an 18% increase in the risk for a suspected developmental delay (relative risk: 1.18, 95% confidence interval: 1.08-1.29). A similar trend was observed for paternal ACEs (relative risk: 1.34, 95% confidence interval: 1.07-1.67). Three or more maternal ACEs (versus <3 ACEs) was associated with a significantly increased risk for a suspected developmental delay that affected multiple domains. Similar effects were observed for early intervention services.

CONCLUSIONS

Parental ACE exposures can negatively impact child development in multiple domains, including problem solving, communication, personal-social, and motor skills. Research is needed to elucidate the psychosocial and biological mechanisms of intergenerational risk. This research has implications for the value of parental ACE screening in the context of pediatric primary care.

Integrated Behavioral Health Care in Pediatric Primary Care: A Quality Improvement Project

The top 5 reasons for pediatric office visits in the United States today are behavioral health concerns. This article describes a colocated behavioral health and care coordination integration model in a pediatric primary care office to reduce barriers to behavioral health care.

Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity

Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.

Integrated Behavioral Health Care in Pediatric Subspecialty Clinics

Comorbid behavioral and physical health conditions are accompanied by troubling symptom burden, functional impairment, and treatment complexity. Pediatric subspecialty care clinics offer an opportunity for the implementation of integrated behavioral health (BH) care models that promote resiliency. This article reviews integrated BH care in oncology, palliative care, pain, neuropsychiatry, cystic fibrosis, and transplantation. Examples include integrated care mandates, standards of care, research, and quality improvement by child and adolescent psychiatrists (CAPs) and allied BH clinicians. The role of CAPs in integrated BH care in subspecialty care is explored, focusing on cost, resource use, financial support, and patient and provider satisfaction.