For many children, adolescents, young adults—it's a stressful world. Over recent years, rates of adolescents reporting thoughts of sadness, symptoms of depression, suicidal ideation and suicide attempts have been rising. The pandemic exacerbated those trends.
It makes sense to conduct behavioral health screening as part of routine pediatric care. Both the American Academy of Pediatricians and the United States Preventive Services Task Force recommend systematic screening. While many pediatric practices now conduct regular screening, the sticking point is how to get patients who screen positive into treatment.
Pediatric Integrated Behavioral Healthcare (P-IBH) provides systematic screening and clinical services, as well as care management. Notably, P-IBH follows up a positive screen with a warm handoff to a clinician who is hired by or contracts with the practice. Then, depending on need, the clinician will initiate 1 or several sessions of brief treatment (or occasionally traditional therapy until external services are available.) These sessions can serve as a bridge to more traditional therapy, or the sessions can provide the patient with the skill building needed to address life stressors.
To test the P-IBH model in Rhode Island, CTC-RI, with funding from the Rhode Island Foundation, created the P-IBH pilot program. 8 pediatric practices enrolled in the P-IBH pilot—2 hospital clinics, 2 FQHCs, and 4 traditional pediatric practices. Divided into 2 cohorts, the pilots ran from 2019–2021 and from 2020-2022. CTC-RI also contracted with consultants to conduct a qualitative evaluation to determine how sites implemented their programs, success factors, and lessons learned. The evaluation team conducted 28 interviews across the 8 sites. Respondents included at least the pilot manager, the behavioral health clinician, and a physician/champion.
The evaluation results showed that even with the challenges of the pandemic—the temporary halting of non-emergent in-person visits; clinicians working from home; open clinician positions; warm handoff challenges; limitations of telemedicine; staff shortages, staff turnover—all 8 sites were able to implement their P-IBH program. Each site conducted systematic screening, increased patient access to behavioral healthcare, and provided care management.
Overwhelmingly, staff, clinicians and providers appreciated that screening could find behavioral health issues before they developed into full blown problems, or find those adolescents who said they felt fine, but whose PHQ scores indicated suicidal thoughts or intent. Respondents reported that screening and handoffs to clinicians helped patients and families normalize mental health as part of overall healthcare.
P-IBH helped patients deal with depression, anxiety, bullying, suicidal ideation, and school anxiety among many other issues.
“We had one parent who really didn't believe mental health issues were a real thing. But when the screening questions were asked … the teen indicated that they were like highly suicidal … this teen had a previous suicide attempt, and the screening provided an opportunity to educate the parent. The parent allowed the child to come back and meet with the IBH clinician—I think that is a success in itself.” IBH clinician
For practices considering their own P-IBH program, starting and sustaining a new program is a complicated process. It involves creating a work plan that considers aspects such as space, hiring, workflows, supervision, program oversight, creating and using a registry, and culture change. For sites new to P-IBH, CTC-RI facilitation provided the technical assistance and structure to coordinate those moving parts.
But is P-IBH sustainable? All sites planned to continue their programs. Sites generally felt that when billing covered their clinician’s salary, their program could be sustainable. Still, sustainability was a concern for some, when factoring in the need for care management.
While this evaluation could not determine cost savings, it is likely that addressing behavioral health issues early will result in long-term savings. In this month dedicated to Mental Health Awareness, we close with this medical provider’s recommendation.
“…so I think every practice should have that (onsite clinician.) Every patient and family should have access to that kind of support in the moment when we’re courageous enough to say, ‘we need help’.…And the payoff may not be to you, insurance company, your foundations; but it’s going to be a payoff to society at large, and that’s really, really important.”