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A five-year study at Boston Children’s Hospital reports success with a program it started in 2013 to bring much-needed behavioral health services directly into primary care pediatricians’ offices.
As reported June 11 in Pediatrics, the program improved children’s access to behavioral health care, with only minor increases in cost, and got high marks from participating pediatric practices.
Based on the findings, the program, which currently reaches more than 70 affiliated pediatric practices in Massachusetts, continues to be expanded and evaluated.
Meeting a need
By late adolescence, up to 20 percent of children will have experienced functionally impairing anxiety, depression or ADHD, the most common and treatable mental health conditions.
But child behavioral health specialists are in chronic short supply with long wait lists, said Heather Walter, Harvard Medical School senior lecturer on psychology at Boston Children’s Hospital and first author of the paper.
Massachusetts, for example, has nearly 300,000 youths with at least one diagnosable psychiatric disorder, but only about 400 to 500 practicing pediatric psychiatrists.
“Nearly a decade can elapse between when a child first shows symptoms of a disorder and when it is diagnosed and treated, which has major consequences in their academic, social and family lives,” said Walter.
“There aren’t enough child psychiatrists to offer this care alone, and we realized we needed partners,” Walter continued. “The obvious physician partners are pediatricians; they see children for years, know them well, are tuned in to child development and are highly trusted by patients and families.”
Empowering pediatricians
The Behavioral Health Integration Program (BHIP) was designed to empower primary care pediatricians to head off—or, if indicated, treat—most cases of anxiety, depression and ADHD, referring only the more complex cases to specialists.
“If a child has schizophrenia or bipolar disorder, we’d want them to be cared for in a specialty setting,” said Walter.
The BHIP offered its services to primary care practices affiliated with the Pediatric Physicians’ Organization at Children’s, LLC (PPOC), on a first-come, first-served basis.
The program has three components:
- In-person and televideo education sessions with child psychiatrists and other behavioral health specialists
- On-demand consults with child psychiatrists by phone, in person or via telepsychiatry
- Operational and clinical support for integrating psychotherapists into pediatric practices.
Five-year outcomes
Walter and colleagues looked at outcomes in the first 13 PPOC practices in Greater Boston to enroll in BHIP. These practices comprised some 105 primary care pediatricians serving about 114,000 children and youth.
“Our overarching goal was to increase children’s access to behavioral health services without breaking the bank,” said Walter.
The study found:
- Significantly increased visits to primary care providers for behavioral health problems.
- Significantly increased psychotherapy visits in the primary care setting, from 0.7 percent to 13.3 percent.
- Significantly increased pediatrician prescribing of medications for ADHD, anxiety and depression in accordance with evidence-based guidelines.
- High satisfaction among pediatricians and on-site psychotherapists: more than 90 percent of those surveyed said they were more able to effectively manage mild or moderate mental and behavioral health problems in the pediatric setting.
- Total ambulatory behavioral care costs rose just 8 percent, as diversion of routine care from more costly specialists helped offset the overall increase in behavioral health visits.
- Emergency room costs for behavioral health visits decreased 19 percent overall.
Although the team didn’t survey parents directly, pediatricians often reported high satisfaction among families who found the arrangement more convenient, less stigmatizing and in some cases more readily covered by insurance.
Recent and future initiatives include:
- Expansion of substance abuse and addiction services
- Family crisis intervention for suicidal adolescents
- A pilot telepsychiatry program
- Interactive, web-based training to reach providers far from Boston
- Partnership with Open Pediatrics, Boston Children’s web-based clinical training platform
- Ongoing partnership with the state- and payer-funded Massachusetts Child Psychiatry Access Program (MCPAP), extending psychiatric consultation services to nearly all of the state’s approximately 500 pediatric practices.
“Providing top-quality behavioral health services to kids in the right setting at the right time will help millions of children receive the care they need and deserve,” said David DeMaso, psychiatrist-in-chief and the HMS George P. Gardner and Olga E. Monks Professor of Child Psychiatry in the Department of Psychiatry at Boston Children’s.
Funding and authorship
Glenn Focht, former chief medical officer of the PPOC who is now at Connecticut Children’s Medical Center, was the study’s senior author.
The BHIP was initially supported by Boston Children’s Provider-Payor Quality Initiative, a collaboration between Boston Children’s Hospital, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Tufts Health Care and MassHealth. Subsequent funding has come from the Massachusetts Health Policy Commission, Commonwealth of Massachusetts, Children’s Hospital Los Angeles Health Network, Sydney A. Swensrud Foundation, Nancy Adams & Schott Schoen Family, Harvard Pilgrim Health Care, SAMHSA and Tommy Fuss Center for Neuropsychiatric Disease Research.
The Pediatrics study was funded by the Boston Children’s Hospital Payer Provider Quality Initiative.
Adapted from a post on Discoveries, the Boston Children’s news and story portal.
