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Team meets kids where they are.

Care for mental and physical health issues is erroneously segregated in the current health care environment, said John V. Campo, M.D.

That's why Dr. Campo and his colleagues have developed a collaborative care model aimed at delivering mental health services within a pediatric primary care practice.

"Most kids have at least one visit per year with their primary care provider, and most behavioral and mental health problems are first discussed in that setting," said Dr. Campo, assistant professor of psychiatry and pediatrics at the University of Pittsburgh's Western Psychiatric Institute and Clinic (WPIC). "So it makes perfect sense to look to primary care as an access point for mental health care."

But what is reasonable is not always readily achievable. "The current primary care culture focuses on acute care, while psychiatric disorders in children and adolescents tend to be chronic and relapsing," Dr. Campo said.

This false dichotomy between mental and physical issues leads to count-less missed opportunities for addressing critical mental health issues. Primary care providers often provide acute care for recurrent somatic symptoms such as headache, abdominal pain, limb pain, and chest complaints, for example. But such symptoms are often linked to emotional problems--which cannot be treated acutely and so often go unaddressed, he said.

How the Model Works

Dr. Campo and his team have applied the chronic care model to pediatric mental health by teaming mental health professionals affiliated with the WPIC and the Family Counseling Center of Armstrong County (Pa.) with clinicians and administrators at Armstrong Pediatrics, a primary care practice operated by a self-governing subsidiary of the Children's Hospital of Pittsburgh. The community-based practice, located 50 miles outside of Pittsburgh, serves more than 10,000 children and adolescents.

The collaborative mental health program is based on-site within the pediatric practice, yet operates as an administratively distinct mental health satellite of the Family Counseling Center.

Staffing for the program involves a full-time nurse care manager with training as an advanced-practice nurse practitioner, a full-time psychiatric social worker, and a pediatric psychiatrist, who is available 1 day per week. (See box.)

"The pediatric psychiatrist is the drag on the system financially, so the idea is to spread the specialty care in order to make the program feasible," Dr. Campo said. This is achieved by the program's emphasis on stepped care, meaning that different levels of care are matched to the needs of a given patient and his or her specific disorder, its severity, and its complexity.

When one of the primary care providers identifies a child with emotional or behavioral problems, the physician directs the family to the nurse care manager, who schedules a brief initial assessment and triage visit to determine immediate clinical needs. For acute and/or complicated triage decisions, the nurse care manager consults with the child and adolescent psychiatrist in person, by telephone, or by e-mail.

Levels of Care

The nurse care manager will then triage the child or adolescent to one of three levels of care, according to predetermined guidelines: usual care, on-site collaborative care team services, and on-site specialty mental health care or off-site referral.

Patients triaged to usual care include those whose behavioral and emotional problems are mild to moderate. This category of patient might include children with attention-deficit issues, conduct and adjustment problems, somatization, or tics. Typically, these children will not have been treated for these conditions previously or they have responded to previous treatment. The therapeutic needs of patients triaged to this level of care are met by the nurse care manager and the primary care clinician, and may include psychoeducation, a behavior plan, self-management, and/or medication.

The next level of care--on-site collabo rative care services--is indicated if the presenting condition is judged to be moderate or severe. "The diagnosis may be uncertain; there may be comorbid disorders, or previous therapies in primary care may have failed," Dr. Campo said.

In addition to the behavioral issues already noted, a diagnosis of Asperger's syndrome or an early eating disorder may justify collaborative care services, which, in addition to the primary care interventions mentioned, might include formal psychotherapy, specialty education, and family support services.

When collaborative care is warranted, it is provided on-site by the primary care provider, the nurse care manager, the psychiatric social worker, and the child and adolescent psychiatrist as needed. These interventions are coded for specialty billing through the Family Counseling Center.

Finally, patients with moderate to severe mental health problems--especially in cases involving dangerous behavior, illegal activity, serious maltreatment, or family dysfunction--warrant on-site treatment with the child and adolescent psychiatrist or off-site referrals. Patients triaged to this level of care are likely to have failed previous treatments and may have a history of hospitalization for mental health problems.

The nature of their problems, such as alcohol or substance abuse, autism, bipolar disorder, psychosis, and serious eating disorders, may require a higher level of specialty care than that which can be provided by the collaborative team, Dr. Campo noted.

Linking the Services

The role of the nurse care manager in the assessment and provision of appropriate levels of care is the linchpin that holds the collaborative care model together. "She is the liaison between the primary care and mental health services. The nurse care manager reduces the physician burden that would otherwise be an obstacle to providing adequate, effective care for patients with mental health problems," Dr. Campo said.

Because she has experience and training in mental health, as well as a familiarity with primary care medicine, "the nurse care manager is able to translate specialty mental health input to the primary care setting and to the primary care physicians, which seems to be critical in our experience," he said.

An examination of mental health triage and referral patterns for 1 year of the program showed a high rate of family compliance with mental health referrals, decreased time between initial referral and active treatment, and overall improved access to specialty mental health services.

In 2002, Armstrong Pediatrics' primary care physicians requested nurse care manager assessment and triage 789 times, representing 2.5% of all of the visits to the practice during that period. Family compliance with a scheduled initial assessment and triage visit was at 91%.

Dr. Campo attributed the "exceptionally high" rate of compliance to several factors, including the quick, easy access to follow-up and the absence of the stigma that is often associated with seeking mental health care.

"For families, there is a big difference between going to a pediatrician's office and going to a psychiatrist's office--even if the care is going to be the same," according to Dr. Campo.

Diagnoses and Referrals

The primary diagnoses for the patients referred to triage in 2002--obtained from billing codes--included common emotional and behavioral problems such as attention-deficit disorder, depression, and anxiety (379 patients), functional pain syndromes and somatization such as recurrent abdominal pain and headache (336 patients), concerns regarding parenting skills (36 patients), learning problems (28), tics (8), and eating disorders (2).

Of the 789 patients referred to the nurse care manager for assessment, 279 represented "first-time" mental health consultations.

Of these, 187 were triaged for routine management, 52 were triaged to the onsite collaborative mental health program for more specialized interventions or psychiatric consultation, 36 were triaged to receive more intensive services at the Family Counseling Center's primary location, and 4 were referred for emergency evaluation and inpatient psychiatric hospitalization.

Stumbling Blocks

The early numbers and the collaborative care team's experiences to date suggest that enhanced primary care management of pediatric mental disorders using a stepped, collaborative care model is feasible and can improve access to child and adolescent mental health services, yet the road to wider implementation of such programs and long-term success is dotted with sizable challenges.

"The first, likely obvious, challenge is fiscal," Dr. Campo said. "The model as proposed does not fit nicely into existing reimbursement categories, in that it straddles both the traditional medical setting and the psychiatric.

As such, it is sometimes difficult to maintain adequate reimbursement." For the Armstrong Pediatrics program, partnering with the local community health center is an effort to address this difficulty, he said.

Cultural issues have to be considered as well. "Our anecdotal experience suggests that the response of primary care physicians to the model is likely to vary depending on the type and location of the practice," Dr. Campo said.

"This model was first established in a rural practice, where a very responsible group of primary care pediatricians felt great responsibility for the comprehensive care of the children and adolescents in a rural county, and had almost no access to mental health services," he said.

In addition, those doctors were especially open to a model that provided better care for their patients and families--although doing so required more from them as physicians.

Not all primary care physicians feel the same, he stressed, with concerns often being focused on liability, disruption of practice flow, and ultimately, cost.

At the very least, given the positive results of the Armstrong Pediatrics program to date, the model provides some practical, evidence-based management guidelines for addressing pediatric mental health issues in the primary care setting, Dr. Campo said.

At the very most, children and adolescents who need help are getting it.

RELATED ARTICLE: Team Roles for Collaborative Care

Child and Adolescent Psychiatrist

* Provides team leadership.

* Supervises nurse care manager and psychiatric social worker through weekly review of triage decisions and intake assessments for on-site program as well as supervision of active cases.

* Consults on selected cases for diagnostic clarification and psychopharmacologic decisions.

* Co-manages selected cases with primary care providers, including patients who don't respond to primary care intervention or who have severe or complicated diagnoses.

* Provides education to primary care providers.

Psychiatric Social Worker

* Provides patient, family education.

* Conducts intake assessments for in-practice referrals.

* Provides specialty psychotherapeutic intervention that includes approaches such as cognitive-behavioral therapy, self-management tools, and family counseling.

* Manages selected cases.

* Serves as school liaison and additional primary care liaison.

Primary Care Provider

* Identifies children with psychosocial problems.

* Establishes initial diagnosis.

* Initiates treatment for noncomplex cases.

* Assesses medical causes of psychiatric symptoms.

* Ensures continuity of care.

Nurse Care Manager

* Serves as liaison between primary care physicians and mental health team.

* Conducts initial assessment and triage from primary care referral.

* Provides initial patient and family education.

* Offers active follow-up and out-reach.

* Provides ongoing case management and coordination.

* Offers treatment support by monitoring adherence, outcomes, and medication safety and providing counseling and self-management strategies.


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Article Details
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Title Annotation:Child/Adolescent Psychiatry
Author:Mahoney, Diana
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Dec 1, 2004
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