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Payment reform offers opportunity to integrate mental health into pediatric care :

August 4, 2016

Practice transformation and new payment models offer effective pathways to providing an increased array of services that optimize pediatric care and the prevention and early detection of health problems. A key transformational opportunity is integrating or re-integrating behavioral health as part of holistic health care.

Decades of “siloed” financing mechanisms and regulatory rules for mental health services as well as real or perceived institutionalized barriers to interprofessional communication have evolved into a fragmented, gated and unhealthy system of carved-out services for behavioral issues. As we reorganize payment systems and recognize the personal and financial impact of behavioral health across multiple systems, we face a great opportunity to bring behavior and mental health back into the realm of pediatric primary and subspecialty practice.

Integration can exist on a continuum from creating formal mental health referral networks to co-locating behavioral health providers within the office to integrated care with shared medical records, care teams and care plans. Pediatricians can refer and co-manage or be the primary behavioral health providers for their patients.

Key competencies from the 2009 AAP policy statement The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care are:

  • assessing and/or triaging children with mental health and substance use symptoms;

  • addressing emerging or undifferentiated problems and problems not rising to level of diagnosis;

  • assessing/managing children with attention-deficit/hyperactivity disorder (ADHD), anxiety, depression and substance use disorders (mild to moderate levels of impairment); and

  • referring, co-managing and coordinating care for children with other conditions, those severely impaired and those beyond our comfort level.

Collaboration and co-management with mental health professionals is key to implementing these competencies. The Academy and American Academy of Child and Adolescent Psychiatry have produced a document on provider-to-provider communication and the Health Insurance Portability and Accountability Act that dispels misconceptions about limits to communicating.

Recognizing the unique needs and opportunities of integrating behavioral health into pediatrics is key to creating effective strategies. Children and their behavioral health issues are influenced by their development, demographic characteristics and dependency on adult caregivers and adult-driven systems such as schools.

Younger children in particular may have behavioral challenges that do not yet rise to the level of a diagnosis. Pediatric primary care presents the opportunity for promotion, prevention and early intervention for child mental health.

Almost a quarter of the children in the U.S. live in impoverished environments, commonly with stressed and unstable financial, physical and emotional conditions. The impact of chronic, unremitting stress on children’s psyche is potentially profound and lifelong.

Nurturing the well-being and life opportunities for parents helps them raise healthy children. We screen mothers for postpartum depression and parents for substance use and intimate partner violence. Increasingly, we are aware of the need for two-generation models of care.

As pediatricians, we also work closely with other systems such as child welfare, early intervention and child care, and schools. These systems can augment our ability to detect behavior patterns and provide interventions early, in hopes of preventing more severe mental illness. This requires more intentional communication and collaboration.

School attendance and school performance are good examples of early and ongoing indicators of child wellness. School behavior problems may be manifestations of undiagnosed learning disabilities, depression, anxiety or ADHD. Being victimized by bullying can contribute to both absenteeism and to behavior changes in children. Substance use, depression or other mental illness can present as deterioration of grades or disconnection from peers and peer organizations.

The Academy has a long history of promoting a whole child approach (in the context of family, school and community) in the medical home. Pediatricians have the primary care advantage of the longitudinal relationship with the child and family and opportunity to promote social-emotional development and address mental health concerns. For children and their families, a healthy social-emotional foundation and early detection and intervention can have a life-long impact on health outcomes.

Dr. Flanagan is a member of the AAP Task Force on Pediatric Practice Change. Dr. Earls is chair of the AAP Mental Health Leadership Work Group.

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