W. Douglas Tynan, Ph.D., ABPP
Kathryn Woods, Ph.D.
Johanna Carpenter, Ph.D.

Childhood is an important time for promoting healthy social and emotional development, identifying developmental and behavioral problems, and intervening before problems become severe. Yet, few children have access to mental health services that promote development of the social and emotional skills or help prevent emotional or behavioral problems before they start. Nearly 1 in 10, or as many as 6 million children and adolescents, suffer from a mental illness that severely disrupts their daily functioning at home, in school or in the community (U.S. Department of Health and Human Services, 1999). In any given year, fewer than 20 percent of these children and adolescents receive mental health services (U.S. Department of Health and Human Services, 1999). Even greater numbers of children exhibit transient emotional or social difficulties that may not develop into a diagnosable mental disorder.

There is no single public or private system that has as its sole responsibility the promotion of children's social and emotional development or the treatment of children's mental health problems. Although children's mental health needs are addressed by numerous public and private systems, there frequently are missed opportunities to promote children's optimal social and emotional development in places where children and families most commonly spend time — schools, child care and primary care facilities to name a few. In particular, primary care can play a unique role in promoting children's social and emotional development.

Primary care is one of the key child-serving systems with which many children, particularly young children and their families, regularly come into contact (i.e., through well-child visits and other routine health care). Primary care settings emphasize prevention and early intervention within a child health and development context and medical home. Primary care providers (e.g., pediatricians, family physicians) are a trusted source of guidance, information and expertise on child health and development, child rearing and mental health treatment. Families often first seek help for mental health issues with their primary care provider and, when they do so, find it less stigmatizing than in other settings (Kelleher, Campo, Gardner, 2006). Indeed, treatment for mental health issues in children is increasingly being provided by primary care providers. In the past 25 years, the rate of psychosocial problems identified by primary care providers has more than doubled (from 7 percent to 18 percent; Kelleher, McInemy, Gardner, Childs & Wasserman, 2000). Approximately 20 percent of all children seen in primary care settings have significant developmental, emotional or behavioral health issues (Schroeder, 2004).

Role and Barriers
The Role of the Pediatric Primary Care Provider

Primary care providers have long recognized the role that they play in promoting the physical, mental and social health and well-being of children and adolescents — a role that is evolving and expanding due to several factors. Many primary care activities to promote the optimal development of children have been found to be efficacious (Regalado & Halfon, 2001), and developmental concerns are one of several health topics to be addressed at each pediatric preventive care visit throughout the first 5 years of life (Council on Children with Disabilities, 2006). A major feature of the Affordable Care Act is payment to primary care providers for developmental, behavioral and autism screening, as well as screening and treatment for drug and alcohol abuse and obesity, which could best be carried out by Psychologists. In addition, greater numbers of families are presenting at primary care practices with questions about psychosocial, behavioral and mental health issues for their child. Half of parents of children seen for well-child visits have some type of psychosocial concern (Schroeder, 2004). In turn, advances in multimodal treatment for mental health disorders such as depression and attention-deficit hyperactive disorder (ADHD) have led many primary care providers to take on greater roles in the management and treatment of mental health problems in children. Finally, and perhaps most noteworthy, significant shortages exist within the mental health workforce. These shortages have caused many primary care providers to take on greater roles in children's mental health, regardless of prior training, skill and comfort level in doing so.

Barriers to Promoting Social and Emotional Development in Primary Care

Clearly, primary care providers have a role to play in promoting children's social and emotional development and in addressing their mental health; however, primary care providers often lack the professional preparation and skills to fully address these needs of children. Developmental pediatric skills among experienced, board-certified pediatricians vary (Connor et al., 2006). Management and treatment of mental health disorders present even greater complexities and challenges for primary care. Effective treatment usually involves both psychotherapy and medication, and primary care providers rarely provide psychosocial treatment as an adjunct to pharmacological treatment (Glied & Cuellar, 2003). Some primary care providers are reluctant to refer children for mental health assessment and treatment, given the lack of mental health providers and inadequate feedback loops between primary care and mental health systems. When children are referred to a mental health provider, evidence suggests that family compliance with mental health referrals is quite low, with one study finding that fewer than half of children referred for specialty mental health services ever obtained care (Glied & Cuellar, 2003).

In addition to these provider limitations, several barriers exist within the primary care practice setting. These include lack of time to address child development and mental health issues in a standard pediatric office visit (Meadows, Valleley, Haack, Thorson & Evans, 2011), poor financing (e.g., low reimbursement rates) of child development and mental health services and administrative barriers (e.g., sharing of health information between providers). The demand to properly identify and treat children's mental health disorders is clearly an area of needed improvement in primary care. Asking primary care to also promote children's social and emotional development adds to this demand. Altogether, the system for addressing mental health issues in primary care has significant problems in terms of accessibility, acceptability and effectiveness (Tynan, 2004).

 

Integration, Models and Strategies
Integration of Mental Health Providers in Primary Care

Given the realities and complexities of addressing children's mental health by pediatricians and family physicians, primary care settings have made efforts to incorporate child development and mental health services. These include modifying staff responsibilities to incorporate activities related to child development, implementing new practice protocols to guide discussions by primary care providers, providing parents with child development resources (e.g., parent groups on age-specific topics, parent libraries, educational handouts) and employing care managers to handle screening and referral of children (Stroul, 2006). In addition, studies indicate that many practices are integrating mental health providers in primary care settings. Integrated care can address many of the key barriers for child development and mental health intervention in primary care, as well as provide many benefits. These include:

  • Greater willingness by the primary care provider to explore mental health issues that might result in a mental health referral,
  • Greater likelihood of using on-site mental health services,
  • Better attendance rates for the first mental health appointment, compared to external referrals,
  • Reduced health care costs due to decreased utilization of medical services by children with unidentified and untreated mental health problems,
  • Less stigma for families in seeking mental health care,
  • Improved parenting practices that promote child development (e.g., reading, non-punitive discipline practices),
  • Enhanced communication among mental health and primary care providers, and
  • Increased exchange of knowledge and skills between mental health and primary care disciplines (Williams, Shore, & Foy, 2006; Rosman, Perry & Hepburn, 2005; Steele, Elkin, & Roberts, 2008; Minkovitz et al., 2007; Kramer & Garralda, 2000; Wildman & Langkamp, 2012).
Models of Integrated Child Development and Mental Health Services

There are various approaches to integrated mental health services in primary care, many of which depend on the needs of the practice and its patient population. Models of mental health integration include (a) training of primary care providers on child development issues and mental health disorders to increase provider expertise; (b) consultation by mental health providers to primary care providers, and (c) co-location of psychologists within primary care practices (Bower, Garralda, Kramer, Harrington & Sibbald, 2001). Integrated and co-location models vary by overall goals, supports and services provided, the credentials of the provider, (e.g., child development specialist, social worker, psychologist), the provider's role in the primary care practice, and the relationship of the provider to the primary care setting (e.g., hired by the primary care practice, affiliated with an external entity, independent employee). In a truly integrated model, child development and mental health services are provided or supported by a psychologist who is located within the primary care practice. Depending on the goals for co-location, co-located programs may focus exclusively on child development services or may also include social and behavioral health services (e.g., counseling for behavioral concerns) and/or provider education and training.

Relatively few studies have compared the effects of different integration and co-location models and approaches on practice-based and child outcomes. In one such study, similar outcomes were found when three co-location model structures were compared: (a) mental health provider employed by a community mental health center and out-stationed in a pediatric practice, (b) mental health provider employed by the pediatric practice and (c) co-location of an independent mental health practice with a pediatric practice. Each of these models was associated with similar improvements in communication among primary care and mental health providers, patient and provider satisfaction, convenience for both patients and providers, and perceived decreases in mental health stigma (Bower et al., 2001). The models differed with regard to Medicaid reimbursement for mental health services provided by the co-located provider.  

Using a Chronic Care Model to Address Mental Health in Pediatric Primary Care

The “chronic care model” is the foundation of many current efforts to improve mental health services in pediatric primary care settings. It includes the following core components focused on improving child health outcomes.

  • Evidence-based Treatment: Treatment that employs evidence-based guidelines.
  • Optimal Practices in the Clinic Setting: Clinical locations that optimize practice within the clinical setting including use of specialized and non-physician providers and active follow-up of patients.
  • Patient Self-Management Support: Improving support for patient self-management to enable patients to take responsibility for their own health.
  • Provider Access to Specialists: Systems that help generalist providers access specialist consultation.
  • Quality Care: Information systems and provider incentives to promote quality care and enable practices to understand the impact of care.
Strategies for Effective Integration in Primary Care

Multiple barriers must be overcome if co-location is to be effective and sustainable. Public and private financing of mental health co-location in primary care is a critical factor to its successful development, implementation and sustainability. Grant funds (e.g., foundations, state and federal government) are common sources of funding that have been used to initiate, develop and implement integrated practices (London, Watson & Berger, 2013). Public insurance (e.g., Medicaid) is a primary source of funding for mental health services for low-income children. Finally, co-location models pay for child development and mental health services through a range of financing structures including fee-for-service models, behavioral health care carve-outs and managed care.

Historically, public and private insurance coverage policies and financing structures have hindered the provision of child development and mental health services in primary care. Indeed, the area of reimbursement is one of the most formidable obstacles to the widespread implementation of pediatric mental health co-location models (Briggs, Racine & Chinitz, 2007). A national expert forum, convened by the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Centers for Medicare and Medicaid Services (CMS), identified several barriers to public insurance reimbursement of mental health services in primary care (Mauch, Kautz, & Smith, 2008):

  • Limits on payments for same-day billing for a physical health and mental health service.
  • Lack of reimbursement for collaborative care and case management related to mental health services.
  • Lack of reimbursement for services provided by non-physicians and contract practitioners and providers.
  • Disallowed reimbursement for services provided by a primary care provider that list only a mental health diagnosis and corresponding treatment.
  • Inadequate reimbursement rates.
  • Lack of reimbursement incentives for screening and mental health services in primary care settings.

General financing strategies that can support successful collocation in primary care include the following:

  • Promote and train primary care and mental health providers on the use of Current Procedural Terminology (CPT) codes to bill for child screening and assessment (i.e., CPT “96110” and “96111” codes) and other child mental health services, as well as codes for initial consultation and psychotherapy services.
  • Promote state Medicaid and private insurance policies that allow mental health professionals working in primary care settings to directly enroll and bill as Medicaid providers.
  • Establish financing structures that support integrated behavioral health care services such as extensive evaluation, care management and psychiatric consultation.
  • Include Psychologists in the population based Patient Centered Medical Home model of care.

 

Confidentiality Issues and Recommendations
Overcoming Confidentiality Issues

The privacy of health care information is protected by federal and state privacy and confidentiality laws including federal medical privacy rules issued under the federal Health

Insurance Portability and Accountability Act (HIPAA). The HIPAA Privacy Rule, perhaps the most significant with regard to co-located services, limits the ways that health plans, pharmacies, hospitals, doctors and other health care providers can use patients' medical information (Hudgins, Rose, Fifield & Arnault, 2013). The HIPAA Privacy Rule permits a health care provider to disclose protected health information about an individual, without their authorization, to another health care provider for that provider's treatment of the individual (American Academy of Pediatrics, 2007); this type of consultation falls within the definition of “treatment” and, therefore, is permissible (U.S. Department of Health and Human Services, n.d.). Although federal privacy rules under HIPAA permit health information sharing, they can impede the timely exchange of information between primary care and mental health providers. Use of an integrated electronic health record has been shown to improve the ability of providers to share health information, but this type of system requires a significant amount of planning to comply with privacy regulations (Hogg Foundation for Mental Health, 2008).  

Policy and Program Recommendations

Key policy and program changes can help promote and enhance the ability of co-located practices to effectively provide social and emotional development, and mental health services to children and adolescents. These recommendations include the following:

  • Provide training opportunities in child health and development topics and mental health disorders (e.g., ADHD, depression) to primary care providers.
  • Educate and train primary care and mental health providers on validated developmental screening tools that are available for use in primary care such as the ASQ:SE (Squires, Bricker & Twombly, 2002) and PEDS (Glascoe, 1997).
  • Develop grant opportunities that enable primary care systems to develop and pilot test integrated care models, evaluate the models, and widely disseminate lessons learned from their implementation.

Create public and private financing systems that support effective integration including:

  • “Unbundle” developmental services from the well child visit.
  • Identify CPT codes that can be used for developmental screening and educate providers about these codes.
  • Promote private and public insurance policies that allow mental health professionals to directly enroll and bill as Medicaid providers.
  • Establish financing structures that support integrated behavioral health care services such as extensive evaluation, care management and psychiatric consultation.
  • Ensure that Medicaid rates for primary care and mental health services are comparable to Medicare.
  • Improve public and private reimbursement of child development and mental health services.
  • Evaluate the impact of co-location models on practice-wide changes, provider outcomes and child outcomes.
Conclusion

Integrating mental health providers in primary care is an effective strategy for enhancing the provision of child development and mental health services to children and adolescents. Integrated providers help address many of the key barriers that limit the ability of pediatricians and family physicians to provide comprehensive child development and mental health services to their patient population. Evaluations of integrated models have shown improvements in both practice and care in multiple areas including: screening rates for child development services, communication among mental health and primary care providers on mental health topics, provider and patient satisfaction with care, and comfort level in addressing mental health topics. Of all the barriers to integration, financing is the most significant in terms of the long-term viability of these practices. But with the passage of the Affordable Care Act and its greater emphasis on care coordination and prevention, comprehensive public and private financing strategies – particularly those that address mental health and primary care provider reimbursement – must be created if integration is to be an effective and sustainable model for states, communities, and primary care practices.

 

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Authors

Johanna Carpenter, PhDJohanna Carpenter, PhD, is a pediatric psychologist at Nemours/A.I. duPont Hospital for Children and an assistant professor of pediatrics at Thomas Jefferson University. Her clinical work and research focus on promoting the psychosocial adjustment of children and adolescents in both hospital-based and integrated primary care settings. She provides consultative and therapeutic services to children and adolescents within one of the Nemours Pediatrics primary care clinics.


Doug TynanDoug Tynan is the Senior Health Psychologist for Nemours Health & Prevention Services and a professor of Pediatrics at Jefferson Medical College. He has had over 25 years of experience in co-located and integrated care programs in both primary and specialty pediatric programs, including private practice and health care system models. His primary research interests have been in the impact of integrated care on overall health, and in the implementation of evidence supported treatments as routine practice in clinical care settings. Tynan has a BA in Psychology from Boston University, an MS in child development from the University of Connecticut, a PhD in Clinical Psychology from Binghamton University and did his clinical internship at the University of Florida Health Sciences Center. He is a fellow in APA Divs. 37 (Society for Child and Family Policy and Practice), 38 (Health Psychology), 43 (Society for the Psychological Study of Lesbian, Gay, Bisexual and Transgender Issues), 53 (Society of Clinical Child and Adolescent Psychology) and 54 (Society of Pediatric Psychology), the co-editor of Clinical Practice in Pediatric Psychology and is also an affiliate member of the American Academy of Pediatrics.

primary-care-woodsKathryn E. Woods, PhD, is a pediatric psychologist in primary care with Nemours/AI duPont Hospital for Children. She completed her graduate training at the University of Nebraska-Lincoln, her pre-doctoral residency at the May Institute in Fall River, Mass., and her fellowship at Connecticut Children's Medical Center. Her clinical interests include early intervention, treatment for sleep, eating and toileting concerns, medical adherence and family-centered care. Her research interests focus on integrated care, health and prevention services, and parent involvement to improve child mental health and physical well-being.