Integrated behavioral health in pediatric primary care provides an exciting opportunity to improve mental health care for children and adolescents. Nationally, approximately 1 in 5 youth experience a mental disorder each year—with steady increases since the COVID-19 pandemic—however, only 10% of youth receive any mental health service regardless of diagnosis. It is critical to identify methods to improve access to both timely and quality care for our youth experiencing mental and behavioral health (MBH) concerns.
One solution is integrated behavioral health (IBH). IBH consists of a collaborative team of primary care providers and behavioral health specialists working together to provide systematic, cost-effective, patient-centered care. Primary care pediatricians are often the first point of contact for children and adolescents experiencing mental and behavioral health concerns. Not only does IBH improve access and quality of care for patients, primary care providers are more equipped to manage their patients’ care with IBH programs. Moreover, integrated behavioral health can improve health outcomes, reduce mental health stigma, decrease provider burnout, reduce healthcare costs, and increase practice revenue (American Medical Association, 2021; Lynch et al., 2019; Njoroge et al., 2016; Gouge et al., 2016). Integrating behavioral health in the primary care setting benefits both patients and providers.
Delivery of integrated behavioral health care varies based on practice setting and resources. Care exists along a continuum from least integrated to most integrated with three model types: (1) coordinated care (2) co-located care and (3) integrated care. Coordinated care consists of a facilitated referral process with primary care providers (PCPs) communicating with behavioral health (BH) providers as needed for guidance in assessing, managing, and referring for MBH concerns. Telephone consultation services, such as the Massachusetts Child Psychiatry Access Project, serve as one example of coordinated care. While coordinated care improves access to MBH services, the level of integration is limited as PCPs and BH providers deliver care separately. At the next level of integration, there is co-located care, which consists of on-site BH providers in the primary care setting. Often BH providers are located within the same facility as PCPs—allowing for more enhanced, informal communication between providers. However, integration is still limited as providers deliver care separately. At the highest level of care is integrated care which consists of regular collaboration between PCPs and BH providers with active co-management of patients. PCPs and BH providers typically work in the same office space and work in tandem to provide a single, cohesive treatment plan for patients.
The Behavioral Health Integration Program (BHIP) is a leading example of integrated care in the United States. BHIP serves as a leading example due its wide-implementation (i.e. over 50 practices and over 300,000 patients have benefitted from this program), innovative approach to IBH (i.e. the program offers multi-component educational, consultation, and operational support), and significant outcomes in peer-reviewed research. Significant findings include improved primary care access to BH services, increased PCP self-efficacy and satisfaction, and an overall increase in BH integration in the primary care setting. This program was implemented in Massachusetts, however, there is opportunity to adapt this program to meet the needs of youth throughout the US—specifically in Georgia where access to mental and behavioral health services is considerably limited.
In Georgia, the prevalence of MBH among youth is similar to the national population as 1 in 5 Georgia youth experience a mental disorder with suicide as the 3rd leading cause of death among Georgia children in 2019. Yet, access to MBH services in Georgia is particularly concerning as Georgia ranks 48th in the nation (including DC) for access to mental health services. IBH programs have been implemented throughout the United States, however there are no current examples in Georgia. Given the need for more integrated behavioral health care, there is opportunity to apply lessons learned from prior research for the development and implementation of similar programs within the state.
In the Spring of 2022, Resilient Georgia conducted a literature search of IBH programs in the US from 2012 to 2022. Jessica Reed (MD/MPH student at Emory University) conducted a national scan of integrated behavioral health under direct supervision from and in collaboration with Dr. Emily Anne Vall (RG’s Executive Director), Neha Khanna (RG’s Director of Strategy and Operations), and Jed Rich (Strategic Consultant). The team at Resilient Georgia searched two large databases (PubMed and PsycINFO) for peer-reviewed publications of integrated behavioral programs. Of the total 1,208 publications reviewed, 53 were evaluations of integrated behavioral health programs. The information from these articles served as the foundation for the national landscape scan, which describes what integrated behavioral health is, why it is needed, how it can be delivered, and best practices for program development and implementation.
Best practices in integrated behavioral include (1) assessing practices’ readiness for integration using validated tools (2) identifying IBH team members based on practice need (3) establishing practice workflow and protocols (4) encouraging ongoing PCP education and training and (5) engaging patients and their families in the integrated model. These best practices and lessons learned from previous IBH programs can serve as the foundation for any stakeholder—at the state or national level— interested in designing and implementing an integrated behavioral health program of their own.
For additional guidance, please refer to the national scan as well as the Behavioral Health Integration Compendium created by the American Medical Association, American Academy of Pediatrics, and American Academy of Child and Adolescent Psychiatry.
References:
1. Behavioral Health Integration Compendium. (2021). American Medical Association. https://www.ama-assn.org/system/files/bhi-compendium.pdf
2. Lynch, S., Greeno, C., Teich, J. L., & Heekin, J. (2019). Pediatric integrated behavioral health service delivery models: Using a federal framework to assess levels of integration. Soc Work Health Care, 58(1), 32-59. https://doi.org/10.1080/00981389.2018.1531104
3. Njoroge, W. F., Hostutler, C. A., Schwartz, B. S., & Mautone, J. A. (2016). Integrated Behavioral Health in Pediatric Primary Care. Curr Psychiatry Rep, 18(12), 106. https://doi.org/10.1007/s11920-016-0745-7
4. Gouge, N., Polaha, J., Rogers, R., & Harden, A. (2016). Integrating Behavioral Health into Pediatric Primary Care: Implications for Provider Time and Cost. South Med J, 109(12), 774-778. https://doi.org/10.14423/smj.0000000000000564
5. <a href='https://www.freepik.com/photos/family-doctor'>Family doctor photo created by gpointstudio - www.freepik.com</a>