Integrated Behavioral Health in Pediatric Subspecialty Clinics

Increasing Mental Health Screening in Pediatric Subspecialty Clinics: An Improvement Project at Brooke Army Medical Center

INTRODUCTION

Mental health screening allows for the early identification of patients at risk of mental health disorders such as anxiety and depression. The Defense Health Administration Procedures Manual 6025.01 established that patients older than 12 years of age should receive annual mental health screening assessing suicidality risk with a standardized screening tool.

MATERIALS AND METHODS

To improve rates of mental health screening in this at-risk population, an A3 Lean approach to quality improvement was undertaken in the Pediatric Subspecialty Clinics at Brooke Army Medical Center.

RESULTS

Baseline data of Patient Health Questionnaire-9 or General Anxiety Disorder-7 screening from pediatric pulmonology and cardiology clinics were 6.3%. Plan-Do-Study-Act quality improvement methods evaluated possible interventions to improve screening. A standard operating procedure (SOP) outlining scoring and interpretation recommendations was distributed in pediatric pulmonology and cardiology clinics. Using the Armed Forces Health Longitudinal Technology Application, a post-implementation chart review was conducted for 8 weeks. With the initiation of Military Health System Genesis, the SOP was adjusted and a root cause analysis was performed. The pediatric gastroenterology clinic cares for patients presenting with functional abdominal pain; therefore, the clinic was added to the second iteration to determine if anxiety or depression may play a role. Providers were educated on documentation and coding. A second post-implementation chart review was conducted for 8 weeks. Over two iterations, mental health screening of new adolescent patients in pediatric subspecialty clinics increased by 794% from baseline. Our providers screened 50% of the adolescent patients.

CONCLUSIONS

With increased surveillance of an at-risk population, more adolescents will receive the standard of care. With refinement of the SOP and expansion to other subspecialties, this project has the potential to expand within Brooke Army Medical Center and other clinics in the Defense Health Administration.

Association Between Educational Resources and Pediatric Fellows' Mental Health Attitudes and Self-Reported Competence

BACKGROUND/OBJECTIVES

Children with chronic medical conditions (CCMC) have high rates of mental health (MH) conditions. This study examines associations between MH educational resources during fellowship and 3 dependent variables: fellows' interest, perceived responsibility, and self-reported competence in assessing MH concerns of CCMC.

METHODS

Subspecialty fellows taking the American Board of Pediatrics in-training examinations in February 2020 were invited to participate in a survey inquiring about MH educational resources. Logistic regression examined associations between MH educational resources and the 3 dependent variables, adjusting for demographics and program-level characteristics.

RESULTS

Of the 97.7% (4216) fellows who responded, 3870 were included in analyses. About 37.5% reported formal MH teaching sessions; 36.7% reported on-site MH professionals engaged in teaching; 41.6% reported co-assessing patients with MH specialists; and 28.3% reported performance evaluation of their MH skills. All 4 resources were significantly and positively associated with self-reported competence in adjusted analyses, with odds ratios (OR) ranging from 1.28 (95% confidence interval (95% CI): 1.03-1.58) for formal teaching sessions to 2.14 (95% CI: 1.73-2.65) for performance evaluation. Resources were positively associated with the dependent variables in a "dose-response" pattern. Respondents who reported having all 4 educational resources compared to zero resources had an OR of 2.20 (95% CI: 1.74-2.78) for high MH interest, 3.18 (95% CI: 2.45-4.12) for high perceived responsibility, and 4.38 (95% CI: 3.43-5.60) for high self-reported competence CONCLUSIONS: Access to mental health educational resources was associated with higher interest, perceived responsibility, and self-reported competence; investing in these resources may improve fellows' skills in addressing the emotional needs of CCMC.

Family Engagement in Services During COVID-19: A Mixed-Methods Study of Caregiver and Staff Perspectives

INTRODUCTION

We examined changes in family engagement before versus during the pandemic in pediatric and family services and perceived facilitators and barriers to family engagement.

METHOD

We employed a mixed-methods assessment of staff and caregiver perspectives related to pediatric and family medicine clinics and family resource centers in rural northern New England. We used narrative synthesis to analyze qualitative interviews (n = 29) and descriptive statistics for quantitative surveys (n = 108).

RESULTS

Staff felt they were not doing as well at engaging families during versus prepandemic, identifying numerous facilitators and barriers. We found differences in resources used by families before versus during the pandemic. We identified discordant perspectives between caregivers and staff regarding how well clinics and centers identified and responded to family needs.

DISCUSSION

Leaders in pediatrics, advanced practice nursing, and related fields can draw on our findings to decide what services and modalities they provide for postpandemic.

Clinical Update: Collaborative Mental Health Care for Children and Adolescents in Pediatric Primary Care

OBJECTIVE

The objective of this Clinical Update is to review the principles, structures, processes, and outcomes of collaborative mental health care in the pediatric primary care setting.

METHOD

A search of the literature on this topic from 2001was conducted initially in 2016, yielding 2,279 English-language citations. These citations were supplemented by references suggested by topic experts and identified through Web searches, increasing the yield to 2,467 total citations, of which 1,962 were unduplicated. After sequential review by Update authors at title/abstract and then full-text levels, the citations were winnowed to 219 based on topic relevance. A follow-up search from 2016 was conducted in 2021, yielding 2 additional citations based on nonduplication from initial search and topic relevance.

RESULTS

The collaborative care approach, arising in the 1990s and gaining momentum in the 2000s, aims to extend behavioral health care to the primary care setting. The goal of collaborative care is to conserve the sparse specialty care workforce for severe and complex psychiatric disorders through shifting certain specialty mental health tasks (eg, assessment; patient self-management; brief psychosocial intervention; basic psychopharmacology; care coordination) to primary care. Collaborative care can be delivered on a spectrum ranging from coordinated to co-located to integrated care. Although each of these models has some empirical support, integrated care-a multidisciplinary team-based approach-has the strongest evidence base in improving clinical outcomes and patient satisfaction while constraining costs. Challenges to integrated care implementation include insufficient mental health education and insufficient specialist consultative and care coordination support for primary care practitioners; space, time, and reimbursement constraints in the primary care setting; discomfort among primary care practitioners in assuming mental health tasks previously undertaken by specialists; and continuing need for and unavailability of ongoing specialty mental health care for severe and complex cases. Essential supporting activities for effective collaborative care include patient and family engagement, professional education and training, evaluation/demonstration of impact, fiscal sustainability, and advocacy for model dissemination.

CONCLUSION

Health professionals who are educated in the collaborative care approach can improve access to and quality of behavioral health care for children and adolescents with behavioral health needs.