Educating residents in behavioral health care and collaboration: comparison of conventional and integrated training models

Integrated Case Presentation Seminar: Bridging Parallel Fields to Improve Psychiatry and Psychology Learner Experience

Daily clinical practice of mental health professionals often requires interaction between providers from diverse training and professional backgrounds. Efforts to engage mental health trainees across disciplines are necessary and have had varied outcomes. The current study reviews the development and implementation of a monthly one-hour integrated case presentation seminar (ICPS) as part of independent psychology and psychiatry two-year fellowships at a Midwestern teaching hospital. The training integrated a semi-structured seminar to facilitate case presentation within a group setting. The focus of the seminar was to allow for exposure to conceptualization, diagnostic, and treatment strategies and skills, as well as science-based practice techniques for trainees. Learner survey results and the sustained offering of the seminar suggest the format and goals of the seminar are feasible and acceptable. Based on the current preliminary findings, similar training programs may find benefit in strategies to enhance integrated training opportunities for psychiatry and psychology trainees.

Elements of Integrated Behavioral Health Associated with Primary Care Provider Confidence in Managing Depression at Community Health Centers

BACKGROUND

Depression is most often treated by primary care providers (PCPs), but low self-efficacy in caring for depression may impede adequate management. We aimed to identify which elements of integrated behavioral health (BH) were associated with greater confidence among PCPs in identifying and managing depression.

DESIGN

Mailed cross-sectional surveys in 2016.

PARTICIPANTS

BH leaders and PCPs caring for adult patients at community health centers (CHCs) in 10 midwestern states.

MAIN MEASURES

Survey items asked about depression screening, systems to support care, availability and integration of BH, and PCP attitudes and experiences. PCPs rated their confidence in diagnosing, assessing severity, providing counseling, and prescribing medication for depression on a 5-point scale. An overall confidence score was calculated (range 4 (low) to 20 (high)). Multilevel linear mixed models were used to identify factors associated with confidence.

KEY RESULTS

Response rates were 60% (N=77/128) and 52% (N=538/1039) for BH leaders and PCPs, respectively. Mean overall confidence score was 15.25±2.36. Confidence was higher among PCPs who were satisfied with the accuracy of depression screening (0.38, p=0.01), worked at CHCs with depression tracking systems (0.48, p=0.045), had access to patients' BH treatment plans (1.59, p=0.002), and cared for more patients with depression (0.29, p=0.003). PCPs who reported their CHC had a sufficient number of psychiatrists were more confident diagnosing depression (0.20, p=0.02) and assessing severity (0.24, p=0.03). Confidence in prescribing was lower at CHCs with more patients living below poverty (-0.66, p<0.001). Confidence in diagnosing was lower at CHCs with more Black/African American patients (-0.20, p=0.03).

CONCLUSIONS

PCPs who had access to BH treatment plans, a system for tracking patients with depression, screening protocols, and a sufficient number of psychiatrists were more confident identifying and managing depression. Efforts are needed to address disparities and support PCPs caring for vulnerable patients with depression.

Association of Behavioral and Mental Health Professionals in Continuity Clinic with Resident-Reported Competence

OBJECTIVE

To assess whether residents who trained with a colocated or integrated behavioral/mental health professional (B/MHP) reported greater competence in the assessment and management of behavioral/mental health (B/MH) conditions than those who trained without an onsite B/MHP. We hypothesized that having an onsite B/MHP would be associated with greater self-reported competence, especially if integrated into clinic.

STUDY DESIGN

Cross-sectional survey of applicants for the initial American Board of Pediatrics (ABP) certifying examination. The independent variable was training in a continuity clinic with no onsite B/MHP, a colocated B/MHP, or an integrated B/MHP. Outcome variables were self-reported competence in 7 B/MH assessment skills and 9 treatment skills, summarized as 2 composite measures. Competence was rated on a 5-point scale; high competence was defined as mean scores ≥4. Logistic regression assessed relationships between independent and outcome variables adjusting for covariates including individual and residency program characteristics.

RESULTS

Of 1503 eligible respondents, 645 (42.9%) reported no onsite B/MHP, 390 (26.0%) a colocated B/MHP, and 468 (31.1%) an integrated B/MHP. In multivariable models, respondents with a colocated B/MHP reported greater levels of B/MH assessment competence (aOR 1.40, 95% CI1.06-1.86) and treatment competence (aOR 1.45, 95% CI 1.03-2.05) compared with those with no B/MHP. Respondents with an integrated B/MHP similarly reported greater odds of assessment (aOR 1.33, 95%CI 1.02-1.74) and treatment competence (aOR 1.53, 95% CI 1.10-2.13) than the reference group.

CONCLUSIONS

Although specific mechanisms were not tested, training with an onsite B/MHP within a continuity clinic may improve pediatric trainees' competence for addressing B/MH conditions.

Interprofessional Education in Child and Adolescent Mental Health: A Scoping Review

To identify elements of effective interprofessional education (IPE) within child and adolescent mental health (CAMH), we conducted a scoping literature review. A search of four databases revealed 32 studies that met inclusion criteria describing IPE interventions regarding CAMH. Studies included a range of medical, mental health, allied health, educational, and community professionals in clinical, school-based, and community-based settings. The majority of studies have focused on autism or general child mental health. Outcomes were generally positive but skewed toward attitudinal and knowledge-based measures. Practice-based interventions tended to support higher levels of educational outcomes, including behavioral, patient-level, or systems-level changes.

Where Do Future Pediatricians Learn Behavioral and Mental Health Skills?

OBJECTIVE

This national study identified the rotations in which pediatric residents received training in the assessment and treatment of behavioral/mental health (B/MH) problems, and examined associations between learning B/MH skills during multiple clinical rotations and resident-reported interest in B/MH issues.

METHODS

Cross-sectional survey of applicants for the initial American Board of Pediatrics certifying exam (62.4% response rate; 1555 eligible respondents). Respondents reported their overall interest in B/MH issues, and specified where they had received training in 7 B.M. assessment skills and 8 treatment skills. Logistic regression models were estimated to identify associations between learning B/MH assessment and treatment skills in multiple clinical rotations and resident-reported B/MH interest, adjusting for respondent characteristics.

RESULTS

Respondents reported continuity clinic as the predominant site of B/MH learning, followed by development-behavioral and adolescent rotations. Multisite learning varied across B/MH skills, ranging from 45.1 % (n = 678) for using rating scales to titrate medications to 82.1% (n = 1234) for eliciting parent concerns. 946 (63.2%) reported having overall interest in B/MH issues. Adjusting for respondent characteristics, learning the majority of B/MH skills in >1 rotation was associated with an increased odds of B/MH interest for both assessment and treatment domains (adjusted odds ratio [aOR] = 1.46, 95% confidence interval [CI] 1.16-1.83 for assessment skills and aOR = 1.36, 95% CI 1.09-1.69 for treatment skills).

CONCLUSIONS

The majority of residents report learning B/MH skills in continuity clinic, with substantial variation in the proportion learning these skills in more than one rotation. Teaching B/MH skills during multiple clinical rotations may enhance resident interest in B/MH care delivery for children.

Pediatric Residency Training for Integration of Behavior Health: Indian Perspective

Behaviour disorders are common in children. Various studies in children and Adolescents in India have found that 6% to 30% of study participants had one or other behaviour This calls for emphasis on integration of behavioral health (IBH) in the training programs for medical undergraduates and postgraduates in paediatrics. This article examines the current medical training programs for IBH of children and adolescents in curriculum of these programs in India. Pediatrics residency programs are described. The impact of Indian culture on IBH issues is also discussed. Ideas for integrating behavioral health in Medical education in India are given.

Improving Integration of Behavioral Health Into Primary Care for Adolescents and Young Adults

Problems related to mood, substance use, anxiety, body image issues, post-traumatic stress, and suicidality are common in adolescence and become even more common in young adulthood. Integrated behavioral health (IBH) in primary care has shown great promise in identifying and treating adolescents and young adults who have these problems. Treatment outcomes in IBH settings outperform those in usual primary care settings where a primary care provider may identify behavioral health problems and refer youth to colocated or outside behavioral health specialists. Despite the success of IBH care systems, limited training opportunities and inadequate financial compensation for these services jeopardize the wide scale expansion and universal adoption of IBH. To optimize patient care, providers from all disciplines in adolescent primary care settings should have dedicated professional training in IBH. This should include incorporating IBH professional competencies into each discipline's formal training program and building interprofessional, multidisciplinary IBH training settings. Likewise, payers should work with primary care systems to create and implement reimbursement models for IBH services. Efforts to expand the footprint of IBH would pay off significantly by building more worldwide BH systems with increased efficacy at identifying and treating adolescents with BH conditions.

Integrated Mental Health Training Relates to Pediatric Residents' Confidence with Child Mental Health Disorders

OBJECTIVE

The primary aim of this study was to determine the association of an integrated mental health training model on pediatric residents' use of (1) secondary screens, (2) mental health referrals, (3) psychotropic medications, and (4) follow-up appointments for mental health concerns. The secondary aim was to determine resident confidence managing mental health conditions.

METHODS

Visits of children ages 6-18 years old with either a positive primary mental health screen or a mental health diagnosis in pre- and post-intervention years (N = 113 and N = 251, respectively) at a single-site continuity clinic were included. Authors also surveyed alumni from pre- and post- intervention years (N = 46) about their confidence with managing mental health disorders. The authors used chi-squared and t-tests to compare visit characteristics between years and multivariable logistic regression to determine correlates of mental health management.

RESULTS

Post-intervention residents more often used secondary screening tools (adjusted odds ratio 5.61, 95% confidence interval 2.08-15.17). There were no differences in referrals, prescribing psychotropic medications, or follow-up visits. Post-intervention graduates reported higher confidence with diagnosis, screening, medication management, and follow-up for mental health disorders.

CONCLUSIONS

After transitioning to an integrated mental health model, residents were more likely to use secondary screens and post-intervention graduates reported higher confidence with managing mental health disorders.

Towards Integrated Youth Care: A Systematic Review of Facilitators and Barriers for Professionals

To overcome fragmentation in support for children and their families with multiple and enduring problems across life domains, professionals increasingly try to organize integrated care. However, it is unclear what facilitators and barriers professionals experience when providing this integrated care. Our systematic review, including 55 studies from a broad variety of settings in Youth Care, showed that integrated care on a professional level is a multi-component entity consisting of several facilitators and barriers. Findings were clustered in seven general themes: ‘Child’s environment’, ‘Preconditions’, ‘Care process’, ‘Expertise’, ‘Interprofessional collaboration’, ‘Information exchange’, and ‘Professional identity’. The identified facilitators and barriers were generally consistent across studies, indicating broad applicability across settings and professional disciplines. This review clearly shows that when Youth Care professionals address a broad spectrum of problems, a variety of facilitators and barriers should be considered.

Registration PROSPERO, registration number CRD42018084527.

The role of integrated behavioral health in caring for patients with metabolic disorders

This review of integrated behavioral health (IBH) provides a background on IBH models, and the benefits of IBH in pediatric practice with an emphasis on how IBH specialists can collaborate with families and clinicians. An overview of intellectual disability (ID) and psychiatric disorders focused on disorders of inborn errors of metabolism (IEM) highlights issues in assessment and monitoring of these patients with implications for clinical practice and the role of IBH in caring for patients with IEM disorders.

Mental health care for youth with rheumatologic diseases - bridging the gap

Youth with rheumatologic diseases have a high prevalence of comorbid mental health disorders. Individuals with comorbid mental health disorders are at increased risk for adverse outcomes related to mental health as well as their underlying rheumatologic disease. Early identification and treatment of mental health disorders has been shown to improve outcomes, but current systems of care fall short in providing adequate mental health services to those in need. Pediatric rheumatologists are uniquely positioned to provide mental health screening and intervention for youth with rheumatologic diseases due to the frequency of patient encounters and ongoing therapeutic relationship with patients and families. However, additional training is likely required for pediatric rheumatologists to provide effective mental health care, and focusing efforts on providing trainees with mental health education is key to building competency. Potential opportunities for improved mental health education include development of clinical guidelines regarding mental health screening and management within pediatric rheumatology settings and incorporation of mental health didactics, workshops, and interdisciplinary clinic experiences into pediatric rheumatology fellowship curricula. Additional steps include mental health education for patients and families and focus on system change, targeting integration of medical and mental health care. Research is needed to better define the scope of the problem, determine effective strategies for equipping pediatric rheumatologists with skills in mental health intervention, and develop and implement sustainable systems for delivery of optimal mental health care to youth with rheumatologic diseases.

On-site Mental Health Professionals and Pediatric Residents in Continuity Clinic

The objective of the study was to examine differences in pediatric resident perceptions and practices related to child mental health conditions in continuity clinic settings with versus without on-site mental health professionals (MHPs). A 20-item questionnaire, based on the American Academy of Pediatrics Periodic Survey Number 59, was administered to pediatric residents in a medium-sized program from 2008 to 2011. Of 130 residents surveyed, compared with their peers, those practicing with the on-site MHPs were more likely to report mental health services as very available in their clinic (odds ratio [OR] = 39.7; P = .000). Residents with on-site MHPs inquired more frequently about attention-deficit/hyperactivity disorder (ADHD; OR = 2.96; P = .029) and referred more frequently for ADHD (OR = 3.68; P = .006), depression (OR = 2.82; P = .030), and behavioral problems (OR = 3.04; P = .012). On-site MHPs in continuity clinics offer great potential to improve resident education and patient care. Additional research is necessary to further understand their impact.

Competencies and Training Guidelines for Behavioral Health Providers in Pediatric Primary Care

This article focuses on the cross-discipline training competencies needed for preparing behavioral health providers to implement integrated primary care services. After a review of current competencies in the disciplines of child and adolescent psychiatry, psychology, and social work, cross-cutting competencies for integrated training purposes are identified. These competencies are comprehensive and broad and can be modified for use in varied settings and training programs. An existing and successful integrated care training model, currently implemented at Children's Hospital of Philadelphia, is described. This model and the training competencies are discussed in the context of recommendations for future work and training.

Incorporating Trainees' Development into a Multidisciplinary Training Model for Integrated Behavioral Health Within a Pediatric Continuity Clinic

Integrated behavioral and mental health systems of care for children require multidisciplinary team members to have specific competencies and knowledge of the other disciplines' strengths and practice needs. Training models for multidisciplinary professionals should consider the developmental level of trainees. The authors describe a model of flexible scaffolding, increasing intensity, and depth of experience as trainees gain skills and knowledge.

Which Pediatricians Comanage Mental Health Conditions?

OBJECTIVE

Given the prevalence of mental health (MH) conditions (MHC) in children, pediatricians should initiate treatment alone or in collaboration with a specialist for children with MHC. However, the majority of pediatricians do not manage or comanage common MHC even with an on-site MH provider. We examined which physician, practice, and training characteristics are associated with pediatricians' comanaging at least half of their patients with MHC.

METHODS

We analyzed responses of general pediatricians (n = 305) from the American Academy of Pediatrics 2013 Periodic Survey. Practice characteristics include presence of an on-site MH provider and perceived access to services. Independent variables included sociodemographics, training experiences, and interest in further training. The outcome was comanagement of ≥50% of patients with MHC. Weighted univariate, bivariate, and multivariable analyses were performed.

RESULTS

Of the pediatricians who reported comanaging ≥50% of their patients with MHC, logistic regression analysis showed that pediatricians who completed ≥4 weeks of developmental behavioral pediatrics training had 1.8 increased odds (95% confidence interval 1.06, 3.08, P = .03) of comanagement, those very interested in further education in managing/treating MHC had 2.75 increased odds (95% confidence interval 1.63, 3.08, P < .001), and those with more training in MH treatment with medications had 1.4 increased odds (95% confidence interval 1.12, 1.75, P = .004) of comanaging children with MHC.

CONCLUSIONS

Specific educational experiences and interest in further education in managing or treating MHC were significantly associated with comanaging ≥50% of patients, suggesting that enhanced MH training among pediatricians could increase the comanagement of children with MHC.

Preparing the Workforce for Behavioral Health and Primary Care Integration

PURPOSE

To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care.

METHODS

Observational cross-case comparison study of 19 U.S. practices, 11 participating in Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach.

RESULTS

Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs.

CONCLUSION

Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration. Until the training capacity grows to meet the demand, practices must put forth considerable effort and resources to train their own employees.

The current and ideal state of mental health training: pediatric program director perspectives

OBJECTIVE

To assess pediatric residency program director (PD) perceptions of the current state of mental health (MH) training, their receptivity to curricular changes, and perceptions of their residents' knowledge and skills in MH care.

METHODS

We performed a cross-sectional study utilizing a Web-based survey of pediatric residency PDs to assess program characteristics, learning modalities PDs currently had or would implement, and their knowledge of the new American Academy of Pediatrics' MH competencies. PDs then ranked their residents' knowledge and skills for 29 MH competencies. Analyses included descriptive statistics and bivariate and multivariate analyses to assess for associations between variables, particularly MH model of care and perceived competence.

RESULTS

Ninety-nine PDs (51%) responded. A total of 87% of PDs reported that MH care was taught as part of another rotation, yet PDs were receptive to curricular changes. Only 45% of PDs were aware of the 2009 American Academy of Pediatrics competencies, and PDs infrequently rated their residents' MH skills and knowledge to be above average. Attention-deficit/hyperactivity disorder (ADHD) was an exception: 64% reported above-average ADHD knowledge in diagnoses and 57% in treatment. There was an association between enhanced MH services in continuity clinics and perceived resident systems-based practice (P < .01) and medical knowledge (P = .04).

CONCLUSIONS

PDs acknowledged that MH training is not emphasized, leading to deficiencies in their residents' knowledge and skills in MH care. The receptivity of PDs suggests the need for targeted dissemination of national guidelines or curriculum. Integrated models of care may be one way to improve resident competencies, but this deserves further study.

Integrating mental health services in primary care continuity clinics: a national CORNET study

OBJECTIVE

To determine whether pediatric continuity clinics integrate mental health (MH) services into care delivery; and to determine whether the level of MH integration is related to access to MH services, types of MH screening performed, self-efficacy, satisfaction with referral sites, and communication with the primary care provider.

METHODS

Pediatric Residency Integrated Survey of Mental Health in Primary Care (PRISM_PC) is a newly designed cross-sectional, Web-based survey of continuity clinic directors participating in a national network of pediatric continuity clinics (CORNET). Definitions of MH models included integrated or nonintegrated MH models or traditional care. The survey included questions regarding access, screening that was performed at sites, comfort with MH management as well as provider satisfaction and communication with referral sites.

RESULTS

Seventy-eight percent (57 of 73) of CORNET site directors responded, representing input from 30% of US pediatric residency continuity programs. Thirty-five percent (n = 20) reported an integrated MH model while 65% (n = 37) reported a nonintegrated MH model. Seventy-nine percent screened for attention-deficit/hyperactivity disorder, 44% for behavioral-emotional issues, and 19% for pediatric depression. No differences were found in terms of screening or tools used on the basis of the level of MH integration. Those with integrated programs were more likely to have access to an on-site psychologist (P = .001) or psychiatrist (P = .006).

CONCLUSIONS

Directors from one-third of training programs surveyed reported some level of MH integration in their primary care teaching clinics. Future studies are needed to compare patient and resident education outcomes between integrated and nonintegrated sites.

Educating residents in behavioral health care and collaboration: integrated clinical training of pediatric residents and psychology fellows

Pediatric residency practices face the challenge of providing both behavioral health (BH) training for pediatricians and psychosocial care for children. The University of Rochester School of Medicine and Dentistry and Rochester General Hospital developed a joint training program and continuity clinic infrastructure in which pediatric residents and postdoctoral psychology fellows train and practice together. The integrated program provides children access to BH care in a primary care setting and gives trainees the opportunity to integrate collaborative BH care into their regular practice routines. During 1998-2008, 48 pediatric residents and 8 psychology fellows trained in this integrated clinical environment. The program's accomplishments include longevity, faculty and fiscal stability, sustained support from pediatric leadership and community payers, the development in residents and faculty of greater comfort in addressing BH problems and collaborating with BH specialists, and replication of the model in two other primary care settings. In addition to quantitative program outcomes data, the authors present a case example that illustrates how the integrated program works and achieves its goals. They propose that educating residents and psychology trainees side by side in collaborative BH care is clinically and educationally valuable and potentially applicable to other settings. A companion report published in this issue provides results from a study comparing the perceptions of pediatric residents whose primary care continuity clinic took place in this integrated setting with those of residents from the same pediatric residency who had their continuity clinic training in a nonintegrated setting.