Implementation of Off-Site Integrated Care for Children: A Scoping Review.

BACKGROUND: As an alternative to co-located integrated care, off-site integration (partnerships between primary care and non-embedded specialty mental health providers) can address the growing need for pediatric mental health services. Our goal is to review the existing literature on implementing off-site pediatric integrated care. METHODS: We systematically searched the literature for peer-reviewed publications on off-site pediatric integrated care interventions. We included studies that involved systematic data collection and analysis, both qualitative and quantitative, of implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability). RESULTS: We found 39 original articles from 24 off-site programs with a variety of study designs, most with secondary implementation outcomes. Models of off-site integration varied primarily along two dimensions: direct vs. indirect, and in-person vs. remote. Overall, off-site models were acceptable to providers, particularly when the following were present: strong interdisciplinary communication, timely availability and reliability of services, additional support beyond one-time consultation, and standardized care algorithms. Adoption and penetration were facilitated by enhanced program visibility, including on-site champions. Certain clinical populations (e.g., school-age, less complicated ADHD) seemed more amenable to off-site integrated models than others (e.g., preschool-age, conduct disorders). Lack of funding and inadequate reimbursement limited sustainability in all models. CONCLUSIONS: Off-site interventions are feasible, acceptable, and often adopted widely with adequate planning, administrative support, and interprofessional communication. Studies that focus primarily on implementation and that consider the perspectives of specialty providers and patients are needed.

Evaluation of an electronic consultation service in psychiatry for primary care providers.

BACKGROUND: This study explores the effectiveness of an electronic consultation (eConsult) service between primary care providers and psychiatry, and the types and content of the clinical questions that were asked. METHODS: This is a retrospective eConsult review study. All eConsults directed to Psychiatry from July 2011 to January 2015 by Primary care providers were reviewed. Response time and the amount of time reported by the specialist to answer each eConsult was analyzed. Each eConsult was also categorized by clinical topic and question type in predetermined categories. Mandatory post-eConsult surveys for primary care providers were analyzed to determine the number of traditional consults avoided and to gain insight into the perceived value of eConsults. RESULTS: Of the 5597 eConsults, 169 psychiatry eConsults were completed during the study period. The average response time for a specialist to a primary care provider was 2.3 days. Eighty-seven percent of clinical responses were completed by the psychiatrist in less than 15 min. The primary care providers most commonly asked clinical questions were about depressive and anxiety disorders. 88.7% of PCPs rated the eConsult service a 5 (excellent value) or 4. CONCLUSIONS: This study indicates that an eConsult psychiatry service has tremendous potential to improve access to psychiatric advice and expand the capacity to treat mental illness in primary care. Future research may include follow-up with PCPs regarding the implementation of specialist advice.

What's known about implementing co-located paediatric integrated care: a scoping review.

Several studies have demonstrated clinical benefits of integrated care for a range of child and adolescent mental health outcomes. However, there is a significant gap between the evidence for efficacy of integrated care interventions vs their implementation in practice. While several studies have examined large-scale implementation of co-located integrated care for adults, much less is known for children. The goal of this scoping review was to understand how co-located mental health interventions targeting children and adolescents have been implemented and sustained. The literature was systematically searched for interventions targeting child and adolescent mental health that involved a mental health specialist co-located in a primary care setting. Studies reporting on the following implementation outcomes were included: acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability. This search identified 34 unique studies, including randomized controlled trials, observational studies, and survey/mixed method approaches. Components facilitating implementation of on-site integrated behavioural healthcare included interprofessional communication and collaboration at all stages of implementation; clear protocols to facilitate intervention delivery; and co-employment of integrated care providers by specialty clinics. Some studies found differences in service use by demographic factors, and others reported funding challenges affecting sustainability, warranting further study.