A Phone Consultation Call Line to Support SBIRT in Pediatric Primary Care.

Background: Screening Brief Intervention Referral to Treatment (SBIRT) is recommended as a routine part of pediatric primary care, though managing patients with positive screens is challenging. To address this problem, the state of Massachusetts created a call line staffed by pediatric Addiction Medicine specialists to provide consultations to primary care providers and access to a behavioral health provider specially trained in managing adolescent substance use. Objective: To describe the uptake and outcomes of a consultation call line and virtual counseling for managing substance use disorders (SUD) in pediatric primary care. Methods: Service delivery data from consultations and counseling appointments were captured in an electronic database including substance, medication recommendations, level of care recommendations and number of counseling appointments completed for each patient. Summary data is presented here. Results: In all, there were 407 encounters to 108 unique families, including 128 consultations and 279 counseling visits in a one-year period. The most common substances mentioned by healthcare providers were cannabis (64%), nicotine (20%), alcohol (20%), vaping (9%) and opioids (5%). Management in primary care was recommended for 87 (68%) of the consultations. Medications for SUD treatment were recommended for 69 (54%) consultations including two for opioid use disorder. Conclusion: We found that both a statewide consultation call line and virtual counseling to support SBIRT in pediatric primary care were feasible. The majority of consultations resulted in recommendations for treatment in primary care.

Depressive symptom screening and endorsement of psychosis risk-related experiences in a diverse adolescent and young adult outpatient clinic in the US.

BACKGROUND: Early identification and intervention is a gold standard for psychotic disorders, for which delays in care can have serious consequences. Screening for psychosis in primary care may circumvent barriers related to stigma and facilitate shorter pathways to care. Yet, there is debate regarding the benefit-risk balance for psychosis screening in general adolescent populations. METHODS: Primary care patients of an adolescent/young adult medical clinic in the US ages 14-21 self-administered surveys assessing age, sex, receipt of psychotherapy, and occurrence, frequency (1-5), and distress (0-3) for 23 psychosis risk (PR) symptoms, including 6 general/nonspecific items and 17 psychosis-specific items. Participants also completed the 9-item Patient Health Questionnaire (PHQ-9); scores of ≥10 suggested clinically significant depressive symptoms. Analyses characterized PR symptoms and examined associations of PR symptom distress with current therapy and depressive symptom severity. RESULTS: Of 212 patients who completed the survey, 75% endorsed ≥1 PR symptom and 27% rated ≥3 on distress for psychosis-specific items. Those with high PHQ-9 scores reported higher PR distress overall (t = -6.1, df = 52.3, p < 0.001) but not on psychosis-specific items such as hallucinations and suspiciousness. One in 9 participants reported heightened PR distress without being in therapy or having high depressive symptoms. CONCLUSIONS: Most adolescents in this primary care sample endorsed symptoms associated with PR. Distress related to these symptoms was less common but occurred even in the absence of depressive symptoms. PR screening only in youth with high depressive symptom screens or in mental health care may miss youth needing further assessment for psychosis.

Adolescent SBIRT Practices Among Pediatricians in Massachusetts.

OBJECTIVES: Adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care is a key strategy to prevent, identify, and respond to substance use problems and disorders, including opioid and other drug addictions. Despite substantial investment in recent years to increase its implementation, few studies have reported on recent levels of SBIRT implementation among pediatricians. We aimed to assess self-reported use of the SBIRT framework with adolescent patients among Massachusetts pediatricians, and describe trends since an earlier survey. METHODS: We analyzed responses to a cross-sectional survey mailed in 2017 to a representative sample of pediatricians in Massachusetts. We computed response frequencies for all SBIRT practice questions. We used the chi-square test to compare current data to data collected in 2014, as we found no demographic differences between the 2 samples. RESULTS: Nearly all pediatricians in the 2017 sample (n = 160) reported annual screening of their adolescent patients (99%). The majority reported giving positive reinforcement (87%), brief advice (92%), counseling (90%), and referral to treatment (66%) in response to screen results. Compared with 2014, a significantly higher proportion of pediatricians in 2017 referred patients who screened positively for problematic alcohol use, but perceived barriers to screening and follow-up remain, such as insufficient time to screen and patient refusal to return. CONCLUSIONS: Among respondents to a Massachusetts pediatrician survey, we found high rates of delivering SBIRT in accordance with published guidelines, though barriers remain. Whether the content of the counseling adheres to guidelines is unknown.

Massachusetts Child Psychiatry Access Project 2.0: A Case Study in Child Psychiatry Access Program Redesign.

The Massachusetts Child Psychiatry Access Program is a statewide public mental health initiative designed to provide consultation, care navigation, and education to assist pediatric primary care providers in addressing mental health problems for children and families. To improve program performance, adapt to changes in the environment of pediatric primary care services, and ensure the program's long-term sustainability, program leadership in consultation with the Massachusetts Department of Mental Health embarked on a process of redesign. The redesign process is described, moving from an initial strategic assessment of program and the planning of structural and functional changes, through transition and implementation.

Screening Adolescents for Alcohol Use: Tracking Practice Trends of Massachusetts Pediatricians.

OBJECTIVES: Substance use screening is a recommended component of routine healthcare for adolescents. A 2008 survey of Massachusetts primary care physicians found high rates of screening, but low rates of validated tool use, leading to the concern that physicians may be missing substance use-related problems and disorders. In an effort to improve practice, a cross-disciplinary group developed and distributed an adolescent screening, brief intervention, and referral to treatment toolkit in 2009. A new survey of Massachusetts primary care physicians was conducted in 2014; this report describes its findings, and compares them to those from 2008. METHODS: A survey was mailed to a randomly selected sample of Massachusetts primary care physicians listed in the state Board of Registration in Medicine database. Item response frequencies were computed. Multiple logistic regression modeling was used to compare 2008 and 2014 responses, while controlling for any demographic differences between samples. RESULTS: Pediatrician respondents in 2014 (analysis N = 130) reported a high rate of annually screening patients for alcohol use (96.2%), but only 56.2% reported using a validated screening tool. Rates of screening and validated tool use were higher in 2014 than 2008. Insufficient knowledge as a reported barrier to screening decreased from 2008 to 2014. However, lack of time or staff resources remained key perceived barriers to screening. CONCLUSIONS: Our findings suggest that adolescent alcohol use screening practices among Massachusetts pediatricians have improved in recent years, during a time of national and statewide efforts to educate physicians. However, opportunities for practice improvement remain.

Behavioral health care for children: the massachusetts child psychiatry access project.

Access to behavioral health care for children is essential to achieving good health care outcomes. Pediatric primary care providers have an essential role to play in identifying and treating behavioral health problems in children. However, they lack adequate training and resources and thus have generally been unable to meet children's need for behavioral health care. The Massachusetts Child Psychiatry Access Project has addressed this problem by delivering telephone child psychiatry consultations and specialized care coordination support to over 95 percent of the pediatric primary care providers in Massachusetts. Established in 2004, the project consists of six regional hubs, each of which has one full-time-equivalent child psychiatrist, licensed therapist, and care coordinator. Collectively, the hubs are available to over 95 percent of the 1.5 million children in Massachusetts. In fiscal year 2013 the Massachusetts Child Psychiatry Access Project served 10,553 children. Pediatric primary care providers enrolled in the project reported a dramatic improvement in their ability to meet the psychiatric needs of their patients. Telephone child psychiatry consultation programs for pediatric primary care providers, many modeled after the Massachusetts project, have spread across the United States.

Clinicians' utilization of child mental health telephone consultation in primary care: findings from Massachusetts.

OBJECTIVE: The authors examined utilization of the Massachusetts Child Psychiatry Access Project, a mental health telephone consultation service for primary care, hypothesizing that greater use would be related to severe psychiatric diagnoses and polypharmacy. METHODS: The authors examined the association between utilization, defined as the mean number of contacts per patient during the 180 days following the initial contact (July 2008-June 2009), and characteristics of the initial contact, including consultation question, the child's primary mental health problem, psychotropic medication regimen, insurance status, and time of year. RESULTS: Utilization (N=4,436 initial contacts, mean=3.83 contacts) was associated with initial contacts about medication management, polypharmacy, public and private health insurance, and time of year. The child's primary mental health problem did not predict utilization. CONCLUSIONS: Telephone consultation services address treatment with psychotropic medications, particularly polypharmacy. Joint public-private funding should be considered for such public programs that serve privately insured children.

Medico-legal risk associated with pediatric mental health telephone consultation programs.

Clinicians providing consultation through mental health telephone consultation programs express concern about the potential legal risk of the practice. In this survey of six state mental health telephone consultation program directors, we report the annual number of children referred for consultation and the number of lawsuits against consultant clinicians. Between 2004 and 2010, 3,652 children per year were referred nationally, and there were no medical malpractice lawsuits against clinicians related to telephone consultation program activity. Although medico-legal risk is always present, the findings of this national study suggest the risk for clinicians providing mental health telephone consultation may be lower than perceived.

Bridging the divide between child psychiatry and primary care: the use of telephone consultation within a population-based collaborative system.

The Massachusetts Child Psychiatry Access Project is a public system for improving access to care for children with mental health problems in which the provision of telephone consultation by child psychiatry teams to pediatric primary care providers (PCPs) plays a central role. In this article, the practice of telephone consultation within this system is explored through the examination of case studies, demonstrating its use in common clinical scenarios. The telephone consultations provide immediate case-based clinical education, and also serve as a gateway for the provision of as-needed direct child psychiatry evaluation and care coordination services. Most importantly, the telephone consultations build sustaining collaborative relationships, enhancing the ability of PCPs to meet the needs of children with mental health problems.

Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project.

BACKGROUND: Inadequate access to care for mentally ill children and their families is a persistent problem in the United States. Although promotion of pediatric primary care clinicians (PCCs) in detection, management, and coordination of child mental health care is a strategy for improving access, limitations in training, time, and specialist availability represent substantial barriers. The Massachusetts Child Psychiatry Access Project (MCPAP), publicly funded with 6 regional consultation teams, provides Massachusetts PCCs with rapid access to child psychiatry expertise, education, and referral assistance. METHODS: Data collected from MCPAP teams measured participation and utilization over 3.5 years from July 1, 2005, to December 31, 2008. Data were analyzed for 35,335 encounters. PCC surveys assessed satisfaction and impact on access to care. RESULTS: The MCPAP enrolled 1341 PCCs in 353 practices covering 95% of the youth in Massachusetts. The MCPAP served 10,114 children. Practices varied in their utilization of the MCPAP, with a mean of 12 encounters per practice per quarter (range: 0-245). PCCs contacted the MCPAP for diagnostic questions (34%), identifying community resources (27%), and consultation regarding medication (27%). Provider surveys revealed improvement in ratings of access to child psychiatry. The rate of PCCs who reported that they are usually able to meet the needs of psychiatric patients increased from 8% to 63%. Consultations were reported to be helpful by 91% of PCCs. CONCLUSIONS: PCCs have used and value a statewide system that provides access to teams of psychiatric consultants. Access to child mental health care may be substantially improved through public health interventions that promote collaboration between PCCs and child mental health specialists.

The interdependence of behavioral and somatic health: implications for conceptualizing health and measuring treatment outcomes.

PURPOSE: The interdependence of behavioral and somatic aspects of various health conditions warrants greater emphasis on an integrated care approach. THEORY: We propose that integrated approaches to health and wellness require comprehensive and empirically-valid outcome measures to assess quality of care. METHOD: We discuss the transition from independent to integrated treatment approaches and provide examples of new systems for integrated assessment of treatment outcome. RESULTS: Evidence suggests that support for an independent treatment approach is waning and momentum is building towards more integrated care. In addition, research evidence suggests integrated care improves health outcomes, and both physicians and patients have favorable impressions of integrated care. CONCLUSIONS: As treatment goals in the integrated perspective expand to take into account the intimate relationships among mental illness, overall health, and quality of life, clinicians need to develop outcome measures that are similarly comprehensive. DISCUSSION: Increased recognition, by researchers, providers, and insurers, of the interdependence between behavioral and physical health holds great promise for innovative treatments that could significantly improve patients' lives.

Implementation of a consumer-directed approach in behavioral health care: problems and prospects.

Consumer-directed care, a payment system designed to make patients aware of the costs of care, requires treatment seekers to be active participants in their health care. Core components of consumer-directed care, such as higher deductibles and increased decision-making responsibilities, might preclude its easy translation from medical to behavioral health care. Aspects of behavioral disorders will force providers, insurers, and patients to compensate for unique barriers to increasing self-care, such as stigma, neuropsychological complications, and poor self-efficacy. This column describes important components of consumer-directed care and the unique barriers that behavioral health care creates for those components. Possible best practices are suggested for surmounting those barriers.