Magazine article Clinical Psychiatry News

Team Meets Kids Where They Are

Magazine article Clinical Psychiatry News

Team Meets Kids Where They Are

Article excerpt

Care for mental and physical health issues is erroneously segregated in the current health care environment, said John V. Campo, M.D.

That's why Dr. Campo and his colleagues have developed a collaborative care model aimed at delivering mental health services within a pediatric primary care practice.

"Most kids have at least one visit per year with their primary care provider, and most behavioral and mental health problems are first discussed in that setting," said Dr. Campo, assistant professor of psychiatry and pediatrics at the University of Pittsburgh's Western Psychiatric Institute and Clinic (WPIC). "So it makes perfect sense to look to primary care as an access point for mental health care."

But what is reasonable is not always readily achievable. "The current primary care culture focuses on acute care, while psychiatric disorders in children and adolescents tend to be chronic and relapsing," Dr. Campo said.

This false dichotomy between mental and physical issues leads to count-less missed opportunities for addressing critical mental health issues. Primary care providers often provide acute care for recurrent somatic symptoms such as headache, abdominal pain, limb pain, and chest complaints, for example. But such symptoms are often linked to emotional problems--which cannot be treated acutely and so often go unaddressed, he said.

How the Model Works

Dr. Campo and his team have applied the chronic care model to pediatric mental health by teaming mental health professionals affiliated with the WPIC and the Family Counseling Center of Armstrong County (Pa.) with clinicians and administrators at Armstrong Pediatrics, a primary care practice operated by a self-governing subsidiary of the Children's Hospital of Pittsburgh. The community-based practice, located 50 miles outside of Pittsburgh, serves more than 10,000 children and adolescents.

The collaborative mental health program is based on-site within the pediatric practice, yet operates as an administratively distinct mental health satellite of the Family Counseling Center.

Staffing for the program involves a full-time nurse care manager with training as an advanced-practice nurse practitioner, a full-time psychiatric social worker, and a pediatric psychiatrist, who is available 1 day per week. (See box.)

"The pediatric psychiatrist is the drag on the system financially, so the idea is to spread the specialty care in order to make the program feasible," Dr. Campo said. This is achieved by the program's emphasis on stepped care, meaning that different levels of care are matched to the needs of a given patient and his or her specific disorder, its severity, and its complexity.

When one of the primary care providers identifies a child with emotional or behavioral problems, the physician directs the family to the nurse care manager, who schedules a brief initial assessment and triage visit to determine immediate clinical needs. For acute and/or complicated triage decisions, the nurse care manager consults with the child and adolescent psychiatrist in person, by telephone, or by e-mail.

Levels of Care

The nurse care manager will then triage the child or adolescent to one of three levels of care, according to predetermined guidelines: usual care, on-site collaborative care team services, and on-site specialty mental health care or off-site referral.

Patients triaged to usual care include those whose behavioral and emotional problems are mild to moderate. This category of patient might include children with attention-deficit issues, conduct and adjustment problems, somatization, or tics. Typically, these children will not have been treated for these conditions previously or they have responded to previous treatment. The therapeutic needs of patients triaged to this level of care are met by the nurse care manager and the primary care clinician, and may include psychoeducation, a behavior plan, self-management, and/or medication. …

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