Integrating Pediatric Universal Behavioral Health Care at Federally Qualified Health Centers

Abstract

BACKGROUND: Research supports integrated pediatric behavioral health (BH), but evidence gaps remain in ensuring equitable care for children of all ages. In response, an interdisciplinary team codeveloped a stepped care model that expands BH services at 3 federally qualified health centers (FQHCs). METHODS: FQHCs reported monthly electronic medical record data regarding detection of BH issues, receipt of services, and psychotropic medications. Study staff reviewed charts of children with attention-deficit/hyperactivity disorder (ADHD) before and after implementation. RESULTS: Across 47 437 well-child visits, >80% included a complete BH screen, significantly higher than the state’s long-term average (67.5%; P < .001). Primary care providers identified >30% of children as having BH issues. Of these, 11.2% of children <5 years, 53.8% of 5–12 years, and 74.6% >12 years were referred for care. Children seen by BH staff on the day of referral (ie, “warm hand-off”) were more likely to complete an additional BH visit than children seen later (hazard ratio = 1.37; P < .0001). There was no change in the proportion of children prescribed psychotropic medications, but polypharmacy declined (from 9.5% to 5.7%; P < .001). After implementation, diagnostic rates for ADHD more than doubled compared with baseline, follow-up with a clinician within 30 days of diagnosis increased (62.9% before vs 78.3% after; P = .03) and prescriptions for psychotropic medication decreased (61.4% before vs 43.9% after; P = .03). CONCLUSIONS: Adding to a growing literature, results demonstrate that integrated BH care can improve services for children of all ages in FQHCs that predominantly serve marginalized populations.

Implementation of a universal screening and follow-up care system for pediatric developmental and behavioral health in federally qualified health center sites.

“…This study contributes to a dearth of literature on integrated pediatric care models in FQHCs (Burkhart et al, 2020; Sheldrick et al, 2022). This intervention relied on strong buy-in from FQHC leadership, as well as resources to hire social workers, purchase electronic tablets, pay for screening costs, and support the dedicated time of quality improvement personnel to oversee implementation.…”

“…Overall, our results suggest that disseminating the multicomponent screening intervention may support populationlevel improvement in the early detection and management of pediatric developmental delays and behavioral health issues. This study contributes to a dearth of literature on integrated pediatric care models in FQHCs (Burkhart et al, 2020;Sheldrick et al, 2022). This intervention relied on strong buy-in from FQHC leadership, as well as resources to hire social workers, purchase electronic tablets, pay for screening costs, and support the dedicated time of quality improvement personnel to oversee implementation.…”

Child health equity and primary care.

“…Psychologists can collaborate with care coordinators to support families as they navigate siloed systems that are uniquely challenging for prohibited populations. Substantial evidence demonstrates the effectiveness of care coordination for chronic medical illness and there is emerging evidence to support its effectiveness in addressing behavioral health concerns (Godoy et al, 2019), including within integrated models (e.g., Sheldrick et al, 2022).…”

Association of Integrating Mental Health Into Pediatric Primary Care at Federally Qualified Health Centers With Utilization and Follow-up Care

“…Starting in mid-2016, 3 Massachusetts-based federally qualified health centers (FQHCs) began implementing Transforming and Expanding Access to Mental Health in Urban Pediatrics (TEAM UP), which is a comprehensive integrated MH care model that serves children from birth through young adulthood . As further described in a recent study of TEAM UP, TEAM UP focuses on promotion, prevention, and early identification of emerging MH issues, swift access to MH services, and psychiatric consultation for complex cases. Services are delivered by a team of MH clinicians, community health workers, and primary care clinicians, who implement the model within a learning community that includes technical assistance, clinical training, and an evaluation group to prove and improve the model.…”

“…A recent study using electronic medical records at TEAM UP FQHCs documented high rates of screening, effective use of warm hand-offs (ie, in-person transfer of care between 2 clinicians) to connect children to care, reductions in polypharmacy, and increases in diagnosis and treatment for attention-deficit/hyperactivity disorder, although the data were limited to TEAM UP electronic medical records, and, thus, no comparison groups were available. An additional study using claims data, which included the same 6 comparison sites, indicated that after 1.5 years of implementation, TEAM UP was associated with increases in all-cause primary care visits, especially among children with baseline MH conditions, with no changes in avoidable utilization.…”