Author: Amie F. Bettencourt, PhD , Corinne M. Plesko, RN, BSN

Journal: Academic Pediatrics

Abstract:

Background: There is a well-documented gap between the need for and availability of mental health services for children nationwide. To address this gap, over 30 regional Child Psychiatry Access Programs (CPAPs) provide psychiatric consultation and other services to primary care providers. Objectives: Summarize the methods used to evaluate CPAPs in the U.S.

Data Sources: PubMed, PsychInfo, CINAHL, and reference checking.

Study Appraisal Methods: A systematic literature review was conducted searching three databases. The search produced 307 unique articles, 278 were excluded for irrelevance, leaving 29 for data extraction. Data extracted included author(s), publication year, provider types, CPAP formats, study sample, design, outcomes examined, results, and limitations. Articles were also appraised for quality using the Johns Hopkins Nursing Evidence Based Practice Evidence Level and Quality Guide.

Results: The 29 articles evaluated 13 unique CPAPs. Most evaluations used non-experimental observational designs (68.9%), 6.9% used quasi-experimental designs, and none used true experimental designs. Evaluations examined the following outcomes: usage of program services (82.8%), provider satisfaction (48.3%), provider comfort/confidence with managing mental health concerns (31.0%), provider practice change (24.1%), patient outcomes (13.7%), family satisfaction (6.9%). Outcomes were measured using surveys, qualitative interviews, or insurance claims data.

Limitations: Review was limited to articles published in English in three databases or identified by reference checking.

Conclusions: Evaluations of CPAPs have largely been descriptive in nature, focusing primarily on program usage and provider satisfaction. Few studies have examined the impact of CPAPs on patients, families, or health systems. Future studies should evaluate the broader impacts of CPAPs.

DOI: https://doi.org/10.1016/j.acap.2020.07.015

Author: Amie F. Bettencourt, PhD., Kelly Coble, MSW, LCSW-C., Shauna P. Reinblatt, MD., Sneha Jadhavha, MD., Kainat N. Khan, MS., Mark Riddle, MD.

Journal: Psychiatric Services

Abstract:

Objective: Maryland’s Behavioral Health Integration in Pediatric Primary Care (BHIPP) is a child psychiatry access program offering child-adolescent psychiatry consultation, resource and referral networking, and direct-to-patient mental health intervention. This study investigated characteristics of patients for whom primary care providers sought BHIPP services.

Methods: Data from 6,939 unique patient contacts between October 2012 and March 2020 were collected on service type, demographic characteristics, presenting concerns, clinical severity, clinicians’ diagnostic impressions, current treatments, and BHIPP recommendations. Descriptive statistics and latent class analysis were used.

Results: Of the 6,939 patient contacts, 38.6% were for direct-to-patient mental health intervention, 27.3% for child-adolescent psychiatry consultation, and 34.2% for resource and referral networking. In total, 50.3% of patients were female, 58.7% were White, and 32.7% were already receiving mental health services. Latent class analysis identified four classes of presenting concerns: anxiety only (44.2%); behavior problems only (30.7%); mood and anxiety (17.1%); and attention, behavior, and learning problems (8.0%). Compared with patients in the anxiety-only class, those in the attention, behavior, and learning problems class were more likely to receive direct-to-patient mental health intervention (OR=3.59), and BHIPP clinicians were more likely to recommend in-office behavioral interventions for those in the mood and anxiety class (OR=1.62) and behavior problems–only class (OR=1.55).

Conclusions: Patients supported through BHIPP varied in presenting concerns, condition severity and complexity, current receipt of services, and BHIPP utilization. Latent class analysis yielded more clinically useful information about the nature and complexity of patients’ concerns than did consideration of individual presenting concerns.

DOI: https://doi.org/10.1176/appi.ps.20220323

Author: Shauna P. Reinblatt, MD., Kelly Coble, MSW, LCSW-C., Jami-Lin L. Williams, MA., Aronica M. Cotton, MD., Amie F. Bettencourt, PhD.

Journal: Journal of the Academy of Consultation-Liaison Psychiatry

Abstract:

Objectives: Child Psychiatry Access Programs (CPAPs) provide consultative support for pediatric primary care providers (PCPs) to treat co-morbid mental health (MH) symptoms among patients with Autism Spectrum Disorder (ASD). We examined differences in illness severity, co-morbidity, and psychotropic medication use between patients with and without ASD for whom PCPs sought consultation from Maryland’s (MD)-CPAP.

Methods: We examined N= 3,641 MD-CPAP consultations from 2012 to 2019; n=311 were consultations for ASD. Demographics, treatment recommendations, diagnoses, and Clinical Global Impression-Severity (CGI-S) scores were collected. Patients who received psychotropic medication or psychotherapy by a MH provider were defined as co-managed. Descriptives and logistic regression were conducted. Sample for regression was N=1,854.

Results: Compared to non-ASD, consults regarding ASD patients were more often male (p<.001), aged 0-5 years (p<.001), severely ill (CGI-S> 4) (p<.001), and prescribed stimulants, non-stimulant ADHD medications, and antipsychotics (p<.001). Controlling for key covariates, consultations about youth: displaying aggression were 3.02 times (p<.001) more likely, with CGI-S>4 were 2.36 times (p<.001) more likely, and prescribed antipsychotics were 4.30 times more likely to concern an ASD patient (p<.001). A larger proportion of ASD patients (vs non-ASD) had co-morbid psychiatric diagnoses of ADHD, a Learning Disability, Disruptive Behavior Disorder vs. a smaller proportion with Major Depressive Disorder.

Conclusions: ASD patients for whom PCPs sought MD-CPAP consultation were more severe and complex than non-ASD patients in terms of comorbid diagnoses and medication regimen. Findings suggest that consultations with CPAPs provide medication management support to pediatric PCPs treating ASD patients.

DOI: https://doi.org/10.1016/j.jaclp.2022.01.004

Author: Aronica Cotton, MD., Mark Riddle, MD., Shauna Reinblatt, MD. and Amie Bettencourt, PhD.

Journal: Psychiatric Services

Abstract:

Objective: Child psychiatry access programs (CPAPs) help increase access to mental health services. This study aimed to provide information on the types of pediatric primary care clinicians (PPCCs) who call Maryland’s CPAP.

Methods: Descriptive statistics and multinomial logistic regressions were conducted with data from 676 PPCCs who called Maryland’s CPAP at least once between October 2012 and June 2019.

Results: On average, PPCCs contacted Maryland’s CPAP 6.8 times. Providers who called seven or more times were more likely to have an allopathic or osteopathic medicine degree and to specialize in pediatrics. Providers calling from rural regions were less likely to call only for referrals.

Conclusions: Most PPCCs contacted the CPAP for consultation or referrals but not both. PPCCs in rural areas were more likely to call for consultation, suggesting that they may be more likely to manage the care of patients with mental health conditions themselves, because of a lack of resources in their locations.

DOI: https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.202000292

Author:  Prerna G. Arora, Ph.D., Elizabeth H. Connor, Ph.D., Angela Blizzard, BA., Kelly Coble, LCSW-C., Nicole Gloff,  and David Pruitt, MD.

Journal: Evaluation and Program Planning

Abstract:

Increased attention has been placed on evaluating the extent to which clinical programs that support the behavioral health needs of youth have effective processes and result in improved patient outcomes. Several theoretical frameworks from dissemination and implementation (D&I) science have been put forth to guide the evaluation of behavioral health program implemented in the context of real-world settings. Although a strong rationale for the integration of D&I science in program evaluation exists, few examples exist available to guide the evaluator in integrating D&I science in the planning and execution of evaluation activities.

This paper seeks to inform program evaluation efforts by outlining two D&I frameworks and describing their integration in program evaluation design. Specifically, this paper seeks to support evaluation efforts by illustrating the use of these frameworks via a case example of a telemental health consultation program in pediatric primary care designed to improve access to behavioral health care for children and adolescents in rural settings. Lessons learned from this effort, as well as recommendations regarding the future evaluation of programs using D&I science to support behavioral health care in community-based settings are discussed.

DOI: https://doi.org/10.1016/j.evalprogplan.2016.09.003

Author: Amie Bettencourt, PhD, Rebecca Ferro, MA, Jami-Lin Williams, MA, Kainat Khan, MS, Rheanna Platt, MD, MPH, Sarah Sweeney, MPH, MSW, and Kelly Coble, LCSW-C

Journal: Academic Psychiatry.

Abstract

Objectives: Nearly 50% of children with a mental health concern do not receive treatment. Child Psychiatry Access Programs like Behavioral Health Integration in Pediatric Primary Care (BHIPP) address regional shortages of mental health treatment access by providing training and consultation to primary care providers (PCPs) in managing mental health concerns. This study assessed PCPs’ comfort with mental health practices to inform expansion of BHIPP services.

Methods: Pediatric PCPs in 114 practices in three rural regions of Maryland were recruited to participate in a survey about their comfort with mental health practices and access to mental health providers for referral. Descriptives, Friedman’s test, and post hoc pairwise comparisons were used to examine survey responses.

Results: Participants were 107 PCPs. Most respondents were physicians (53.3%) or nurse practitioners/physician’s assistants (39.3%). Friedman’s test, χ2(7)= 210.15, p<.001, revealed significant within and between-group differences in PCP comfort with mental health practices. Post hoc pairwise comparisons indicated greater comfort providing mental health screening and referrals compared to prescribing psychiatric medications, providing psychoeducation or in-office mental health interventions. A Wilcoxon-signed rank test showed significantly more respondents agreed they could find a therapist than a psychiatrist in a timely manner, Z= −5.93, p<.001.

Conclusions: Pediatric PCPs were more comfortable with providing mental health assessment and referrals than treatment. However, PCPs reported difficulty finding therapists and psychiatrists for their patients. Findings underscore the need for longitudinal training to increase PCP comfort with mental health treatment. Additionally, strategies such as telepsychiatry are needed to address the disproportionate need for child psychiatrists.

DOI: https://link.springer.com/article/10.1007/s40596-021-01434-x

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Author: Prerna G. Arora, Ph.D., Elizabeth H. Connors, Ph.D., Kelly Coble, MSW., LCSW-C., Angela Blizzard, BA., Larry Wissow, MD., MPH., David Pruitt, MD.

Journal: Psychiatric Services

Abstract:

This column describes a qualitative study in which 32 primary care providers (PCPs) reported barriers to and facilitators of using a behavioral health (BH) consultation program. Barriers included program incompatibility with organizational culture, limited exposure to the program, existing access to referral sources, and negative beliefs about BH consultation. Reported facilitators included having personal relationships with BH program staff, exposure to program information, and positive beliefs about BH consultation. PCPs recommended outreach activities and optimal program features to increase use of BH consultation.

DOI: https://doi.org/10.1176/appi.ps.201600479

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Author: Elizabeth H Connors, PhD., Prerna Arora, PhD., Angela M. Blizzard, BA., Kelly Bower, PhD., Kelly Coble, LCSW-C., Joyce Harrison, MD., David Pruitt, MD., Janna Steinberg, MA, and Lawrence Wissow, MD, MPH.

Journal: The Journal of Behavioral Health Services & Research

Abstract:

Primary care providers (PCPs) frequently encounter behavioral health (BH) needs among their pediatric patients. However, PCPs report variable training in and comfort with BH, and questions remain about how and when PCPs address pediatric BH needs. Existing literature on PCP decisions to address pediatric BH in-office versus referring to subspecialty BH is limited and findings are mixed. Accordingly, this study sought to examine parameters and contextual factors influencing PCP decisions and practices related to BH care. Qualitative interview results with 21 PCPs in Maryland indicated that decisions about how and when to address pediatric BH concerns are influenced by the type BH service needed, patient characteristics, the availability of BH services in the community, and possibly PCPs’ perceptions of BH care as a distinct subspecialty. Findings suggest that efforts to support individual PCPs’ capacity to address BH within primary care must be balanced by efforts to expand the subspecialty BH workforce.

DOI: https://doi.org/10.1007/s11414-017-9580-9

Author: Rheanna Platt,MD, MPH., Sean Pustilnik, MD., Elizabeth Connors, PhD., Nicole Gloff ,MD., Kelly Bower, PhD, RN.

Journal: General Hospital Psychiatry

Abstract

Objective: To describe the clinical severity of patients for whom Primary Care Providers (PCPs) requested consultation from Maryland's Child Psychiatry Access Program (CPAP), and examine the proportion and associated characteristics of severe cases being managed alone by PCPs versus co-managed with mental health specialists.

Methods: Data were collected for 872 cases based on calls received between October 2012 and December 2016. Severity was measured by consultant-assigned Clinical Global Impression-Severity (CGI-S) score. The unadjusted odds of a PCP managing a case alone for select patient and provider characteristics was calculated in a sub-sample of 229 severe cases.

Results: 73.8% of cases were categorized as mild-moderate (CGI-S 1–4) and 26.3% as severe (CGI-S 5–7). 67.3% of severe cases were managed by a PCP alone; 32.8% were co-managed. The unadjusted odds of a severe case managed alone was lower for cases with greater numbers of psychotropic medications (OR 0.76, 95% CI 0.6, 0.96), prescription of antidepressants (OR 0.51, 95% CI 0.28, 0.95), or antipsychotics (OR 0.45, 95% CI 0.22, 0.94) compared to co-managed cases.

Conclusions: PCPs manage patients with severe mental health concerns, often without assistance from specialists. CPAPs should systematically consider how to support the PCPs' role managing clinically severe cases.

DOI: https://doi.org/10.1016/j.genhosppsych.2018.02.010

Author: Joyce Harrison,MD., Kate Wasserman, MSW., LCSW-C., Janna Steinberg,MA., Rheanna Platt,MD, MPH., Kelly Coble,MSW, LCSW-C., Kelly Bower, PhD, MSN/MPH, RN.

Journal: Current Problems in Pediatric and Adolescent Health Care

Abstract:

Given the gap in child psychiatric services available to meet existing pediatric behavioral health needs, children and families are increasingly seeking behavioral health services from their primary care clinicians (PCCs). However, many pediatricians report not feeling adequately trained to meet these needs. As a result, child psychiatric access projects (CPAPs) are being developed around the country to support the integration of care for children. Despite the promise and success of these programs, there are barriers, including the challenge of effective communication between PCCs and child psychiatrists. Consultants from the Maryland CPAP, the Behavioral Health Integration in Pediatric Primary Care (BHIPP) project, have developed a framework called the Five S’s. The Five S’s are Safety, Specific Behaviors, Setting, Scary Things, and Screening/Services. It is a tool that can be used to help PCCs and child psychiatrists communicate and collaborate to formulate pediatric behavioral health cases for consultation or referral requests. Each of these components and its importance to the case consultation are described. Two case studies are presented that illustrate how the Five S’s tool can be used in clinical consultation between PCC and child psychiatrist. We also describe the utility of the tool beyond its use in behavioral health consultation.

DOI: https://doi.org/10.1016/j.cppeds.2016.11.006

Author: Amie F. Bettencourt, Ph.D., Carson Allen, B.S., Kelly Coble, L.C.S.W.-C., Terrence Hibbert, M.B.A., Dustin E. Sarver, Ph.D.

Journal: Psychiatric Services

Abstract:

Objective: Pediatric Mental Health Care Access (PMHCA) programs increase access to mental health care by providing training, consultation, and resource-referral support to primary care providers (PCPs). The authors compared trends in services provided by two PMHCA programs during the COVID-19 pandemic.

Methods: Maryland and Mississippi PMHCA programs had 2,840 contacts with PCPs from January 2019 to March 2021. Descriptive trends on PMHCA program utilization, service type, clinical severity, diagnostic complexity, and PCP contact reasons were reported.

Results: Both programs observed significant increases in call volume during the COVID-19 pandemic compared with before COVID-19. Increases were observed in calls regarding patients with multiple diagnoses (Maryland, 20% to 37%; Mississippi, 0% to 11%) as well as patients with mood and anxiety symptoms.

Conclusions: Changes in PMHCA program usage suggest that PCPs identified more complex mental health concerns, particularly regarding mood and anxiety, during the pandemic than before COVID-19. Trends underscore the importance of PMHCA programs in supporting PCPs with managing pediatric mental health concerns.

DOI: https://doi.org/10.1176/appi.ps.202100479

Author: Rebecca A. Ferro, MA., Riley DiFatta, BA., Kainat N. Khan, MS., Kelly Coble, L.C.S.W.-C., Shauna P. Reinblatt, MD., Amie F. Bettencourt, Ph.D.

Journal: The Journal of Behavioral Health Services & Research

Abstract:

Many children experience adversity, yet few receive needed psychiatric services. Pediatric primary care providers (PCPs) are uniquely positioned to intervene but often lack training and resources to provide patients with adverse childhood experiences (ACEs) the psychiatric support they need. The current study examines characteristics of youth with and without ACEs who were the focus of PCP contacts with a statewide child psychiatry access program (CPAP). Compared to those without ACEs, patients with ACEs were more often receiving medication treatment at time of CPAP contact, prescribed two or more psychotropic medications, and diagnosed with two or more mental health disorders. Study findings indicate that patients with ACEs for whom PCPs sought CPAP support were experiencing more clinically severe and complex mental health concerns. These findings underscore the important role of CPAPs in supporting PCPs with pediatric patients who have ACEs and will inform training provided by CPAPs to PCPs.

DOI: 10.1007/s11414-023-09836-5