Collaborative Care for Youth: Statewide Success Stories

The need for consultative services like the ones described by this month’s author, Bob Hilt, M.D., reflects the very real workforce shortages in our field; in some communities the wait to see a child psychiatrist can be as long as nine to 12 months, if one is available at all. This often leaves primary care providers as the sole mental health prescriber for a child and the need for those of us in the mental health field to help them with that task. Dr. Hilt and his colleagues have stepped up in spades by completing more than 10,000 provider-to-provider consultations since 2008, helping community providers deliver limited intervention services and using “teachable moments” to help shape care not just for one child, but for subsequent children a provider might see. —Jürgen Unützer, M.D., M.P.H.

There is a need to improve access to high-quality child psychiatric services, as highlighted by the following statistics: (1) half of all lifetime cases of mental illness begin by age 14, (2) there is a severe shortage of child psychiatrists—fewer than eight child psychiatrists per 100,000 U.S. children, and (3) about 80 percent of children with mental illness fail to receive specialty mental health treatment. Unaddressed child mental illness unfortunately translates into more long-term mental health disability for adults.

Collaborative care offers a way to leverage child psychiatric expertise to impact the lives of whole populations of children, though how best to do this for kids is still being explored. Collaborative care could include referral support, mental health screening and tracking, training for nonspecialists, specialist telephone consultations, direct patient consultations, co-located therapists, oversight care reviews, EMR integration, and/or fully integrated mental/behavioral health services within a primary care practice.

The following is how two state Medicaid divisions have approached this challenge. Washington State Medicaid has for nearly a decade operated statewide child mental health consult service programs. The first of its initiatives was mandatory second-opinion medication reviews for state-defined “outlier” child psychotropic prescribing, such as child doses over twice the adult FDA maximum. While the initial goal was obtaining second-opinion authorization/denial recommendations, over time the consulting child psychiatrists learned to use oversight reviews to offer more clinically useful collaborative care support for a provider’s most challenging cases. This approach made a huge difference in provider-reported value of the program. For instance, last year’s mandatory second-opinion review feedback from prescribers rated a mean of 6.0 on a 7-point scale regarding the statement, “The consultant offered appropriate and helpful treatment suggestions for my patient.”

The second collaborative care initiative was to give all primary care providers access to elective, hotline-like, telephone-based consultations with a child psychiatrist about any patient they see. This Partnership Access Line (PAL) has been staffed such that primary care providers can expect to nearly always get directly connected to a child psychiatrist when they call. They also receive access to a social worker helping with referrals, access to televideo patient consultations, locally hosted free CME education events, and a treatment guide designed for primary care mental health. Provider feedback for this service has consistently been positive. This collaborative care support service was made available by both Washington and Wyoming Medicaid divisions. More details of the PAL elective primary care consultation service can be accessed here.

Combining elective PAL consultation and mandatory second-opinion review consultation programs into a single service allows greater staffing flexibility (it’s difficult to always have a child psychiatrist “available”) and helps to ensure the fidelity of message regardless of the door of entry for collaboration assistance. The consultants work as a team, discuss challenging scenarios together to reach a best consensus approach, and formally audit the consultations for consistency of best practice messaging. Overall system outcomes have been notable; for instance, in just the first three years of combined PAL/Second Opinion consult services, Washington’s preexisting rapid increase in child antipsychotic use reversed course, and then decreased by 17 percent.

Collaborative care systems need to be explicitly tailored to local needs. In working with Wyoming Medicaid, we learned that children in their foster care system had additional challenges with getting timely access to child psychiatric assessments, and this lack of access negatively impacted overall treatment planning. So we created a path for rapid-access but in-depth system collaboration televideo patient consultations for the foster care system. An analysis of the whole package of Wyoming’s collaborative care (PAL, Second Opinion, and foster care consults) found desirable outcomes beyond positive provider feedback. There were 42 percent fewer kids under 5 receiving psychotropic medications and 52 percent fewer kids receiving more than 150 percent of the adult FDA maximum-dose psychotropics. Also, by reducing clinically unnecessary residential care placements, the collaborative care system saved money with a 1.8-to-1 return on investment.

Based on all of these experiences, I encourage others to consider working with one of the many types of developing collaborative care systems in their own areas, as it can be highly rewarding work. ■