Psychiatrists' Creativity Closes Rural Treatment Gap

Rural children with serious mental illness often live far from child psychiatrists, but new programs are trying to bring specialty care to these children while training primary care physicians who treat them in their local communities.

The acute shortage of child psychiatrists in rural America is no abstraction to Glenn Kashurba, M.D., of Somerset, Pa. Kashurba is the only such specialist in an area the size of Connecticut. He'd like to share the load with someone, but he gave up trying to recruit another child psychiatrist 10 years ago.

“Even when you get people to practice in rural areas, they burn out,” said Kashurba, co-chair of the American Academy of Child and Adolescent Psychiatry's Rural Psychiatry Committee, in an interview. Cutbacks in child psychiatry fellowships in rural areas have made the field only more urban, so few residents are even exposed to an alternative, he said.

“The system is irrevocably broken,” said Daniel Connor, M.D., a professor of psychiatry at the University of Massachusetts. “The enormous barriers to care, the underfunding of the public health sector—especially for children—and the paucity of child psychopharmacologists mean that more rural children with psychopathology are seen in primary, ambulatory practice who can't be referred to specialists because of long waiting lists and a lack of practitioners.”

No single solution to this shortage is in sight, but several new approaches seek to bring the expertise of specialist child psychiatrists to rural clinics.

Massachusetts Reverses Order of Care

At the University of Massachusetts, Connor, Ronald Steingard, M.D., and others have created the Massachusetts Child Psychiatry Access Project, in which primary care physicians and child psychiatrists collaborate in the care of children with mental disorders.

“Managed care has erected high barriers to access child mental health care, but it still allows access to primary care doctors,” explained Connor in an interview.

In managed care, most specialties, including psychiatry, operate on the principle that the patient reaches the most highly trained person last, he said. The University of Massachusetts model reverses that, putting the child psychiatrist one step away from the pediatrician or family doctor. In one sense, the connection is literal: the program is housed in the department of pediatrics so that the psychiatrists interact informally with pediatricians in the medical center.

But connecting the program to outlying doctors is a pager clipped to the belt of the child psychiatrist on duty, said Connor. At any time, the 139 primary care doctors scattered across rural Massachusetts can call for immediate advice while the young patients are still in their offices.

“Our protocol calls for answering within 20 minutes to discuss and evaluate the patient,” he said. “This fundamentally redefines the role of the child psychiatrist from office-based practitioner to a consultant. It puts the most highly trained specialist at the front end and not the back end.”

The initial conversation between primary provider and specialist serves several functions. It sharpens the referral question and offers education and immediate feedback to the local doctor. Half of all cases can be resolved on the phone, said Connor. Others are referred to local behavioral health services. Referrals to the university's child psychiatry unit are scheduled within three weeks for a 90-minute interview that results in a diagnosis and treatment plan.

Many children return to their pediatricians for follow-up. The most severely ill are offered a one- to four-session inpatient intervention to stabilize symptoms using some combination of psychopharmacology, cognitive or family therapy, or other treatments. Once stabilized, they go back to their communities for care by their primary care doctors.

If they cannot be stabilized in that time, they are referred to community mental health centers for further treatment. The plan accepts any medical insurance, including Medicaid, said Connor.

The child psychiatrists visit every primary care site each year to improve communication and evaluate satisfaction with the program. They also offer continuing medical education, case conferences, and grand rounds for primary care physicians.

“The idea is to help them get more competent so that more kids can get seen,” said Connor.

Pennsylvania Uses Triage System

A child-psychiatry program in rural Armstrong County, an hour northeast of Pittsburgh, has a different origin and operates on a slightly different model. The program had its roots in an invitation to John Campo, M.D., of the University of Pittsburgh Medical Center's Western Psychiatric Institute and Clinic to lecture about psychopharmacology to local pediatricians. Campo was then asked to consult for the pediatricians, but payment issues were a barrier until the county health department agreed to license the pediatric practice at a local clinic as a mental health site, allowing Campo to spend one day a week training pediatricians and consulting.

Although the program is based in the pediatric practice, it has evolved, said Campo. He still drives to Armstrong County once a week, but initial referrals from pediatricians usually go to the program's chronic care manager, a nurse practitioner who lives in the area, for a first evaluation and triage. She has become experienced enough to handle routine matters, with only an occasional call to Campo between his scheduled visits.

On site, Campo spends his first hour discussing new cases, deciding with the case manager whether patients need to be seen by him or can be referred to a social worker or other professional. He then reviews existing cases or those the primary care physicians have found more challenging—children with multiple comorbidities or rare drug side effects, for example.

Those in need of more specialized care are referred to the community mental health center or to Western Psychiatric Institute and Clinic.

“Generally, people up there like to stay close to home, so they're usually referred to the community mental health center for further care,” said Campo. “Our primary question is always, Can it be reasonably dealt with in primary care?”

Yet the changing culture of pediatric primary care doesn't make that easy, he said. “Primary care doctors are asked to do a lot. Half the pediatricians say they're willing to screen for depression, for example, but the other half say they're willing but don't have time for follow-up.”

Half the nurse manager's salary is covered by the pediatric practice and half by the county mental health agency. Campo's work is billed at less-than-market rates, but he sees the arrangement as a laboratory in practice-based research as a clinical service.

“Without a strong commitment from the county, the system wouldn't work,” he said. The system looks good to Armstrong County, too.

“Our local pediatricians are now more aware of behavioral health issues,” said Hal Altman, M.D., vice president for medical affairs at Armstrong Memorial Hospital. Altman grew up in the county and returned there after pediatric residency at the University of Pittsburgh, where he first met Campo. “We reduce the costs of frequent workups for somatic complaints like belly pain or headaches and can capture kids we missed before, rather than refer them off site, and that helps reduce stigma.”

Maine Adds Telepsychiatry

In Maine, psychiatrist Andy Hinkens, M.D., M.P.H., of Maine Medical Center in Portland uses an online video link to see patient and parents or guardians at Cary Medical Center, 300 miles north, near the Canadian border. These telepsychiatry visits, however, are preceded by much planning and preparation, said Hinkens, the training director for child and adolescent psychiatry at Maine Medical Center.

“It's as if they were coming to see us here in Portland,” he said. “We send all the usual Maine Medical Center forms to Cary, where a local liaison person helps the patient or parents fill them out. Then they're faxed back here, and the patient's medical history is entered into our central computer.”

Hinkens also had to get credentialed at Cary, although that was easier than in some telepsychiatry settings since Maine Medical and Cary are in the same state.

Hinkens spends about an hour with the patient at Cary on the video link, then the patient leaves, and Hinkens discusses the case with the local physician. That discussion leads to treatment recommendations and medication suggestions. The pediatrician writes any prescriptions and can consult with Hinkens later. The system has been in use for two years, and he has seen about 20 patients a year, all Medicaid eligible.

Back in Pennsylvania, Kashurba applauds any effort to solve the problem of access to psychiatric care in rural areas, regardless of the technology involved.

“We haven't seen any improvement in access for rural families,” said Kashurba. “So we need to try multiple approaches to solve the problem.”

More information is posted online at<www.icommunityhealth.org/documents/masschildpsychiatryaccessproject.pdf>.▪