Payment reform offers opportunity to integrate mental health into pediatric care
Patricia J.Flanagan, M.D., FAAP and Marian F.Earls, M.D., FAAP
Practice transformation and new payment models offer effective pathways to providing
an increased array of services that optimize pediatric care and the prevention and
early detection of health problems. A key transformational opportunity is integrating
or re-integrating behavioral health as part of holistic health care.
Decades of “siloed” financing mechanisms and regulatory rules for mental health services
as well as real or perceived institutionalized barriers to interprofessional communication
have evolved into a fragmented, gated and unhealthy system of carved-out services
for behavioral issues. As we reorganize payment systems and recognize the personal
and financial impact of behavioral health across multiple systems, we face a great
opportunity to bring behavior and mental health back into the realm of pediatric primary
and subspecialty practice.
Integration can exist on a continuum from creating formal mental health referral networks
to co-locating behavioral health providers within the office to integrated care with
shared medical records, care teams and care plans. Pediatricians can refer and co-manage
or be the primary behavioral health providers for their patients.
assessing and/or triaging children with mental health and substance use symptoms;
addressing emerging or undifferentiated problems and problems not rising to level
assessing/managing children with attention-deficit/hyperactivity disorder (ADHD),
anxiety, depression and substance use disorders (mild to moderate levels of impairment);
referring, co-managing and coordinating care for children with other conditions, those
severely impaired and those beyond our comfort level.
Collaboration and co-management with mental health professionals is key to implementing
these competencies. The Academy and American Academy of Child and Adolescent Psychiatry
have produced a document on provider-to-provider communication and the Health Insurance Portability and Accountability
Act that dispels misconceptions about limits to communicating.
Recognizing the unique needs and opportunities of integrating behavioral health into
pediatrics is key to creating effective strategies. Children and their behavioral
health issues are influenced by their development, demographic characteristics and
dependency on adult caregivers and adult-driven systems such as schools.
Younger children in particular may have behavioral challenges that do not yet rise
to the level of a diagnosis. Pediatric primary care presents the opportunity for promotion,
prevention and early intervention for child mental health.
Almost a quarter of the children in the U.S. live in impoverished environments, commonly
with stressed and unstable financial, physical and emotional conditions. The impact
of chronic, unremitting stress on children’s psyche is potentially profound and lifelong.
Nurturing the well-being and life opportunities for parents helps them raise healthy
children. We screen mothers for postpartum depression and parents for substance use
and intimate partner violence. Increasingly, we are aware of the need for two-generation
models of care.
As pediatricians, we also work closely with other systems such as child welfare, early
intervention and child care, and schools. These systems can augment our ability to
detect behavior patterns and provide interventions early, in hopes of preventing more
severe mental illness. This requires more intentional communication and collaboration.
School attendance and school performance are good examples of early and ongoing indicators
of child wellness. School behavior problems may be manifestations of undiagnosed learning
disabilities, depression, anxiety or ADHD. Being victimized by bullying can contribute
to both absenteeism and to behavior changes in children. Substance use, depression
or other mental illness can present as deterioration of grades or disconnection from
peers and peer organizations.
The Academy has a long history of promoting a whole child approach (in the context
of family, school and community) in the medical home. Pediatricians have the primary
care advantage of the longitudinal relationship with the child and family and opportunity
to promote social-emotional development and address mental health concerns. For children
and their families, a healthy social-emotional foundation and early detection and
intervention can have a life-long impact on health outcomes.
Dr. Flanagan is a member of the AAP Task Force on Pediatric Practice Change. Dr. Earls
is chair of the AAP Mental Health Leadership Work Group.