It’s like finding the Holy Grail! For pediatricians, successfully integrating behavioral
health (BH) in a busy pediatric practice is an aspirational goal that isn’t always
easy to achieve. The barriers to successful behavioral health integration include
space, billing, and often finding mental health providers willing and able to co-locate
with a pediatrician. In this month’s Pediatrics, Dr. Heather Walther and colleagues from Massachusetts provide us with the first
results of their statewide Behavioral Health Integration Program (BHIP) which are
quite promising (10.1542/peds.2018-3243).
BHIP was formed in 2013 and created a statewide support network to provide integrated
BH services in independent pediatric practices. They signed up 400 doctors and 84
practices statewide. Each practice committed to: 1) designate ≥1 PCPs (physicians/nurse
practitioners) to attend the education component and serve as BH “champion” for the
practice; 2) utilize the consultation component as needed; 3) engage in integrated
practice transformation including creating a BH team comprised of PCPs, BH clinicians
(BHCs [psychologists/social workers/counselors]), and care coordinators (CCs); and
4) provide on-site clinical BH services. Using a learning collaborative model, the
group provided education on managing behavioral health conditions as well as practice
management (e.g, how to bill), real time phone support for providers seeing children
with behavioral issues, and an onsite behavioral health service. This first paper
highlights the outcomes at year 5 for the first 12 practices enrolled in the program.
The outcomes demonstrated in the 5-year quality improvement program included increased
practice-level BH integration, psychotherapy and medical BH visits, and guideline
congruent medication prescriptions for anxiety/depression and attention deficit/hyperactivity
disorder. Additionally, while ambulatory BH spending increased 8%, emergency BH spending
dropped 19% suggesting a shift of services to the practice setting. Participating
providers reported high self-efficacy managing BH issues.
The work done in Massachusetts is another great example of the power of multi-practice
learning collaboratives. Prior learning collaboratives have been used to improve asthma
care, developmental screening, and obesity among other topics. Many statewide collaboratives
are coordinated through NIPN – the National Improvement Partnership Network hosted at the University of Vermont. The American Academy of Pediatrics has also supported these types of improvement methods through the Quality Improvement
Network (QUINN). In my opinion, these collaboratives offer the best methodology to
actually improve and transform practices as well as quality outcomes.
Most importantly, the BHIP program offers a “real-life” tested and now evidence-based
way states can improve BH services to resource limited areas. What most astounds me
is that this was the first paper demonstrating outcomes, since other states (like
Maryland) have also adopted the BHIP model and embraced providing support to practices to
help alleviate the challenges faced by pediatricians in communities with inadequate
mental health resources. Link to this important study to learn more.