Ayanda Chakawa, PhD
Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Full BiographyLeslee T. Belzer, PhD
Psychology Director, Integrated Primary Care Program, Division of Developmental & Behavioral Health; Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Full BiographyA team of Children’s Mercy integrated care psychologists is shedding new light on the potential of an integrated approach to expand access to behavioral health care for children whose families might not otherwise seek it.
“Which Model Fits? Evaluating Models of Integrated Behavioral Health Care in Addressing Unmet Behavioral Health Needs Among Underserved Sociodemographic Groups,” published in the August issue of the Journal of Evidence Based Practice in Child and Adolescent Mental Health, presents results of a retrospective examination of two ways such care is offered at the CM-Broadway Pediatric Care Center.
Leslee Belzer, PhD, and Trista Perez Crawford, PhD, both Pediatric Psychologists in CM’s Division of Development and Behavioral Sciences (D&B), were involved in the study spearheaded by Ayanda Chakawa, PhD, Clinical Psychologist in CM’s D&B and Assistant Professor of Pediatrics at the UMKC School of Medicine. Former CM Psychology Resident Natalie Brei, PhD, now practicing at a counseling center in Lincoln, Nebraska, also contributed to the project.
The group’s work fills current gaps in evidence-based knowledge about the potential of embedding behavioral health care in primary care settings. It indicates that a newly implemented “consultation” model developed by the CM psychologists that engages behavioral health care in real time during a visit to the child’s medical provider, combined with services embedded in the primary care clinic, can break down barriers families face and expand access for children whose behavioral health needs too often go unmet.
And as pandemic-related life disruptions heighten concerns about the wellbeing of the nation’s children, the CM team’s research results could not be more timely as they expand the consultation model through telehealth services.
As Dr. Chakawa put it: “For decades, research has shown that we are in a crisis-level of mental health need in the U.S. and recent societal events have further exacerbated this need. So we must work strategically to provide access,” especially to those for whom stigma, lack of time or resources, language differences, mistrust of services and providers due to disproportionate treatment and outcomes in health care and other realities of underserved populations have made access difficult.
Consultation and colocation
Unmet behavioral health care needs are particularly pronounced among children in underserved groups based on factors such as socioeconomic status, race/ethnicity, English language proficiency, gender and age. Traditional approaches to serving these needs through referral to psychologists at the hospital or in the community require families to complete intake documents and may involve long wait times for appointments that can dissuade care-seeking. Add resistance some have to the very idea of mental health care, and referral becomes a non-starter for many families in marginalized groups.
The “colocation” and consultation models with the integrated behavioral health program developed by the CM team, can blunt those barriers.
Colocating mental health services embed behavioral health providers within patient-centered primary care medical homes. Dr. Perez Crawford has been colocated at the Broadway PCC since 2013, which was an important step in improving access. But colocation still requires a separate appointment and intake paperwork that can prove daunting to family members who are pressed for time or resources, resistant to behavioral health care or challenged by other barriers.
So in 2017 the CM integrated behavioral health care team developed the additional consultation approach that can engage either Dr. Chakawa or psychology residents trained in integrated care and supervised by Dr. Perez Crawford or Dr. Belzer, in the primary care provider’s exam room during the medical visit itself.
“If a parent calls the pediatrician saying ‘my son’s not sleeping’ or ‘my daughter is having tantrums,’ the PCP may recognize a behavioral health issue with a medical component, and a joint appointment can be scheduled,” Dr. Belzer said. If a parent mentions a relevant issue during the medical visit, the consultation model enables a behavioral health provider to join the appointment in the moment.
Relevant issues include problems related to externalizing concerns (e.g., inattention and disruptive behaviors), internalizing concerns (e.g. anxiety, depression), developmental delay (e.g. autism spectrum disorder, speech, learning, intellectual delay), medical concerns (e.g. pill swallowing, sleep), obsessive/habitual behavior (e.g. OCD, chronic skin-picking or hair-pulling), feeding/elimination and trauma adjustment.
No matter the issue, “the patient and family meet us while they’re already there,” Dr. Belzer said.
At 30 minutes in length, consultation visits are shorter than a traditional behavioral health session, and may require separate, colocated follow up or referral to CM specialty services such as the Eating Disorder Clinic, D&B Autism Team, Family Therapy Clinic, or Hearing and Speech Clinic. But the “warm hand-off” from PCP to behavioral health specialist can ease families’ initial trust, time and stigma barriers.
Learning and adapting
The team initially designed the in-the-moment consultation to be initiated by a page from the medical provider to the behavioral health representative.
“But as the program grew, so did demand, and to offer quality care, we had to be more efficient,” Dr. Chakawa said. “So we collaborated with medical home staff to develop a more manageable workflow process to replace the live-page format.”
These days, specific time slots visible in the electronic medical record are designated during four half-day clinics a week, which the PCP or other clinic staff can fill with a joint visit from either Dr. Chakawa or psychology residents supervised by Dr. Perez Crawford or Dr. Belzer in the medical exam room or via telehealth.
Promising research results
To assess whether the combination of colocation and consultation models increases use of services, the team did a retrospective review of the visits of 188 patients, ages 2 through 17, who received services from the colocation or scheduled-format consultation models between Oct. 1, 2019, to Jan. 1, 2020. They also reviewed a sample of 67 patients who received services from the live-page consultation format from the same time period in 2018 to 2019 for comparison purposes.
Results as documented in the published paper support the strategy.
“The overall implication of our results for the real-world setting is that both the consultation and colocation models, as part of a multi-tiered behavioral health program, provide pragmatic means for innovating care that results in greater access to behavioral health services, amidst the known health disparities and barriers to care access,” the study’s authors wrote in their summary.
In particular, “building a consultation model that allows for live-pages and flexible scheduling of warm handoffs in-person or via telehealth is a key component to reducing disparities in care for traditionally underserved populations,” they added.
For Dr. Chakawa, who joined CM in 2017 as an intern, completed a fellowship here in 2018-2019 and took a faculty position last year, the work is a good fit for her clinical and research interests in growing CM’s integrated care program.
“Increasing access to high quality behavioral health care is essential, and integrated care is an effective strategy to help accomplish that, especially to racial/ethnic minority, lower socioeconomic status and immigrant populations who are traditionally underserved,” she said.
Making it work, especially through real-time consultation, requires a high level of coordination and communication, Dr. Belzer added, as well as extra care coordination and the help of patient access schedulers, nursing, telehealth technology staff and other support services.
“But it’s a mission of the Broadway Clinics to be an inner-city hub serving the wellbeing of ALL children, including bringing behavioral health care to those from marginalized and historically disenfranchised groups,” she said.
By sharing the results of their data, they are helping lead the way for others.