NHMH NO HEALTH WITHOUT MENTAL HEALTH A 501(c)(3) non profit   San Francisco - Washington DC Director’s blog

PEDIATRIC Integrated Care: The Montefiore Experience

Published Tuesday 24 of March, 2015

NHMH recently interviewed Dr. Rahil Briggs, PsyD, the Director of Pediatric Behavioral Health Services at the Montefiore Medical Group in the Bronx, New York. Montefiore is unique in providing both integrated adult and pediatric behavioral health services. While the adult services at Montefiore follow the collaborative care model, pioneered by the AIMS (Advancing Integrated Mental Health Solutions) Center, at the University of Washington, www.aims.uw.edu, Montefiore’s pediatric model is designed to make its own significant contribution to the evidence base in this area.

Dr. Briggs is an expert in early childhood development, infant mental health, and the parent-child relationship. Ten years ago, she began her practice in Montefiore and has since been instrumental in setting up their preventive pediatric mental health care clinical program.

Her career interest had always been in psychology and early childhood, birth-5 years, development. Dr. Briggs had noticed that children who came to mental health care after those ages, had often already been suffering quite a while with behavioral health conditions. Also characteristic was that things usually had to get pretty bad before parents would even bring in their small children who were having behavioral health problems. And finally, often appointments were made and then cancelled.

So her focus moved to the pediatric primary care setting, the one place where all children must come for care at some point. Peds PC is a non-stigmatizing place; moreover, when it comes to pediatrics, primary care often has a very favorable connotation for families. These factors galvanized her interest in routinely integrating mental health care into the pediatric primary care clinics at Montefiore.

Starting in 2006, Montefiore launched a program for parents of infants and toddlers called Healthy Steps, www.healthysteps.org. The patient population is youngsters from birth to 5 years. In addition to their pediatrician, these little ones are seen by Healthy Steps Specialists, psychologists and social workers, specially trained in child development and behavioral health to screen for, monitor and treat behavioral problems.

Healthy Steps continually monitors the child’s behavioral and developmental well-being at every well-baby check-up. Parents are offered a dedicated hotline to answer questions regarding care, educational materials, optional home visits, parent discussion groups and referrals to children’s specialists when needed. Interestingly, parents are also themselves offered on-site treatment for their own depression, anxiety and other mental health concerns, in an environment of privacy.

The program has met with success in treating Montefiore Medical Group’s covered 100,000 children, 35,000 of whom are ages birth-5 years. To date, Montefiore is providing Healthy Steps in their 4 largest practices, with a patient population of 15-17,000 kids, birth to 5. By the end of 2015, it should be available in all their pediatric sites. Due to the plasticity of the developing brain, the Healthy Steps program at Montefiore has shown that it is significantly easier to provide early intervention, and ensure appropriate development and behavior, versus fixing problems long after they’ve emerged. Also, they were able to document a significant correlation between parents with difficult childhoods and the well-being of their own children. Offering integrated care had a powerful impact on that dynamic, with parents able to access mental healthcare for themselves, when needed, in the pediatric setting and thereby interrupt the otherwise powerful intergenerational transmission of risk and trauma.

In 2014, Montefiore expanded its pediatric integrated behavioral health to cover the pediatric lifespan, from birth through age 18. All patients receive universal screening for behavioral issues as a part of every well child visit. The pediatrician follows up, exploring the issues in more depth, and if appropriate, a warm handoff is made to a behavioral specialist in the pediatric clinic. Montefiore has developed short-term treatment modules aimed at school-age and adolescent children for care of anxiety, depression, trauma, attention deficit, etc. At the start is a brief assessment, using motivational interviewing techniques, followed by 4-6 sessions to treat the presenting problem. Child psychiatrists and psychologists are also available to do consultations with the pediatric primary care doctors.

Lessons Learned: Dr. Briggs shared Montefiore’s main takeaways from its 10 years experience providing integrated medical-behavioral care in pediatric primary care:

  1. Providers considering implementation of the collaborative care should find a champion within their existing clinical program, able to function as a liaison between change agents and other incumbent clinicians in the practice.
  2. To the extent behavioral screening can be presented as universal, there for everyone, it helps to reduce the social stigma parents often experience when seeking behavioral health care.
  3. Workforce development is a crucial central issue. Success depends on hiring the right people to work in an integrated care culture – people who are flexible and can work within an unpredictable setting, who practice CBT (cognitive behavioral therapy) and other evidence-based techniques, who can do brief assessments and who have what Dr. Briggs terms an “integrated care backbone,” or the ability to take on only those cases that are appropriate for this unique integrated care model, and ensure that inappropriate cases are referred and managed elsewhere (either by the pediatrician or another provider in the community).
  4. Training of healthcare professionals in an integrated practice is essential; the medical and behavioral fields need to develop sufficient training programs, such as fellowships, post-doctoral opportunities, and post-graduation training to teach these new skills.
  5. Physical location counts. Behavioral specialists in pediatric primary care need to be close enough to the pediatric exam rooms that the warm hand-off will be successful.
  6. Behavioral health providers in the pediatric setting also struggle with issues of patient privacy and confidentiality, e.g. when the setting is not a mental health clinic per se, how do you honor the privacy of the patient while still providing integrated care; to what extent do you document or chart a parent’s mental health concerns in a child’s chart?
  7. Value-based provider payment methods will “incentivize” wider implementation of this integrated care model. Paying for this care under traditional fee-for-service is challenging.
  8. Parity of medical and behavioral care is difficult to achieve in a carve-out world, where medical and behavioral healthcare delivery and provider networks are separate and independent. Also, children are typically not high users of healthcare services in general, so the financial incentives are lower for some insurers. Still, value purchasing should “incentivize” this model of care.

Florence C. Fee, J.D., M.A.

Executive Director