As many as 15 million children and adolescents in the United States are in need of behavioral health services, and it is often the pediatric primary care system that is their first contact with formal assessment and intervention services. However, pediatric primary care providers (PPCPs) face challenges to assessing and managing children with behavioral health concerns, including lack of time, lack of training, and lack of behavioral health specialists to whom they can refer. The Connecticut Behavioral Health Partnership has forged relationships between primary care and behavioral health providers through its enhanced care clinic (ECC) initiative, which focuses on improved access to behavioral health services and coordination of care for children insured by Medicaid. We report on interviews with 24 PPCPs and 8 staff/ administrators from 12 pediatric practices throughout the state about their experiences with the ECCs. The majority of participants expressed satisfaction with the behavioral health partnerships and, based on their experience, would join the partnership again.
Keywords: behavioral health, pediatric, integrated care, Medicaid
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Approximately 15 million youth in the United States meet the diagnostic criteria for a mental health disorder (American Psychological Association, 2008). (1) Pediatricians provide a variety of interventions to children, including brief counseling, referrals to mental healthcare providers, and the majority of prescriptions for psychotropic medications (U.S. Public Health Service, 2000; Williams, Palmes, Klinepeter, Pulley, & Foy, 2005). Literature suggests that when a pediatrician provides early treatment for a mild to moderate behavioral health disorder, the incidence of long-term disability for children and adolescents is decreased (Williams, Klinepeter, Palmes, Pulley, & Foy, 2004).
In this article, we report on one component of an initial assessment of the enhanced care clinic (ECC)/primary care initiative, a program developed in Connecticut to support partnerships between mental health providers and primary care practices. This phase of the assessment entailed interviews with both pediatric primary care providers (PPCPs) and staff at ECC-partnered practices. The Child Health and Development Institute, a subsidiary of the Children's Fund of Connecticut, funded this project.
Despite the important role that PPCPs play, primary care providers face several barriers in addressing psychosocial and behavioral difficulties in children (Pidano, 2007; Trude & Stoddard, 2003; U.S. Public Health Services, 2000) including difficulty identifying mental health issues, lack of time to address any issues that may arise, and inaccessibility of mental health specialists (Brugman, Reijneveld, Verhulst, & Verloove-Vanhorick, 2001; Costello, 1986; Pidano, 2007).
In Connecticut, one strategy geared toward improved access to behavioral health services and increased care coordination was the development of the ECC initiative through which mental health agencies could apply for inclusion in a new class of providers (State of Connecticut, 2006). Designation as an ECC requires that, over time, the organization will meet five primary criteria related to accessibility of services, collaborative care management with primary care providers, member services, quality of care, and cultural proficiency (Connecticut Behavioral Health Partnership, n.d.). Organizations qualified as ECCs receive enhanced HUSKY/Medicaid reimbursement rates (on average 25% higher than the standard fee schedule) for behavioral health services provided to HUSKY clients (State of Connecticut, 2006). The first group of 29 ECCs was designated in April 2007, with 10 others approved approximately a year later.
In March 2008, Connecticut developed a set of requirements for ECCs to address in memoranda of understanding (MOU) with primary care practices. ECCs were required to enter into two MOUs with primary care practices by September 2009. MOU requirements included protocols for patient referral to ECCs, protocols for patient referral from the ECC to the primary care provider, communication guidelines, responsible parties, education and training, and optional components (State of Connecticut, 2008).
In conducting this second phase of the project, we used a semistructured interview format to obtain information related specifically to the experiences that PPCPs and office staff/administrators have had with their ECC partners since these formal relationships began. In addition to obtaining descriptive data about the practices, we asked about participants' initial reactions to the idea of a partnership, communication with and referrals to the ECCs, level of satisfaction with the partnered agency, and willingness to participate again if asked.
METHOD
Participants and Practices
We interviewed 19 pediatricians, three APRNs, one RN, one LCSW, and eight non-provider staff. They reported a range of training experiences in behavioral health through participation in continuing education (83.33%), a rotation during residency (66.67%), or a fellowship (12.5%). Providers reported marked variation both in the number of children in their individual patient panels and in their overall practices. Estimates of patients insured by HUSKY/ Medicaid ranged from 5% to 95%, and the percentage perceived as having behavioral health issues ranged from 15% to 80%. Overall, the most common behavioral health concerns reported were attention-deficit/hyperactivity disorder, mood disorders, and anxiety. Other diagnoses included oppositional defiant disorder, autism, posttraumatic stress disorder, conduct disorder, and substance abuse.
Procedure
The Human Subjects Committee at the University of Hartford approved the content and methodology for this study. All participants were treated in accordance with the American Psychological Association's (2002) Code of Ethics. We mailed introductory letters to the contacts at the pediatric practices, explaining the study and inviting them to participate in in-person, semistructured, individual interviews. A week to 10 days after the letters were mailed, we contacted practices by telephone or e-mail to assess willingness to participate and to schedule times for interviews in their offices. All participants signed informed-consent forms prior to the interviews. The semistructured interview lasted approximately 30 to 60 min.
RESULTS
Twelve of 28 practices (42.6%) agreed to participate in this phase of the project, including 24 PPCPs and eight office staff/ administrators. The data from the interviews were reviewed by the research team to determine emergent issues among pediatric providers and staff/administrators with respect to their relationships and satisfaction with the ECCs with which they were partnered. Most of the results were derived from open-ended questions and were qualitative or narrative, but some data were obtained using scaled ratings. Because of the modest participation rate, we were not able to analyze results statistically but summarize the interview data below.
Among those interviewed, the reported initial reaction to the program was overwhelmingly positive. Sixteen of the 24 providers offered responses such as a 'great idea' and 'exactly what [was] needed.' Five providers reported that they were pleased to have a place to refer their patients for mental health treatment, and two providers and one staff member reported that they were already involved in such a relationship on an informal basis. Staff members were also optimistic, with six of the eight staff members interviewed believing that it was a good idea. Of those who reported any initial reservations about the program, funding was cited as a cause for concern, as was a lack of patients to refer due to insurance constraints; specifically, this concern referred to the fact that patients insured other than by HUSKY/ Medicaid are not entitled to such benefits as the access requirements at ECCs include availability of an appointment within 2 hr for emergency situations, 2 days for urgent situations, and 2 weeks for routine situations.
Participants cited a variety of reasons for forming an official relationship with an ECC, including a preexisting informal relationship, insurance, proximity, and the belief that the ECC could offer services to patients that the medical providers could not. Three of the providers established a relationship with an ECC because the clinic would see patients quickly based on level of urgency, and one stated that there was no 'downside' to such a partnership.
Fifteen of the 17 providers (88%) who responded to a question about expectations stated that their expectations were met or exceeded, as did the three (100%) staff members.
Some interviewees reported that their practice had initiated changes as a result of the ECC partnership, with the most frequently mentioned being regular meetings between the pediatric offices and the ECCs and the creation of a formal referral form. In contrast, interviewees from seven practices saw no change after the formation of the partnerships with the ECCs. Furthermore, representatives from six practices reported having no formal guidelines for contacting or referring to their partner ECC, and five providers reported having no contact person at the ECC. Participants from eight practices indicated that there were no forms for communication between the pediatric office and the ECCs.
Communication is a critical component in the partnerships, both when it is improved or working well and, similarly, when it would benefit from additional improvement. This was an almost universal theme throughout the interviews. Those participants who reported the use of communication forms rated their level of satisfaction at a higher level (M = 4.46 on a 5-point scale) than those who did not report use of a form (M = 3.5).
Perhaps most telling, nearly three quarters of providers expressed the opinion that the partnerships were working extremely well or very well.
Finally, when asked whether they would enter into such a partnership again, all but one participant (who was unsure) said that it was very likely or absolute that she or he would choose to take part in the program a second time.
DISCUSSION
Virtually all of the interviewees reported that they consider the ECC initiative to be beneficial to providers and patients. When asked whether they would participate in such a partnership again (i.e., would make the same decision given their experience to date with the ECCs), all but one participant stated that they would 'very likely' to 'absolutely' would do so. Although approximately one quarter of participants reported no change in activity following the formation of an ECC partnership, a number of the remaining practices cited regular meetings between mental health and medical staff, the use of a formal referral form, and the availability of a consulting psychologist as the most beneficial changes. When information about diagnosis, treatment goals, and medication, for example, was shared, medical providers tended to indicate that the relationship was successful. Indeed, based on provider and staff comments, our overall impression was that communication between mental health and medical providers seemed to be one of the most influential factors in medical providers' perceptions of the success of the relationship.
In addition, and importantly, despite the positive feedback received regarding changes in communication between the partners, close to half of the PPCPs reported that lack of communication or difficulty maintaining communication was the biggest challenge in providing consistent, collaborative care to patients. Such difficulties included the lack of formal guidelines for contacting the mental health clinic, the absence of an identified liaison between the medical and mental health practices, and the lack of referral and feedback forms to facilitate flow of information between providers.
In addition to difficulties in communication, issues related to the availability of mental health professionals for consultation and difficulty meeting treatment requirements of both private and public insurance were cited as aspects of the partnership requiring improvement.
Although this study provides a limited overview of providers' and staff/administrators' experiences with the ECC initiative, their responses suggest that this aspect of coordinating patient care is moving in a positive direction.
Limitations
This project yielded important, but preliminary, information about the ECC initiative in the State of Connecticut and, to date, is the only assessment of the initiative from the perspective of pediatric providers, administrators, and staff. Limitations of the data presented include the modest number of participants, variations among interviewers, and self-report data with the attendant advantages and disadvantages. In particular, we did not have access to practice management data or to patient records, both of which would have allowed us to consider our results in conjunction with quantitative and more objective data, such as verifiable numbers of patients referred to ECCs. Finally, the timing of this project was such that most practices had been involved with their ECC partners for only a relatively short period of time. Therefore, their responses were based on limited experience and are likely to evolve over time.
Recommendations and Future Directions
Provide Training
The results of this study strongly suggest that preparation for participation in a project like the ECC initiative is critical. The interviewees varied markedly in their understanding of the ECC initiative, the manner in which they were introduced to it, and the type of working relationships with ECCs that they described. We recommend that future initiatives ensure (a) that the primary care partners receive substantial training about and a thorough introduction to the partnership requirements and goals; and (b) that the Medicaid program monitors, through direct contact, the activities of both the medical and the behavioral health partners.
Communication Is Key
Communication is a critical component in the partnerships. The participants in this study focused on communication and its importance; it appears that, for this group of PPCPs and staff, written communication may play an especially crucial role with regard to their level of satisfaction with their ECC partners.
Collaboration Is Critical
Partnerships will benefit from collaborative planning from the very beginning. This will ensure that referral, consultation, and ongoing communication are carried out in mutually acceptable ways. Major initiatives such as this need to balance consistency and flexibility. Although the ECC initiative encompassed a number of required elements, every pediatric primary care practice and every ECC is unique. We were impressed with the manner in which some of the partners worked to meet the requirements and yet created systems based on their own particular circumstances. We recommend that future partners invest in significant preparation and groundwork to get to know each other as well as possible and to design policies and procedures that are compatible with their own office cultures and systems prior to launching their partnerships.
Consider Incentives
This initiative provides incentives in the form of enhanced payments for services (125% of customary fees) to ECCs, but there is no financial incentive for the partnered pediatric practices. It may be that a financial incentive would strengthen PPCPs' willingness to collaborate with ECCs.
Enhance and Expand Data Collection
Although self-report data can be both rich and useful, they are limited. Future research should include other sources of information such as chart reviews, tracking the process and progress of patients who are referred to ECCs, and reports from patients, parents, and ECC providers about their experiences with referral processes and coordination of primary and behavioral healthcare.
Consider the Context
Finally, this project should be understood in the broader context of trends in pediatric primary care and training in pediatrics, especially those that address the integration of medical and behavioral healthcare in contrast to more traditional models of care. The American Academy of Pediatrics' defines a medical home as 'primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective to every child and adolescent' (American Academy of Pediatrics, n.d.). This concept is receiving much attention in the current child health literature and supports the expanded capacity of pediatric primary care to better address patients' mental health needs.
Conclusion
Connecticut's ECC initiative represents an ambitious effort to link primary care providers with community-based behavioral healthcare providers to improve continuity and coordination of care by encouraging collaboration and communication between professionals. Its designers deserve credit for their goals and vision, as do the participating pediatric practices and ECCs. One of our core findings--that virtually every participant we interviewed would choose again to be involved in a partnership--suggests that the 'early returns' on this initiative are quite positive from the perspective of the PPCPs.
DOI: 10.1037/a0023474
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(1) The words youth and children are used in this article to designate those birth to 18.
ANNE E. PIDANO, PHD
KRISTEN H. MARCALY, MA
KRISTEN M. IHDE, MA
EILEEN C. KUROWSKI, PsYD
JENNIFER M. WHITCOMB, BA
This article was published Online First April 25, 2011.
Anne E. Pidano, PhD, Kristen H. Marcaly, MA, and Jennifer M. Whitcomb, BA, Graduate Institute of Professional Psychology, Department of Psychology, University of Hartford; Kristen M. Ihde, MA, Village for Families and Children, Inc., Hartford, Connecticut; and Eileen C. Kurowski, PSYD, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts.
We would like to express our gratitude to the Child Health and Development Institute/Children's Fund of Connecticut for their support of this project, to Dr. Lisa Honigfeld, and Dr. Katherine Black for their careful reading of, and helpful feedback on, earlier drafts of this manuscript, and especially to the pediatric providers and staff who graciously shared their time and thoughts with us in the interviews on which this report is based.
Correspondence concerning this article should be addressed to Anne E. Pidano, PhD, Graduate Institute of Professional Psychology, Department of Psychology, East Hall 117C, University of Hartford, 200 Bloomfield Avenue, West Hartford, CT 06117. E-mail: pidano@hartford.edu
