Creating Medical Homes: Integrating Behavioral Health Services Into a Residency Training Pediatric Primary Care Clinic
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Project CLIMB (Consultation Liaison in Mental Health and Behavior) provides fully integrated and co-located behavioral health services in a high-volume pediatric primary care training clinic. The program is unique in that it jointly trains both pediatric and mental health providers in an integrated care model, where children receive comprehensive services that include timely mental health care ‘right here, right now’. It increases trainees’ knowledge base, facilitates their competence in providing comprehensive and coordinated services to underserved populations, and models interprofessional interaction and community coordination. Project CLIMB is a paradigm of practice-based learning and system-based practice. It is multi-disciplinary in terms of both interprofessional education and collaborative practice. Trainees and participants include pediatric and family medicine residents, medical students, psychology and allied health trainees and both academic and community-based mental health professionals working with children and families. Training innovations involve utilization and follow-up of mental health and behavioral screening tools and the interface of electronic medical record templates. These combine with clinical informatics strategies to advance the quality of care and communication among providers. Specific examples of this include postpartum depression screening and follow-up for referrals made regarding delays found on developmental screening (manuscripts in progress).
*2012 Readiness for Reform (R4R) Innovation Challenge
- Train pediatric and mental health providers in an integrated care model in which children receive comprehensive services that include timely mental health care i.e. ‘right here, right now’ in the context of a medical home.
- Teach mental and behavioral health screening, identification, and follow-up in the context of primary care practice.
- Increase trainees’ knowledge base, and facilitate competence in providing comprehensive and coordinated services to underserved populations who have limited access to community mental health resources.
- Health Equity Research, 2012 Readiness for Reform (R4R) Innovation Challenge, Integrated Mental and Behavioral Health, Medical Home, Resident Education, Health Systems, Clinical Informatics, Electronic Medical Record, EMR, Practice-Based Learning, System-Based Practice
Authors & Co-Authors
Maya Bunik, MD, MSPH
University of Colorado School of Medicine
Ayelet Talmi, PhD
University of Colorado School of Medicine
Effectiveness and Significance
Evaluation & Measurement:
Our measures of success are:
- The success in creating access to integrated mental health services for large numbers of families who have received CLIMB services/
- Both faculty and trainee satisfaction (informal and formal program surveys).
- The national recognition we have received by invited workshop and invited science presentations mainly at Pediatric Academic Societies and other local conferences e.g. Annual American Academy Pediatrics chapter meeting, Pediatric Challenges for Colorado Community providers.
- Research abstracts and manuscripts that have resulted as part of this work (see files with abstracts).
We have developed a fully integrated mental health model of care in a large outpatient teaching system that is now sustainable.
Special Implementation Guidelines or Requirements
How we began: We began with grant funding for psychologist and psychiatrist team as administrative support. Because of relationships that they had fostered we were quickly able to engage community partnership and Harris Postdoctoral Psychologist Fellows to be part of the clinical staffing and transformation efforts in clinic. Postpartum depression screening was the first step in engaging providers. We determined that we would screen at all visits in the first 4 months of life. Quickly the co-located team began to work together and it quickly expanded to consultation on other mental health issues e.g. suspected co-morbidities with ADHD.
Required Resources or Guidelines: Our collaboration efforts systems-wide address the continuum of mental health integration from direct services, to training, to sustainability. Our model emphasizes training in, and provision of, continuity of care between pediatric practice and the community following the Family-Centered Medical Home model. As such, we pulled from personnel resources from pediatric and behavioral health faculty from the University of Colorado School of Medicine Departments of Pediatrics and Psychiatry (UCSOM) as well as the Aurora Mental Health Center (AuMHC), our local community mental health agency. Long-standing collegial clinical and academic relationships between psychology, psychiatry, and pediatrics at UCSOM and AuMHC enabled the partnership conceptually, and funding initially from state foundations and later from clinical service reimbursement enabled it logistically. Staffing of Project CLIMB included a 0.5 FTE psychologist and a 0.5 FTE psychiatrist, pediatric faculty in their primary care precepting roles, an a full-time mental health counselor clinician from AuMHC to provide services and coordinate community referrals, and psychiatry and psychology fellows and residents. As noted earlier, pediatric and family medicine residents and students at many levels were involved as trainees.
- Integrated mental health care decreases the burden on the primary care provider and at the same time ‘introduces’ the family to mental health care when there may be predisposed barriers to access.
- Building an integrated mental health services program facilitated interprofessional training and education and collaborative practice that promoted care for “our patients” and decreased the propensity for practice in discipline silos. Initially had CLIMB providers in separate charting/consultation area in clinic. Better to have everyone mixed up and sharing a common space.
- Screening processes were much more readily adopted by the pediatric primary care setting when providers knew they had on-site mental health resources and with ongoing training and continuous improvement processes. Starting with postpartum depression screening as the initial screening mechanism was a good place to start and we would recommend that to others beginning this process.
- CLIMB providers were an additional team of teachers for short didactics, noon conferences and practice-based in a busy teaching clinic. The therapeutic nature of their interactions was helpful with our very high risk families—in terms of debriefing for trainees on difficult cases. We also found that identification and treatment increased tremendously after didactics, trainings, and clinical informatics strategies were implemented.
- Frequent communication on roles of the clinic social worker and CLIMB team were important as the social worker traditionally fulfills this role in traditional non-integrated clinic settings.