Despite the shortage of behavioral therapists, there are some ways pediatric practices can access help for children and teens, and improvements could be made. (Image: Adobe Stock / Illustration: David Chrisom, Boston Children’s)
The mental health crisis among children and teens does not appear to be abating, and COVID-19 has clearly exacerbated matters. A recent study found that suicide attempts and self-harm were among the few indications for hospitalization that did not decline during the first waves of the pandemic. On the contrary, the past year has seen a spike in suicidal thoughts and suicide attempts.
“We have seen an exponential rise in anxiety and depression, exacerbated by the stress and social isolation of the pandemic,” said Fred Kern, MD, a pediatrician and managing partner at Bridgewater Pediatrics, a member of the Boston Children’s Primary Care Alliance.
Unfortunately, unless families pay out of pocket, most adolescents struggle to access specialized mental health services. Due to the low reimbursement rates, many child psychotherapists and psychiatrists do not accept insurance, and those who do tend to have a long waiting list.
“There just aren’t enough behavioral health providers in the community that accept insurance to meet the need,” said Nanci Ginty Butler, a licensed clinical social worker and director of mental health in the Division of Adolescent and Young Adult Medicine at Boston Children’s. .
Despite the shortage, there are some ways that primary care pediatric practices and their patients can access help, and improvements could be made. Below you will find a number of initiatives that you should be aware of.
1. Embedded Behavioral Therapists
Pediatric practices affiliated with larger providers like Boston Children’s are beginning to “embed” behavioral therapists. Through the Behavioral Health Integration Program (BHIP), Boston Children’s partners with the 80+ practices of the Pediatric Physicians’ Organization at Children’s (PPOC). Many of these practices have at least one behavioral therapist on site, who will prescribe psychotherapeutic visits and medication for ADHD, anxiety, and depression.
Call for change
Check out recent congressional testimony by Boston Children’s CEO Kevin Churchwell, MD, calling for more federal funding for behavioral health.
Bridgewater Pediatrics was an early adopter of the BHIP model and now employs three embedded behavioral therapists — as many as the number of full-time pediatricians. They were all screened, vetted, and trained by the Boston Children’s behavioral health team, who also conduct regular case reviews to monitor care.
A recent five-year study led by the PPOC’s Medical Director for Behavioral Health, Heather Walter, MD, MPH, found that the BHIP increased children’s access to behavioral health services with only small increases in costs and high numbers of participating practices.
“Eight years ago, if a teen had a behavior problem, we would give them a list of five practitioners in the community and say ‘good luck,’” Kern says. “Now the care takes place in the context of the medical orphanage, where teens and parents have years of trust, without the barriers and stigma. Being seen as willing to help teens with the major challenges they face – anxiety, depression, suicidal thoughts, trauma, bullying, substance use – is a huge boon to the practice.
For more information about BHIP, email Program Director Jonas Bromberg, PsyD, at email@example.com.
2. Web-Based Behavioral Health Training
Going forward, Boston Children’s will offer web-based behavioral health training in partnership with Open Pediatrics, the hospital’s clinical training platform. “This allows us to expand our training to a national and international audience, significantly increasing the capacity of pediatricians to provide evidence-based behavioral health care to their patients,” said Walter.
3. Comprehensive services through MassHealth
As a result of a class action lawsuit, MassHealth (Massachusetts Medicaid) offers a range of services under the Children’s Behavioral Health Initiative (CBHI). The core services are threefold: psychotherapy at home; coordination of intensive care for young people with complex emotional or behavioral problems; and 24/7 mobile emergency assistance in crisis situations.
MassHealth maintains a list of CBHI providers and some commercial insurance companies have also agreed to pay for CBHI services. “I often recommend that parents check with their insurance company to see if they will reimburse for these services,” says Ginty Butler.
4. Expert Consultations: The Mass Child Psychiatry Access Project (MCPAP)
MCPAP’s partnership with Boston Children’s allows pediatric caregivers to have telephone consultations with child and adolescent psychiatrists. Services are free to all children and families regardless of insurance, funded primarily by the Massachusetts Department of Mental Health with some support from major payers. Consultations can relate to the diagnosis, the level of care required and the treatment recommendations. In severe circumstances, consulting psychiatrists can facilitate referral of patients to emergency or specialist services. For less severe but complex cases where diagnosis or treatment remains uncertain, MCPAP may schedule telephone or video consultations for child psychiatrists directly with the patient and family, providing feedback to the pediatrician on ongoing behavioral health management.
5. Care coordination
Practices affiliated with an Responsible Care Organization (ACO), such as the Tufts Health Together with Boston Children’s ACO, have access to a continuum of supportive and preventive care. Services include care coordination and connecting families to housing, food, SSI, transportation, behavioral health services, and other necessities that can affect teens’ physical and mental health outcomes.
“ACO’s care coordination teams can help patients and families solve problems such as homelessness, food insecurity, access to specialized medical care, navigating the transition to adulthood and adult care, intimate partner violence and behavioral crises,” says Ginty Butler. “The ACO partnership allows us to provide additional support to families trying to navigate complex healthcare systems.”
6. Family-oriented crisis intervention
Family-Based Crisis Intervention (FBCI) is a short intervention developed by Boston Children’s to avoid the need for psychiatric hospitalization. Originally designed for emergency departments, FBCI stabilizes suicidal adolescents and provides them and their families with training and tools to safely manage crises at home. The FBCI team is adapting it for primary care and is currently testing it in four pediatric practices in urban, suburban and rural Massachusetts, with promising results to date. For more information, email Elizabeth.Wharff@childrens.harvard.edu or Abigail.Ross@childrens.harvard.edu.
Looking to the future
Much more needs to be done to make behavioral health care truly accessible. Earlier this year, the Commonwealth of Massachusetts announced a Roadmap for Behavioral Health Reform. The program creates a centralized “front door” to connect people with behavioral health and addiction treatment before a crisis occurs. As this initiative develops, it should expand access to care by funding Community Behavioral Health Centers and expanding the integration of behavioral health services into primary care practices.
“Due to the acute need, many programs are being viewed and developed,” says Kern. “I think increasing the number and availability of behavioral therapists in pediatric practices is the direction we need to go.”
Visit Boston Children’s Hospital’s Department of Psychiatry and Behavioral Sciences