Off-site integrated care can help provide mental health services for children, adolescents

Three models of off-site integrated care can help to meet the growing need for mental health services in children and adolescents, according to a report in the November/December issue of Harvard Review of Psychiatry. The journal is published in the Lippincott portfolio by Wolters Kluwer.

Led by Andrea E. Spencer, MD, of Boston University School of Medicine and Rheanna E. Platt, MD, MPH, of Johns Hopkins University School of Medicine, the researchers analyzed available evidence on direct and remote approaches to integrating mental health care services with primary care for children. "Off-site interventions are feasible, acceptable, and often adopted widely with adequate planning, administrative support, and interprofessional communication," the researchers write.

Off-Site Approaches to Pediatric Mental Health Care – What's the Evidence?

Up to 20 percent of children have a psychiatric disorder, highlighting a "large and growing gap" between the need for and availability of pediatric mental health care. Integrating mental health services with primary care is a promising strategy for increasing access to pediatric mental health care. But for several reasons, it's difficult to "co-locate" qualified metal health providers (MHPs) at primary care practices or clinics.

Off-site integration – referring to various types of partnerships between primary care practices and specialty MHPs – may offer advantages over on-site integration. The new report provides an overview of available evidence on emerging approaches to off-site integration of mental health care services for children and adolescents.

In a scoping review of the evidence, Drs. Spencer and Platt and colleagues identified 39 papers reporting on 24 off-site integrated pediatric mental health and behavioral care programs. The researchers analyzed three categories of programs:

• Direct in-person models – In-person evaluations performed at specialty agencies, coordinated through primary care. Most of these programs involved partnerships between primary care sites and existing mental health agencies.
• Direct remote models – Remote evaluations of children with mental health or behavioral issues using technology: telepsychiatry approaches using videoconferencing or telephone calls.
• Indirect remote models – Real-time telephone consultations between primary care practitioners and MHPs – usually child and adolescent psychiatrists.

On analysis of implementation outcomes, all three models were well used and well accepted by providers and families. Programs with strong communication, timely and reliable specialty services, additional support after the initial evaluation, standardized care approaches, and ongoing support were better accepted by primary care practitioners. Programs with adequate planning and ongoing administrative support had better feasibility, adoption, and penetration.

Off-site integrated care seemed more appropriate for some groups of patients, such as those with less-complicated attention-deficit/hyperactivity disorder, depression, or anxiety; but less so for others, including preschool-aged children and those with conduct disorders. "Funding and adequate reimbursement were barriers to sustainability in all models." the researchers add.

"[O]ff-site pediatric integrated behavioral health programs...have the potential to expand integrated care without substantial infrastructure changes and to reach a broader population of patients than on-site programs," Drs. Spencer and Platt and coauthors conclude. They emphasize that further studies testing guidelines, protocols, and application of integrated care models in specific groups of patients will be needed for successful future expansion of these programs.