Collaborative care: Don’t forget about youth behavioral health

The national debate around youth mental health is intensifying. Illinois, for example, has become the first state to mandate mental health screenings in public schools, while other organizations and states champion fitness, nutrition, and strong families as solutions. Since managing youth anxiety early reduces their risk of developing major depression during adolescence, many of these discussions represent steps in the right direction. However, one critical fact remains: In many communities, behavioral health resources for youth are stretched thin—if they exist at all.

Pediatricians and other primary care providers frequently find themselves on the front lines, caring for patients’ behavioral health even though psychiatric guidance isn’t always very clear. The approach to behavioral health treatment tends to differ from that of primary care, too. It’s a lot to ask of PCPs to manage all of a child’s primary care needs, perform mental health screenings and complex care coordination, and manage behavioral health beyond the scope of typical pediatric primary care—all within the confines of a standard 15-minute office visit.

One way to improve outcomes, reduce PCPs’ workload, and bridge behavioral health resource gaps is to bring the collaborative care models currently used in adult settings to youth. For instance, one pediatric clinic that leveraged a collaborative care model with 7,900 patients found that 84% of referred children enrolled in care, 56% remained engaged or successfully completed the program, and graduates experienced a 40% reduction in PHQ-A (PHQ-9 for adolescents) scores.

Integrating psychiatrists and other behavioral health professionals into youth primary care settings provides youth with timely access to mental health services, enabling early identification, faster intervention, and improved outcomes. When children access integrated collaborative care models at a younger age, the return on investment increases because it changes the care trajectory for the whole family.

But what does “integrated collaborative care” mean, exactly?

Defining integrated, collaborative care

Collaborative care models take many different forms, but they ultimately break down the silos between behavioral and physical health care. Fully collaborative integration means not only fostering multidisciplinary communication but also enabling immediate multidisciplinary care. To be truly effective, psychiatrists, clinical social workers, or other behavioral health professionals should be physically on-site in youth primary care settings. This allows PCPs to make sure that youth who require behavioral health support receive a brief assessment, intervention, and follow-up plan—all before they leave the practice.

There are three reasons an immediate “warm handoff” from a PCP to a behavioral health professional is so important:

1. It gives youth access to the proper resources quickly. The early involvement of behavioral health expertise helps ensure kids receive the appropriate levels of care for their needs, which can change the entire trajectory of the patient and family experience by preventing unnecessary escalation to emergency department or inpatient settings. This, in turn, can improve overall community-wide access to behavioral health services.
2. It decreases the stigma associated with behavioral health. Placing behavioral health in the more familiar and trusted primary care setting attests to its importance as a component of comprehensive well-being. Additionally, it provides an easy way to validate any concerns a family might have. Together, these factors provide a more comfortable, responsive experience for youth and their families.
3. It encourages more comprehensive clinical management.It’s not uncommon for behavioral health conditions to involve physical concerns. Anxiety, for example, often presents with symptoms such as heart palpitations, dizziness, or stomachache. PCPs working hand in hand with trusted behavioral health professionals can reduce the potential for medication management conflicts, set more aligned patient management goals, and speak more consistently with youth and families about those goals.

However, effective collaboration results in the development of programs that aid not only youth and their families but also PCPs. Programs should:

• Have safety pathways in place. A structured approach is necessary to determine when it’s appropriate to refer a child to a collaborative care program, and when a child’s needs exceed such programs. Validated risk screening tools that families can easily complete during a visit [e.g., the Columbia Suicide Severity Rating Scale (C-SSRS) or Ask Suicide-Screening Questions (ASQ)] can assist with those decisions.

Still, PCPs must be properly trained to use the safety screening tools, and workflows must be in place for instances when screening indicates a course of action is necessary. For PCPs, one benefit of having behavioral health resources on-site is the ability to receive real-time decision-making support when they have safety concerns for their patients.

• Be well-designed but adaptable. Many multi-layered components must fit together to form a structured program. For example, how will the program identify patient populations, screen consistently, and put safety components in place? What care team members and registry will be used? A collaborative care program should be flexible enough to accommodate primary care partners of all types and sizes, but within a fully baked configuration with a proven track record.
• Demonstrate measurable outcomes. One academic medical center, for example, recently observed that as youth were successfully managed through its collaborative care program, it experienced a decrease in youth ED visits and referrals to outpatient psychiatry.

Turning collaborative care into better outcomes

Many of the diagnoses that lend themselves to collaborative care—such as generalized anxiety disorder and mild depression—tend to present within school-age youth. Therefore, there are many downstream benefits of a multidisciplinary approach to connecting children and families with appropriate behavioral health resources.

Collaborative patient management can give pediatricians and other PCPs the resources to address less complex behavioral health concerns more confidently. The appropriate management can free child psychiatrists' capacity to see those who truly require their level of care. Perhaps most importantly, moving behavioral health support into the PCP’s office provides a clear safety net for families. Parents are more likely to seek out behavioral health resources for their children when they know they’re available through their trusted PCP.

Jamie Hanna, MD, is the National Medical Director for Children’s Behavioral Health at Magellan Health. She began her clinical training in pediatrics before becoming board-certified in Psychiatry and Child and Adolescent Psychiatry.Prior to joining Magellan Health in 2020, Dr. Hanna served as an Assistant Professor and Assistant Training Director at the Louisiana State University School of Medicine, working with the acute behavioral health unit, consult liaison services, and emergency psychiatric services at the Children’s Hospital of New Orleans.