Primary care physicians are in position to connect young patients to appropriate mental health resources. Here’s what you need to know.
Behavioral issues have long been underrecognized, underappreciated, and often stigmatized. Behavioral health challenges in children are now approaching a crisis level, having become particularly acute as COVID-19 disrupted children’s social and educational experiences outside their homes.
Limited mental health resources coupled with social and economic barriers have created a dangerous combination, particularly at a time when we are experiencing an increase in mental health risk factors. These challenges are felt more acutely by populations who have historically been faced with greater barriers to accessing care, including those with disabilities or housing insecurities, as well as racial and ethnic minorities. Socioeconomically disadvantaged children and adolescents – such as those growing up in poverty – are two to three times more likely to develop mental health conditions than peers with higher socioeconomic status.
One way of overcoming such barriers to care is harnessing overlooked avenues for accessing mental and behavioral health, in particular primary care physicians. A full 75% of children diagnosed with a mental health disorder are currently seen in primary care, representing a significant opportunity to better connect patients and their families to appropriate behavioral health resources.
There is no “wrong door" to access mental health resources. It is important that access and treatment for mental and behavioral health care is available at any point of entry across the care continuum, including prevention and wellness, screening and early detection, intervention, and post-discharge and access to ongoing care. This comes with the responsibility to make sure effective infrastructure is in place to ensure that those with mental and behavioral health needs will be identified, assessed, and have access to treatment, either directly or through appropriate referrals, no matter where they enter across the realm of services.
One key to successful and sustainable behavioral health integration in primary care is equipping primary care physicians with the appropriate tools, resources, support, and training to conduct screening, practice early intervention, and/or provide referrals for treatment. It is important to emphasize that mental and behavioral health care delivered in this setting is much more likely to be effective and sustainable if complemented by a strong secondary level of care that primary health care workers can turn to for referrals.
Effective prevention and wellness strategies require a combination of clinical, social, community, and policy leaders working together to destigmatize conversations around mental and behavioral health. It’s essential to educate community members on how to promote healthy habits and fund initiatives that address the underlying drivers of mental and behavioral health conditions. Both health care organizations and community leaders play a significant role in this part of the continuum.
Opportunities in this space include implementing appropriate social and emotional learning standards and programs, supporting professional development for educators, and providing funding for teachers and school leaders to work with families to support student health needs. Digital solutions can be used to enable these activities, such as applications being used to provide clinically validated, on-demand, self-directed educational resources about mental health and wellness.
Approximately 50% of all lifetime mental illness begins by age 14, and 75% by age 24. Given this data, it’s clear that most cases of adult mental and behavioral disorders make their first appearance prior to or during adolescence, making screening, early detection, and referral to appropriate levels of care imperative. While some action has been taken to promote the implementation of programs dedicated to screening and early detection of mental and behavioral health conditions, needs during this critical period are still largely unmet.
Effective screening using standardized tools, including the PHQ-2 and PHQ-9 for depression and the GAD-7 for anxiety, in a variety of care settings will better ensure that patients are evaluated at an early point in their care. This will ensure that the stages of their behavioral health care that follow – assessment, diagnosis, treatment, and ongoing monitoring – will be more appropriate and effective.
Primary care physicians can use screenings to account for the diverse ways in which mental health challenges can manifest, such as changes in physical health, sleep patterns and other behaviors. This shifts the focus from a reactive, wait-to-fail model to a proactive system in which needs are identified early and interventions are delivered efficiently to the appropriate level of need required.
Providing timely access to appropriate mental and behavioral health care is a universal challenge. Only about 11% of children aged 3 to 17 years received mental health care prior to COVID-19, and only one in five children who needed care were able to find a specialized provider.For those children receiving appropriate mental health care from a specialized provider, the average delay between onset of symptoms and treatment is 11 years. The discrepancy between those diagnosed with mental and behavioral health conditions and those who actually receive treatment highlights the barriers to accessing treatment, including shortage of providers, stigma, financial complications, difficulty in physically reaching providers, and lack of culturally sensitive care. To overcome access barriers, health systems can integrate mental and behavioral health into other sites of care such as primary care settings.
Placing mental and behavioral health care in pediatrician’s offices and other settings of care, either physically or through digital modalities, enables more efficient behavioral health care delivery. This comprehensive co-location of services allows for more timely consults, patient triaging, comprehensive care management at the point of care, and transitional care and referral without the stigma associated with seeking care for behavioral health conditions.
In addition to integrating physical and behavioral health resources through the physical co-location of services, integration can also be supported through digital solutions. For example, behavioral health integration can be enabled by digital tools that conduct closed-loop referrals to streamline referrals to behavioral health services and resources, creating additional operational value and efficiency. These digital solutions contribute to improved care navigation across intervention resources, allowing individuals to seamlessly navigate to a variety of convenient behavioral health resources that fulfill their need for that care. Typically, the success of these digital referral solutions depends on the network of organizations on the platform, as well as whether the patient/family can easily navigate to the appropriate resources once the referral has been made.
Effective follow-up and access to ongoing care post-discharge are critical to improving health outcomes, reducing readmissions, and reducing the overall total cost of care. Readmission rates for patients with behavioral health comorbidities have also been shown to be nearly twice those of patients without a behavioral health comorbidity. These increased readmission rates can be due to the fact that individuals being hospitalized for behavioral or mental health conditions often do not receive adequate follow-up care, despite the recommended post-discharge care treatment protocols. Organizations typically struggle to know whether a patient adheres to their care plan once they leave the visit or if a referral was successful upon being discharged from their facility/care. Post-acute discharge processes are often manual and cumbersome, and patients with lower-acuity needs can be effectively monitored from home.
Strategies to improve post-discharge compliance and overall access to ongoing mental and behavioral health care include effective patient engagement tools such as medication adherence, peer network tools, and remote patient monitoring (RPM). RPM may serve as an extension of the care team by allowing individuals to share biometric and other data (e.g. mobile app-based, test-based, etc.)from a nonclinical setting with their care team as a part of a provider-supported program of care. Ultimately, this RPM model strives to evaluate patients more frequently and facilitates greater opportunities for the patient and family to share information with their health care team, thereby detecting developing mental and behavioral health problems earlier than would be possible through scheduled clinical visits.
Addressing this crisis will require an all-of-society effort, one that spans policy, individual, and institutional changes on how we view and prioritize behavioral health – and digital solutions have a vital role to play, both as a locus of care and as powerful enablers of the changes to both access and availability of care.
The good news: We are heading in the right direction, and new legislation is pushing for mental health services to be covered by insurance at parity with physical health care. As we have shown, though, there are effective tactical steps we can take across the care continuum to drive meaningful change. Addressing these behavioral health access challenges will require a top-down effort to create the right incentives to support our youth and their families.
Scott Cullen, MD, is executive vice president of strategic innovation and chief clinical officer for AVIA. As a former primary care physician, he is well aligned with AVIA’s vision for digital transformation in the health systems of the future – one that combines digital health innovation, clinical outcomes, and equitable and effective health care experiences.
Ontara Sarker, a behavioral health expert, leads Avia’s Center For Care Transformation.