Do you sometimes feel you do not have the experience, tools, and financial support needed to establish or participate in collaborative care and integrative team-based care delivery?
SPECIAL REPORT: CHILD AND ADOLESCENT PSYCHIATRY
As private practice child psychiatrists and pediatricians, and sometimes as members of large programs, we sometimes feel that we do not have the experience, tools, and financial support we need to establish or participate in collaborative care and integrative team-based care delivery, including a Washington AIMS type of Collaborative Care Model (CoCM). This is not true, as I will endeavor to show in this article.
The Path to Collaborative Care
COVID-19 has created a great need for earlier access to effective care for youth with both psychiatric and medical issues. Our work toward a population-based model as child and adolescent psychiatrists and pediatricians, to hasten access to care, has created new opportunities to benefit from team-based practice for us and our patients. This is an approach to care that child psychiatrists and pediatricians are already prepared for based on our medical training, in our pediatric, psychiatric, and consultation-liaison rotations with other mental health and medical professionals. In practice, we have had mutual referrals to a wide variety of professionals, as well as further opportunities to share knowledge and grow in our connections—with schools, community mental health agencies, and often with multiple levels of care for the youth we serve. We have also had opportunities to walk together—child psychiatrists and pediatricians—on our path to collaborative and integrated care. This process began long before COVID, and now is the time for honing these skills for enhancement in effective care for some part of—maybe even a chunk of—our workweek.
Each of us finds our own path to collaborative care. My own path began with a special CL rotation in medical school, in which I had the privilege to help a hospital neurology unit deal with the rage and refusal of care by a young man who suffered quadriplegia from an auto accident. Intervention involved joining with the neurology and psychology teams to work with the young man to bring about mutual understanding and a compassionate but directed approach. This was a great success for a multidisciplinary team during a 1-month rotation. I was then fortunate to have chosen residency and child fellowship at a multidisciplinary, team-oriented program where we learned team-based care through training by and with other mental health professionals and another wonderful pediatrics rotation.
In addition to training in psychopharmacology and psychotherapy, I had access to learning play therapy from an experienced LCSW, family therapy out of Philadelphia Child Guidance, and collaborative approaches to treatment at community mental health centers, a community-based hospital and an outpatient psychiatric practice. Following fellowship, my practice experience in Norfolk, VA continued with Navy families in residential treatment on a multidisciplinary child psychiatric unit, during which time a multiprofessional team and established a day hospital program for youth. Later in Dover, DE we created 2 more.
The Importance of Connecting
It is important to find venues for contact with pediatricians and other mental health professionals. Evening dinner presentations on topics relevant to child psychiatrists and pediatricians are a wonderful way to have conversations on mutual areas of concern for youth and discussion of treatment approaches, including ways to approach complex youth. In our case, a local pediatric group asked if we could continue some mutual consulting. I was able to obtain a 2-year grant from our local BCBS DE program, where I was serving with their Medical Director on a QI committee.
Over the 2 years of the grant, I would visit the pediatric practice for an office-wide hour and a half lunch once a month, during which we would discuss topics in child psychiatry, review cases for psychopharmacology and therapeutic interventions, and seek community services for those in need. Over time, self-evaluation by the pediatric team documented increased confidence and competence in pediatricians providing psychiatric care for many of their patients. Learned more pediatrics was of great benefit to the child psychiatrist as the pediatric team grew in acumen. Our local psychiatric hospital reached out to find out why they were finding a drop in admissions from this pediatric practice. The answer was clear—the practice was now providing more prevention and early intervention, managing youth in their own offices while connecting with mental health outpatient services.
These are many ways to create connection with other collaborative professionals, and we each have our own path to community-involved practice. The joy we see in families and school teams who feel supported by collaborative teams may energize our efforts to enhance our current practice services. Oxford Language defines “enhancement” as “an increase or improvement in quality, value, or extent.” Enhancement in practice offers each psychiatrist, pediatrician, and other essential mental health or medical team clinician the opportunity to increase or improve quality (access), value (equity), and extent (multidisciplinary workforce). The definition reflects the need for our patients as we advocate for our professions. Enhancement in practice also means that to transform care delivery, we do not need to give up traditional practice. But we can add to our options.
Following a presentation on collaborative care to a county pediatric association a few years ago, a large DE practice asked if we could meet monthly at their office to review cases and topics in child psychiatry. This began a wonderful association with a pediatric team, which was already multidisciplinary and providing some in-office and outreach child mental health services—and dedicated to providing more. With COVID-19, our meetings turned to telemedicine. When the time came to institute a pediatric-adapted Washington AIMS CoCM, sponsored by our Delaware Child Psychiatry Access Program (DCPAP), which was established under a HRSA grant now available in all states, the pediatric practice was receptive and ready. Their pediatric physician’s assistant, who was already acting in the role of a de facto behavioral health care manager (BHCM), was excited to refine her process of outreach to youth with behavioral health and psychiatric issues. Our practices were fortunate in having participated in a free statewide training on the CoCM model by Lori Raney, MD, and HMA Associates. APA also continues to offer online training and resources in setting up CoCM at aap.org, as does the University of Washington AIMS Center. Our DCPAP child psychiatrists, in consultation with pediatric offices statewide, have provided CME programming for pediatricians and mental health professionals and access to personalized pro-to-pro psychiatric consultations on child psychiatric patients. We will be offering training in CoCM to offices and schools wishing to pilot this model. With the support of our HRSA grant, we were able to provide psychiatric consultation to Delaware Pediatrics, at which we set up a registry (list of patients to be followed by the BHCM), reviewed screening tools, and accessed the support of University of DE in evaluating our data, as part of our DCPAP program. Subsequently, we established billing of collaborative care CPT codes to local commercial payers and Medicaid MCOs.
Psychiatrists take pride in our thorough and detailed psychiatric evaluations and follow-up care of our patients. In collaborative care work, we often have discussions regarding patient care for youth we may never see in person. Akin to “curbside consults” but with a bit more time to review patients with pediatricians or BHCMs, we also become proficient at joining our input with the thorough evaluations already conducted by pediatric and mental health team members, and the updates and screening tools assessed regularly by the pediatric practice BHCM for patients on the registry. We do not have to give up what we are doing to make transformational changes in the care of youth.
An essential component of enhancing psychiatric and pediatric practice is this: can we get paid for our services? If the pediatric practice accepts insurance, and insurers in your state—including Medicaid and Medicaid MCOs—cover these pilot and established programs, then the practice can add patients to the registry, which brings them into the CoCM model. Employers, business groups, and thus payers, are seeking ways to increase access to care and more are funding Collaborative Care CPT codes. Some have already moved to PMPM payments for each patient receiving CoCM. Just as we advocate with insurers and other payers for reasonable rates for E&M and psychotherapy services, we can advocate for reasonable coverage from insurers for reasonable coverage of collaborative care CCCPT codes.
Billing to the payer for each patient on the registry is on a per patient/per month basis, and the code submitted is based on time spent by the BHCM, who reviews patients with the collaborating psychiatrist, pediatric clinicians, mental health, school, and community professionals, as well as with the patient and family. The code is already valued, however, based on the expected time commitment of the child psychiatrist. These medical codes, which include time for patient review by the BHCM with the child psychiatrist, are submitted by the pediatric practice for payment. The psychiatrist is paid on a contractual basis with the pediatric practice, usually at an hourly rate. In many ways, this is no different than those of us who contract our psychiatric service time with a community agency offering mental health services. CoCM does not exclude billing separately for direct patient E&M with primary care or embedded mental health professionals. Thus, we deliver service as a team, bill as a team, and advocate for fair reimbursement as a team.
Successful start-up and implementation of CoCM for the pediatric practice, which also hires or contracts with a BHCM, includes establishing a registry, deciding on measures (screeners and parameters to follow to show patient improvement over time), E H R and billing system adaptations for billing collaborative care CPT codes, and can be aided by such things as a CPAP program, specifically trained insurance company care managers (eg, BCBS Michigan), code reimbursement upgrades by a certain percentage as offered by payers to support implementation (eg, NC Medicaid), and hopefully by new grants for Behavioral Health Integration (BHI) as funded through the recently passed Congressional Omnibus Bill. These BHI implementation funds are required to devote at least 10% of their funding to CoCM establishment, thanks to efforts by APA. Other BHI initiatives offer alternate opportunities utilizing other psychiatric and mental health collaborative and integrative models, including BHI models which we can implement in conjunction with our colleagues in psychology. Going forward, the institution and maintenance of CoCM models should not be dependent on grants alone, nor out of funds derived from traditional care, whether in outpatient practices or large institutions. CoCM needs to be sustainable through appropriate reimbursement by payers.
A recent meeting of experts by the Meadows Policy Institute garnered input on successful models already working and effective steps toward sustainability and scaling of collaborative care models, and supporting steps for practices in moving forward with implementation.
On a community level, we are seeing expansion of collaborative and integrative models of care with the support of various state, CMS Medicare and Medicaid, insurer, and ACO initiatives. Our pediatric and child psychiatry practices and professional organizations, including AAP and AACAP, are committed to enhancement in practice and transformation in health care delivery and funding. Our youth and families are desperate for access, equity, and availability of needed professionals. Employers and purchasers of healthcare are requesting funding for these models when negotiating coverage for their employees. The evidence base is clear that CoCM works for adults, and our expert teams are showing that they work in youth as well. As we all know, working with youth is likely to tie in additional systems of support including schools, community agencies, and families.
Team based care will better provide for prevention and earlier intervention, increase safety for youth, and expand the professional knowledge base that only multidisciplinary cooperation can bring. Our paths are joining to create a wider road to team-based care. To be a part of such a transformation is an honor and an affirmation of all we have to offer to youth and their families. Consider directing your own developmental path, training, and experience to this wonderful enhancement in practice.
Dr Borer is a child and adolescent psychiatry specialist in Dover, DE.