Integrating behavioral health within primary care settings

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Virginia Hatch-Pigott’s, MD, FAAP, LMSW, article, "Child welfare: Now that we know better. Let’s do better," is a powerful read for all pediatric health care providers to think about and collectively consider meaningful, impactful policy changes for children living within the foster care system.

Hatch-Pigott highlights the trauma children experience before and often while living within the foster care system. She states, “The real problem is the lack of timely appropriate mental health services for these [foster care] children” (p. 14).¹

Her experiences caring for children within the foster care system, advising foster care parents, as well as her analysis of foster care statistics led her to recommend changes for funding at the macro and micro child welfare levels as well as the importance of changing the immediate evaluation of the children to focus on trauma-informed therapies. I highly recommend reading Hatch-Pigott’s article.

Comprehensive health care systems for children in foster care

Early in my career as a pediatric nurse practitioner (PNP), I had the pleasure of working with children within the foster care system, their foster care parents, and meeting the biological parents who were receiving therapies to improve their own behavioral issues and parenting skills.

My role was embedded within a foster care agency that provided comprehensive services from psychiatrists, psychologists, and social workers including case workers for each child and family, nursing care, with medical care provided by PNPs and pediatricians. The overarching goals were family healing and returning the children safely to their biological parents. We understood the importance of integrating mental health and behavioral health services within the primary care visits to enable the children to emerge as healthy individuals from the trauma they experienced prior to admission.

Integration of Mental and Behavioral Health into Primary Care

Today, the integration of mental health within the primary care system is supported in the literature but how often it is operationalized, and what is the effectiveness of these systems? A literature search shows several models have been developed and implemented to support behavioral health integration into primary care systems.

A report of an 18-month pilot study in which a Developmental and Behavior Access Clinic (DBAC) was designed for pediatricians to be trained and initially mentored by developmental-behavioral pediatricians to provide developmental care to children revealed that the average wait time for children to receive the needed developmental behavioral (DB) care decreased from 218 days to 41 days. This pilot study supports opportunities to include behavioral health into primary care settings.²

A comprehensive study for the integration of behavioral health (BH) services included an educational program, Behavioral Health Learning Community (BHLC), that delivered 10 sessions (16 hours) over a 2-year period was reported for 13 pediatric practices enrolled in a statewide program that included 105 primary care providers who cared for approximately 114,000 patients.³ Study outcomes revealed increased access to quality behavioral health (BH) services, provider self-efficacy and professional satisfaction, without increasing health care costs.³

I recently published an editorial in the Journal of Pediatric Health Care discussing the integration of behavioral and mental health care in pediatric primary care populations.⁴ I discussed the role of Pediatric Primary Care Mental Health Specialists (PMHS) developed and offered by the Pediatric Nursing Certification Board.⁵ Individuals who hold the PMHS credential often practice in dual roles serving both primary health care and behavioral/mental health care needs of the pediatric populations. From my personal experiences, parents appreciate having access to pediatric and/or pediatric-focused family nurse practitioner providers who provide these comprehensive services within one practice setting.

Impactful Policy Changes

If infants and young children living within the foster care system and all infants and young children could speak for themselves, what would they say to policy makers? “Help me please, I need to be safe, cared for, and loved.”School-age children and adolescents can inform their healthcare providers of their concerns while living in the foster care system, but do we, the professionals, speak with policymakers on their behalf? The mental health of the pediatric population is in crisis. As mentioned, Dr. Hatch-Pigott supports funding at the macro and micro levels within the child welfare system to improve the outcomes for children within the foster care system. Funding for mental health services for all children also needs to be a legislative priority. PNPs need to continue their advocacy efforts through collaboration with all pediatric providers, remain actively engaged in helping children and families by supporting timely and appropriate health policy initiatives, and through continued support for legislative initiatives offered by the National Association of Pediatric Nurse Practitioners (NAPNAP).

References

1. Hatch-Pigott, V. Child welfare: Now that we know better, let’s do better. Contemporary Pediatrics. 2014;40(04):13-19. https://www.contemporarypediatrics.com/journals/contemporary-peds-journal/may-2024

2. Jeung J, Talgo J, Sparks A, Martin-Herz SP. Expanding developmental and behavioral health capacity in pediatric primary care. Clin Pediatr (Phila). 2023;62(8):919-925. doi:10.1177/00099228221147753

3. Walter HJ, Vernacchio L, Trudell EK, et al. Five-year outcomes of behavioral health integration in pediatric primary care. Pediatrics. 2019;144(1):e20183243. doi:10.1542/peds.2018-3243

4. Hallas D. Integrating Behavioral and Mental Health Care in Primary Care for Pediatric Populations. J Pediatr Health Care. 2024;38(3):293-294. doi:10.1016/j.pedhc.2024.01.004

5. Pediatric Nursing Certification Board. The Pediatric Primary Care Mental Health Specialist (PMHS) role, settings, and ethics. Accessed May 20, 2024. https://www.pncb.org/pmhs-role