BHIPP Bulletin

Volume 9, Issue 10

April 2024

This month's BHIPP Bulletin is a contribution from

Rheanna Platt, MD, Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine and BHIPP Consultant.

In the last legislative season, the Maryland state legislature passed, and Governor Moore signed SB101/HB48, which requires Maryland Medicaid to reimburse for the Collaborative Care Model (CoCM). The CoCM is one model of integrated care with documented improved outcomes in both pediatric and adult settings. The aim of this bill is to incentivize primary care practices to integrate mental health services by increasing financial feasibility. With this new development on the horizon, this newsletter will review evidence-based models of integrated care, including the CoCM. Integrated care continues to be widely supported as a strategy to address the youth mental health crisis, as was announced in the Surgeon General’s Report on Protecting Youth Mental Health and the declaration of a national emergency in pediatric mental health announced collaboratively by the American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP), and the Children’s Hospital Association. 

What are the different models of integrated care and the evidence for these models?

Integrated care is broadly defined as bringing together different healthcare components and providers (e.g., somatic and behavioral health), but can take many forms. The Substance Abuse and Mental Health Services Administration (SAMHSA) describes different levels of integration, from minimal collaboration, where mental health and other healthcare providers have separate systems and rarely communicate, to fully integrated, where mental health and other health care professionals share the same sites (are co-located), vision, and systems, and providers work together as part of the same care team. The BHIPP consultation warmline is one model of integration in which primary care providers can consult informally with off-site mental health professionals without direct patient contact. Co-located models, like BHIPP’s social work co-location program, offer distinct advantages in providing direct access to mental health specialists. Among the co-located models, the most well-studied is the CoCM, which is based on chronic illness care and includes five core principles:

• Patient-centered team care: shared care plans between primary care and behavioral health providers
• Population-based care: using a patient registry and defined population
• Measurement-based treatment to target: through regular, routine measurement (e.g. with scales such as the PHQ-9) and adjustment of treatment if improvement goals are not met 
• Evidence-based care: using evidence-based treatment modalities including Problem Solving Treatment (PST), Cognitive Behavioral Therapy (CBT), and medications
• Accountable care: reimbursement for quality and outcomes

The collaborative care team includes (1) a primary care provider who oversees patient care and prescribes psychotropic medication (with support from a psychiatric consultant); (2) a behavioral health care manager, typically a nurse, social worker, or psychologist, who coordinates treatment and communication amongst team members, proactively tracks patient outcomes, and provides brief evidence-based treatments (e.g., PST, CBT); and (3) a psychiatric consultant who assists the team with diagnosis and treatment planning. The consultant does not directly see most patients but is available for ad-hoc consultation. Initially developed for adult primary care settings, there are now multiple studies on collaborative care in pediatric patient populations, and a recent meta-analysis of pediatric integrated care found collaborative care to have some of the strongest clinical effects among pediatric patients (Asarnow et al., 2015).

The Primary Care Behavioral Health model includes a behavioral health consultant (BHC) who works alongside medical providers in a team-based model. Principles of this model include the BHC (1) serving as a ‘generalist’ who assists in the care of patients of any age with any condition; (2) being accessible, attempting to meet with patients or intervene on the day patients are referred; (3) sharing clinic space and resources with the team; (4) seeing a high volume or high proportion of the clinic’s patient population (typically seeing patients for brief (15-30 minute problem-focused visits); (5) serving as an educator to team members to increase/improve team members assessment and intervention skills; and (6) being a routine part of the team and of biopsychosocial care (Reiter, Dobmeyer & Hunter, 2018). This model has been found to be associated with both patient and provider satisfaction as well as with improved patient clinical outcomes (Reiter, Dobmeyer & Hunter, 2018).

Another integrated care model, for which Maryland Medicaid is now providing enhanced reimbursement, is the HealthySteps model. This model is focused on early childhood (prenatal to age 5). HealthySteps incorporates an early childhood development specialist (this individual may come from a variety of professional backgrounds) into pediatric primary care. HealthySteps is a tiered model with some services that are delivered to all patients, while other services are provided to those identified as being at risk or experiencing symptoms.

Resources for starting and sustaining integrated care

There are many considerations for starting and sustaining an integrated care model, including patient volume, payor considerations (i.e., whether integrated services can be reimbursed), and desired level of integration or involvement of primary care providers. Below we outline several resources that may be of assistance to those interested in implementing integrated care in their practice. These resources include toolkits, billing guidance, examples of programs, and links to trainings in select models of integrated care. 

1. https://integratedcareforkids.org/: This website developed by AACAP includes a database of integrated care programs, a bibliography of relevant studies, presentations and trainings, and links to screening measures, and relevant websites.

2. https://www.samhsa.gov/national-coe-integrated-health-solutions: The Center of Excellence for Integrated Health Solutions, funded by SAMHSA, provides resources for organizations working to integrate primary care and behavioral health.

3. https://publications.aap.org/toolkits/pages/mental-health-toolkit?autologincheck=redirected: The AAP provides a Toolkit on Addressing Mental Health Concerns in Pediatrics.

4. https://www.cfha.net/learn-network/what-is-integrated-care/: The Collaborative Family Healthcare Association provides information on integrated care including descriptions of common models of integrated care (including collaborative care and primary care behavioral health).

5. https://aims.uw.edu/collaborative-care: The University of Washington Advancing Integrated Mental Health Solution (AIMS) Center provides information about the CoCM including an implementation guide, billing and financing information, links to webinars, online training, and resources for patient/caseload tracking.

6. https://www.healthysteps.org/get-started/: To learn more about the HealthySteps model and guidance/training resources for implementation.

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.

BHIPP Announcements

Join the BHIPP ECHO Core Foundations Series Learning Collaborative!

Register for the BHIPP ECHO Core Foundations series! The third session will be held on May 1st from 8:00-9:00am. Join our multidisciplinary team of child behavioral health experts on the first Wednesday of every month between November 2023 and June 2024 for virtual case-based learning and didactic presentations. This series is great for providers who want to improve their knowledge of child mental health and develop foundational skills. Free CME and CEU credit is available for participation.

Sign up for the BHIPP ECHO Beyond the Basics Series!

Register for the BHIPP ECHO Beyond the Basics series! The next session will be held on May 9th from 12:00-1:00pm. Join our multidisciplinary team of child behavioral health experts every month for virtual case-based learning and didactic presentations. This series is great for providers who have already participated in BHIPP ECHO, or who feel like they are experienced in treating behavioral health in their practice and are looking to explore advanced topics. This series is held on the second Thursday of the month from 12:00-1:00pm between October 2023 and May 2024. Free CME and CEU credit is available for participation.

Providers in Cecil, Kent, Harford, and neighboring counties: Register for our CME/CEU training event!

Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) is pleased to partner with the Cecil County Health Department to offer an in-person, free CME/CEU training event for primary care, emergency medicine, urgent care, and mental health providers and care teams working with children and families in Cecil, Kent, Harford, and neighboring counties. A light breakfast and lunch will be provided, as well as opportunities for providers to meet and network. Join us on May 18th from 8:30am-2:00pm!

Register for the upcoming BHIPP Mental Health Crisis Training!

Register for the next BHIPP Mental Health Crisis Training on May 21st at 12:00pm. In response to the increase in mental health crises among children and adolescents, BHIPP has expanded its services and training opportunities. BHIPP Mental Health Crisis Trainings are a series of interactive, virtual learning sessions on practices, strategies, and resources to support emergency medicine and primary care professionals in addressing pediatric mental health crises. Free CME and CEU credit is available for participation.

Complete this survey on Tourette Syndrome to receive a

 $50 e-gift card!

The Tourette Syndrome Center of Excellence at Johns Hopkins Medicine and Kennedy Krieger Institute in collaboration with Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) is conducting a brief survey to better understand pediatric primary care providers (PCPs) knowledge about Tourette Syndrome and related tic disorders (collectively TS) and to identify current practices of PCPs when encountering children and adolescents with TS. We will use this information to inform development of clinical tools to assist PCPs when encountering youth with TS in their everyday practice. PCPs will receive a $50 e-gift card upon completion of this 20-minute survey.