Mental health issues are common in pediatric patients, with rates rising during COVID, yet modern time constraints make it challenging for primary care providers to meet these needs. Fortunately, child psychiatry access programs are designed to be an efficient way to consult with experts, who can give tailored, practical guidance in minutes. Learn how the UCSF Child and Adolescent Psychiatry Portal (CAPP) program can help PCPs everywhere enhance their patient care.
thank you so much. Really nice to be here and to see everyone and to talk about this program that we're really excited to share. And I think, you know, even before Covid, I think that we can all acknowledge there's been a real challenge with accessing care for um for Children for their mental health. And this report was released from the Little Hoover Commission in august of this year. So it's very recent, talking about the Even greater concerns now that we have about children's mental health, we know that about one in five kids experiences a diagnosable mental health condition and um and that suicide is the second leading cause of death amongst young people ages 10-34. And um and that accessing care has been a challenge. Um and since Covid rates of depression and anxiety have doubled and even tripled across all ages, but in particular for young people. And um and there have been an increase in emergency related visits proportionately for things like um suicidal thinking, and and experts warn of a looming tsunami of unmet mental health needs amongst young people. And And and also suggests that some Children, adolescents 20 time support and investment in order to really advance back. This is from the Kaiser Family Foundation, from a report that was just released in august where parents described multiple reasons for not being able to access child mental health services, but one of the biggest ones was not being able to find a provider um feeling too busy not being able to get the time off of work, not being able to afford the cost, feeling afraid or embarrassed. She's related to stigma which we know are very real and then feeling like maybe it wasn't necessary after all. Um and then just general pandemic related concerns and here we have the distribution of the workforce of providers that shows that this is not unique to one geographic area, but rather it's a problem across the entire United States and really frankly across the entire world. Um So this is a map workforce snapped from the american Academy of Child and adolescent psychiatry that shows that most of the country is in a severe shortage area. There an estimated 8300 child psychiatrists in the US and an estimated need for over 40,000 and in California we can see that, you know, in some urban areas there is um only high shortage, but that for the most part part we're either in a severe shortage or really don't even have any providers. And these numbers are similar for child therapist, child psychologist, developmental pediatricians. So thinking about, you know, how do we help help to meet the ever growing need. And there are different ways of doing this but we are really not going to be able to you know, create more appointment slots. And so we need to think a little bit more creatively about how we can address these needs. Um the American Academy of pediatrics in 2002 issued a statement around the workforce around the medical home as a model of delivering primary care that is accessible continuous, comprehensive family centered, coordinated compassionate and culturally effective and that it's easy for the child and family to obtain, including geographic access and insurance accommodations. And so we conceptualize this as a workforce development strategy that really helps to expand that knowledge skills and confidence in addressing more mild to moderate conditions. So this pyramid is from a stepped care approach put forth by the University of Washington aims treatment center that looks at pc ps delivering care for um for the majority of patients in this tier one approach and that when there are more severe needs. And this model is used not just for mental health but also for other conditions like diabetes that might require a specialist that more complex or acute presentations Um in Tier five need to be managed by a specialist. And um and that these conditions that are maybe less severe and less acute can be managed within primary care with consultation from a specialist. Yes, our program is is a type of child psychiatry access program or pediatric mental health care access program. That is not a new model of delivery. The first state funded program was actually started in 2000 and four in massachusetts. And um And that was followed by the second program in Washington State in 2007, and since then, a number of other states have Have gotten, you know, onto this train as well. And there are state funded programs in over 20 states and these types of programs exist in over 30 states and they're thought to have three key components. The first is real time in the moment, consultation. Primary care provider needs some support, decision making support when they're seeing a patient. And then the second is education, being able to to have training and educational events that not only in part the didactic information but also really almost more importantly helped to build relationships and communities so that, you know, the PCP knows that they can trust and rely on the advice that's given by the consultant on the other end. And then the third piece of this is around referrals and care coordination and as you might imagine, this is often the most complicated component of this. But these are the key components of a child psychiatry access program. This is a quote from one of our pediatrician partners and who has also been participating in our project echo series as well as being a regular color and talking about the increased support through the pandemic, knowing that the complexity and acuity of what everyone is seeing across the board, including primary care has really increased. And here we have a video that I think captures nicely the spirit of our program. So hopefully this will play you run here. So yeah, In our practice we take care of kids as pediatricians do from birth to age 22 and recently over the last few years, what we've seen many kids who are looking for help with mental health. We know that one in five Children experiences a significant mental health disorder. And over the past 10 years, rates of psychiatric hospitalizations for Children have more than doubled. There are an estimated 8000 child psychiatrists in the country and an estimated me for over 40,000. So in light of just being aware that there was this gap, the creation of the Cap program was really very helpful. Cap is a child psychiatry access program that is aimed at helping to improve primary care providers knowledge skills and comfort in managing mental health condition. We provide real time psychiatric consultation to primary care providers. Child psychiatry access programs are a cost effective and evidence based way of addressing the really high prevalence of pediatric mental disorders and the demand for services. Cap has been amazing for our practice. If I have a patient that I have concerns about and want some guidance on, I just hop on the phone, call them up and then we usually talk or anywhere between five and 10 minutes coming up with a plan together. It is the ability to know that there is someone there with whom you can have a discussion as an expert who is accessible to you to ask the question, answer the question, what else should I do and that just feels supportive pediatricians are in a great position to really address the ever growing mental health needs of Children that they serve. And if you think about how many thousands Children a pediatrician will treat over the course of their careers. It's really amazing to think about the collective impact that captain have all kids have behavioral and mental health needs having available to us has really helped us to be able to kind of address the whole child in a more holistic way. Mm hmm. Yeah, so with that I'm gonna turn the microphone over to DR weaver. Thank you. Maybe. Here we go. Um okay, so as dr stein Bushel was saying, our cap is our program is modeled after similar child psychiatry access programs around the nation. And um there are a few components of these programs that we similarly have with our program. The primary piece of cap is the real time direct connect consultation. So that's the telephone consultation peace between the primary care provider and a child psychiatrist. We also have something called the second step psychologist consultation, which I'll discuss in a few moments. Um and then the other pieces of our cap program include continuing medical education events. So seminars, webinars are project echo series and various cmI events that we posted through after the past two years. Um a lot of resources on our website, including resources for providers as well as families and parents and finally the care coordination piece. So helping patients and families connect to the care that they need. Um and we're pleased to announce that we recently hired a care coordinator to help us really flesh out this role and provide further support to the patients that the primary care providers are calling in about the next slide please. So this slide just highlights our mission, vision and values. We developed these about a year ago, during a strategic strategic planning phase. Um just to highlight that our mission is to promote pediatric mental health and wellness through consultation, education, resource navigation and innovation throughout California's communities. Um and that we value equity, inclusivity, diversity partnership, your professionalism, prevention and stigma. Free access to care for all next slide. So um this slide is to highlight at, you know, some of the reactions that primary care providers may initially have when they learn about the cat program. And often um folks are really excited to hear that there's an additional resource for them where they can call in and receive consultation and advice on what to do for their patients with mental health concerns. But understandably, you know, there are some mixed responses initially from primary care givers. Um and here on the left, this is a survey of some thoughts of primary care providers before and after they implemented uh integrated care. And so as you can see a lot of ideas and themes around, you know, this kind of program is going to slow me down. I don't have time to address more than one problem. I already do a good job of treating mental illness or this is going to drag on me like an anchor. And um you know what this study shows is that in actuality after uh you know the implementation of a similar program that a lot of primary care providers actually found that their attitudes and opinions shifted and um that they found the program helped to speed them up become more efficient taking a load off their plate um feeling that they were giving better care to their patients and having just generally more time to finish their notes. And um here on the right there's a study that came out of the uh make pap program which is the child psychiatry access program in massachusetts that started in 2000 and four. And a study showed that about 86% of families expressed satisfaction with their pc ps handling of their child's mental health um concern after the PCP consulted with Mick pap. Um and that generally you know the recommendations made to P. C. P. S helped to strengthen the P. C. P. S. Role as a mental health provider. So we can see some benefits in these types of programs not only to Pc ps knowledge and comfort and attitude but also directly experienced by families and kids and parents next slide please. And um here we just wanted to highlight that um you know there exists a continuum of uh you know utilizing technology in supporting mental health care and integrating behavioral healthcare into um uh primary care. And so that can range from the bucket on the left including patient facing technologies such as web site web apps and web services and then um sort of more complex and um and then kind of finally ending direct evaluation and that our program sits here in the in the area of the collaborative care outlined in green where um similar child psychiatry access programs sit. So really not quite yet at the direct care but really providing a lot of that additional support. Next slide please. So I just wanted to review how some of the services that cap offers works. So as I mentioned before the primary service that we offer is this telephonic psychiatric consultation between the primary care provider and a psychiatrist. And um the consultation is available monday to friday during regular business hours 8 30 to 5. And there is a there to waste acts the consult One is you can call the cap 1-800 number as outlined here or on our cap website. We have a button right on the homepage that says request a consultation online. And so the primary care provider or you know medical staff can um call in or enter online some of the brief information about the patient that they're calling in about. Um and that includes you know name, demographics insurance. Um And I should just note that the insurance information is collected. Not for billing purposes but rather for our own tracking and resource mapping purposes. Um And then after that the the consultation will begin. The psychiatrist will talk with the primary care provider via the phone. Um And um that can range anywhere from three minutes of 20 minutes depending on typically how much time the PCP has and I know that you know generally um you all have very busy day so we try to just be flexible and um you know cognizant of of your work workflow. And then at the end of every consultation we always return a consult letter either via fax or email depending on your preference. And the consul letter highlights some of the recommendations that were discussed during the telephone consultation. Um The consultation can occur as I mentioned. Um No throughout the business day monday to friday. And you have the option of either requesting a call back immediately from the psychiatrist or scheduling it during a time. That's convenient for you say we have a lunch hour from 12 30 to 1. You can you know request a consultation in the morning and say please call me during that period of time. Next slide please. And then as I mentioned sort of already briefly some of the information that we collect about the patients. It's just brief demographic information. We do not bill insurance or build the PCP. Um And we do request, you know, the preferred method for receiving the concept letter, whether that's facts or email next slide. And here we just wanted to highlight some of them more common questions that are uh, the RPC PSR calling in about. So, um, this is a little little out of date. But you know, when this table was assembled, this is based on the number of calls we've gotten up until june of this year. So at that point it was 650. Now it's about 850. Um, and as you can see the demographics of the patients that are being called in about, um, there's a wide range of ages anywhere from, you know, early childhood to there's a the teenage years and even beyond transitional age, 50% about teens. So it's often about teenagers who are experiencing some sort of mental health issue. Um, uh, pretty even divide in terms of gender and then a really diverse um range of racial and ethnic backgrounds for the patients who are being called in about. Um, here on the right, you can see that many of the questions more often are regarding medications that we are no means, you know, only a medication consultation line. And so as you can see, there's a variety of secondary questions as well. And we tend to, you know, address not only, you know, any medication questions that come up, but also questions about treatment planning, appropriate therapy resources, behavioral management and diagnosis. And we just want to emphasize that our mission is not to ensure that every child is put on two medications but really to think holistically and about the whole child together with you on the phone to determine you know the appropriate next steps and sometimes that may involve medications. Um Although sometimes you know it does not and we would certainly talk that through with you next slide please. And as I mentioned briefly before we have something called a second step consultation. So we consider that initial phone call between the psychiatrist and the primary care provider to be the first step. And the second step, psychologist consultation is actually a brief one time meeting between the patient and family and a one of our UCSF psychologists to discuss you know behavioral or mental health concerns. Often to provide brief behavioral guidance um and resources and tips for navigating a very complex system here as well as next steps. Um We have to UCSF psychologists who staff the second step line. One of them is an early child specialist and she specializes in working with parents of kids uh the age six or under and the other works with school age Children as well as adolescents and has expertise particularly in A. D. H. D. And behavioral techniques. Um Again this is not a sort of referral for ongoing therapy for our psychologist but we do have the capacity to offer this one time consultation which many families do find helpful especially when they're having trouble navigating the system or waiting, you know to establish care next slide please. And then as we previously mentioned, another really important arm of our cap program is the training and education piece and it's a really you know supporting primary care providers in um feeling more comfortable and um shoring up their knowledge and resources in terms of feeling uh they can manage a lot of the mild to moderate conditions on their own. And so we haven't had a variety of both past and ongoing educational webinars and events including a monthly webinar on a variety of behavioral and mental health topics. We had a webinar series Uh you know during the during the early days of the COVID-19 pandemic about a variety of issues that arose with pandemic. We have an ongoing series in collaboration with our youth substance use colleagues at UCSF to discuss uh different topics related to substance use in Children. And um last year we had a day long cmI event. We were one of five programs awarded Aces aware grant to provide training on aces and trauma informed care. Um And so that was you know, really valuable for many of our pediatrics partners. And then we have a project Echo pilot going on right now with a group of pediatricians where um the providers meet on a monthly basis and discuss cases as well as different themes and topics with regards to mental health and really you know learn from each other and support each other X slide. So a few of our goals during the consultation process. Um one we really aimed to provide timely tailored culturally attuned and most importantly practical advice that the provider can, you know sort of hang up the phone and then turn around and give a call to the to the child or speak with a parent in the room. Immediately be able to implement the recommendations that we give. And we believe that each conversation although it applies to a particular case in a particular child is always a teachable moment and it's a learning exchange between the provider and the the psychiatrist next slide. And um so here I just wanted to talk briefly about the enrollment process. So um as we highlighted we have a variety of services available through cap. And um the way to access these services is to complete our brief enrollment process. And that includes a practice clinician or representatives such as an office manager administrator completing our enrollment form on behalf of practice. And then after that we will work with you to schedule a brief enrollment meeting. So that's a zoom meeting where we review how to utilize the cap services. Um and you know a description of the types of consultation and services that we offer and then after that meeting, the practice is considered enrolled. So all the providers and the practice then have access to our consultations, Events resources, et cetera. We don't enroll by provider. We enroll uh, you know, the entire practice. So um, you know, even if there is some ambivalence in terms of some providers being interested in others being more lukewarm. Um, we just encourage the entire practice to enroll and then, you know, all providers are able to use the service if they so choose next slide please. And then during the enrollment process will collect some key points of information. Um, so some practice demographics including um, you know, the patient population served and the number of youth lives served for that practice. Um, the names and provider emails of all the clinicians who may use cap in the future. And then most importantly, we really encourage you to identify a site champion. And so that's someone usually a clinician who um is particularly interested or invested in sort of the mental health and behavioral health and wellness of his or her patients. And um ideally would be able to try out cap and then um, you know, serve as a liaison and a champion and encourage coworkers and colleagues to um, you know, think about cap and to also try out cap as well. We found that the sites and the practices um thus far that we've enrolled where we have the sort of highest uptake and um hybrids of utilization generally have, you know a site champion identified who is able to really kind of support the implementation of our program. Thanks Clyde and you know this program is not something that we're doing single handedly over at UCSF. So we really rely on all of our community partners both around the bay area and um as we're expanding into the other uh counties, the northern California you know really um just want to say how grateful we are for the supportive all of our partnerships and support. So here we have a list, this is just a few of many next line please. And um this slide I think is now growing out of date but this is a brief overview of our team numbers as you can see we have a number of child psychiatrists on duty and a different child psychiatrist staffs the consultation line each day monday to friday. We also have r two child psychologists who staff the second step consultation line as well as at pediatrician Dr jeong. Um And now we're so pleased to have our program manager Rachel moore with us as well. So we do need to update this slide next slide please And just wanted to provide a brief disclaimer that again the advice that we provide during the consultation is based on what is discussed during the telephone call. So um you know it does not supplant face to face evaluation um and it does not include chart review but we do do our best just based on the information that you provide during the consultation to, you know, provide the guidance in the in the right way next slide and to end. Um We wanted to show this slide, which is sort of a cute analogy. Um Sunflowers communicate with each other underground through their root system in order to ensure optimal growth for all. So similarly we want to ensure we are connecting for care with you in order to ensure optimal development for all of California's Children, which is ultimately the goal. We have a cap.