Perceptions of Pediatric Behavioral Health Integration in Community Health Centers

This week, we will discuss and review the article “Perceptions of the Implementation of Pediatric Behavioral Health Integration in 3 Community Health Centers.” The article was published in the Journal of Clinical Pediatrics in August 2019 by Fong, Temene, Morley, Morris, Estela, Singerman, & Bair-Merritt.

What did they do?

Using interviews with community health professionals, the authors identify overarching themes related to the impact of behavioral health integration (BHI) on clinical practice, as well as themes about facilitators and subsequent barriers to BHI. As a quick reference point, BHI refers to the process of embedding behavioral health services into typical physical health care services.

Why did they do it?

As previously discussed in some of our earlier blog posts, the prevalence of child mental health problems in the United States (and around the world) is on the rise. As stated by the authors, approximately 1 in 5 children in the United States has a mental health disorder. We also know that more than half of adults with a diagnosed mental health disorder report onset of their illness during childhood or adolescence.

Pediatric primary care settings represent an accessible means for the delivery of behavioral health services. As the authors highlight, there are frequent visits to primary care during childhood and the focus is generally preventative, family-centered care. The authors posit that while pediatric BHI is a targeted model, early identification of implementation factors on clinical practice is critical for optimizing these types of models in real-world contexts.

How did they do it?

Three community health centers caring for low income families participated in this research. A comprehensive plan for integrated care delivery was developed by each participating health center. Midway through the implementation of the program, researchers conducted in-depth interviews with all professionals involved in the program. The 38 total participants represented 3 distinct groups; Primary care physicians (PCPs), behavioral health clinicians, and other staff (e.g., nurses, community health workers, family partners, etc.). Interviewers assessed participants’ perceptions about the impact of BHI on clinical practice, facilitators and barriers to BHI implementation, and suggestions for improvement of BHI.

What did they find?

Overall, participants identified two primary themes regarding the impact of BHI on clinical practice, five themes related to facilitators of BHI implementation, and five themes representing barriers to BHI implementation.

Regarding the impact of BHI on clinical practice, the identified overarching themes were positive. Staff reported that the implementation of BHI allowed, and even persuaded them to form closer relationships with other staff outside of their discipline, which allowed them to work together as a team. Participants also reported that they felt greater professional fulfillment from providing better patient care, both within the organization and their team, and individually.

Overarching themes about facilitators of BHI included; the need for a collective commitment to BHI by staff from all levels, leadership support (such as training opportunities and soliciting staff feedback for improvements), teamwork and mutual respect within the team, proximal closeness of team members, and data driven quality improvement.

Many of the themes identified by participants when asked about barriers to BHI map on to the literature we have previously discussed on the topic of behavioral health integration, and include inadequate staffing, insufficient space, limited provider time for tasks such as direct patient care, issues with billing or reimbursement, and internal coordination challenges.

What does it all mean (our take)?

As we have touched on previously, the process of integrating behavioral health with existing primary care systems is highly important, yet also incredibly challenging. There are numerous clinical benefits to utilizing an integrated care model, but particularly in the world of primary care, the system being integrated would need to be highly streamlined, able to communicate efficiently with existing EHR systems, in many ways automated, require minimal training, and so on. Research like the study summarized here (we highly encourage you to read this article) is critical in guiding the development of systems that will eventually be able support a healthcare model that allows for comprehensive physical and mental healthcare to be evaluated in a single visit setting. Thanks to this work, and similar work being completed by others, the goal of integrated care is certainly within reach.