The positive effects of integrated medical and behavioral health care are confirmed by an ever growing body of evidence. The literature claims that effective integration has the potential to improve patient health and significantly lower costs. Yet it offers few practical tips for start-ups. Is integrated care feasible only for well-funded practices with unlimited academic support? Ample resources and support do help, but in certain situations it is not the dearth of resources, but rather the dearth of imagination that limits robust growth in health care.
I recently joined a pediatric practice as a pediatric mental-health provider. My motive for seeking such a position arose from my first-hand experience of taking care of patients in a fragmented health-care model. This real-life lessons turned into a call for action and a desire to share some of my insights.
1.The outcome of any disease is often related less to the severity of the illness than to independent psychological or social factors. Investment in resilience building is therefore valuable as it may lead to more positive outcomes. Such an insight calls for action: a study of eligible candidates who receive group coaching with the help of mobile applications between visits to their health-care providers.
2. Pediatricians routinely offer anticipatory guidance during well-child visits. Various services and programs educate the public about suicide, substance abuse, and bullying. However, little intervention of such kind exists for non-crisis conditions, which are equally rampant and are likewise associated with high morbidity, academic truancy and underachievement, and family stress. Examples of such include anxiety or dysthymic disorders. The chance that a preschooler with inhibitory temperament, for example, will develop some degree of social anxiety or avoidant behavior exceeds 50%. Anticipatory intervention and guidance in elementary or middle school could well minimize anxiety in high school.
3. It is not uncommon for pediatricians to seek collaboration with child mental-health providers. However, one never hears about the reverse situation, that is, mental-health providers in a busy psychiatric practice looking for pediatric providers to join their group. In my opinion, child psychiatrists need pediatricians as much as pediatricians need child psychiatrists.
Discussions about healthy sleeping hygiene, eating habits, etc.are considered routine practice during well-child visits in pediatric offices. This is not the case with pediatric psychiatric practice. Indeed, the American Academy of Child and Adolescent Psychiatry (AACAP) has come up with no practical parameters for broaching such topics.
In my experience, at least one in every 5 patients who does not respond to psychiatric intervention, including psychopharmacology, can achieve desirable results simply by adjusting eating habits and addressing poor sleeping hygiene. I often say to a parent “unless your child eats lunch, his or her concentration is not going to improve.” From a child psychiatrist’s perspective, coaching the patient and his or her family in self-care is a necessity with a dual advantage; it targets prevention and, in some cases, acts as an intervention.
I would therefore like to study whether introducing the practice of well-child visits in a child psychiatry clinic would alleviate symptoms and improve children’s overall well-being.
4. Pediatric practices commonly offer evening educational classes, but for parents only. It is uncommon for pediatric health-care workers to meet with children, pre-teens, and teenagers in the absence of parents. In psychiatric clinics, the opposite holds true; sessions that include parents are rare. Both models are of great value. Such opportunities allow for the integration of patients in ways that incentivize treatment compliance and partnership with providers.
5. Integrated care does not only mean integration among medical professionals. Its most important goal is to facilitate patient integration. There are many ways to accomplish this task. For example, the Boston Children’s Hospital Department of Psychiatry has created a journaling website, on which patients can share their stories about coping with chronic conditions. Although this is a non-medical intervention, it does have medical benefits. It also allows medical providers to step into a new non-medical role.
Such forms of intervention create a cohesiveness that is unique to a patient’s journey, eliminate fragmentation, increase the patient’s ability to tolerate time between visits, and thus promote autonomy. What else can help patients between visits? Various forms of such intervention—telemedicine, mobile health applications, mini check-ins, etc—are flourishing.
In sum, the transition from the current healthcare delivery model to genuine integration poses both endless challenges and opportunities. My position is that a collective “can do” or “think opportunity when facing challenges” attitude can slowly but surely make such integration work.
No manual for startup practices is currently available to child psychiatrists who are newly integrated into a busy pediatric group that has no external funding or academic support. My goal is to fill this gap by producing such a manual, all the more so as our new pediatric group is now fully committed to integration!
As a physician working primarily with children for more than two decades, I fully understand that children’s health is more than just a medical issue. I feel privileged to be a doctor and, at the same time, I feel a deep sense of responsibility to work towards making a better health care system for this vulnerable part of our population.
There is drastic shortage of child psychiatrists for our nation’s 75 million children and teens. Currently there are only 8,300 child psychiatrists nationwide, some 30,000 short of what is needed. In Massachusetts, waits of four to six weeks for a child psychiatry appointment are common, and several community mental health centers report three month waits.
The American Academy of Child and Adolescent Psychiatry (AACAP) has worked hard to make the government aware of the crisis of limited access to child psychiatrists. I was inspired by AACAP’s legislative program to get involved in persuading policymakers to address the shortage of child and adolescent psychiatrists.
In the spirit of doing my part to address the crisis in access, I have also signed up to volunteer with the National Association of Free and Charitable Clinics to provide free care to homeless women and chidren in greater Boston area and I have created my website as a place where stakeholders can interact and come together on behalf of our children.
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