Prior to beginning work on this be certain to have read all the required resources for this week I have attached them below with all there references as well.The collaborative practice of clinicians a

BRIEF REPORT An Integrated Primary Care Approach to Help Children B-HIP! Lorna H. London Rush-Copley Medical Center, Aurora, Illinois Erin C. Watson and Jared Berger Adler School of Professional Psychology, Chicago, Illinois This article outlines a collaborative health care initiative entitled “Be Happy, Involved, and Positive (B-HIP)”—a grant-funded program through the Illinois Children’s Health- care Foundation. The B-HIP program was developed in January 2009 at the Rush- Copley Medical Center to address the previously undiagnosed mental health care needs for pediatric patients in a primary care setting. This article seeks to illustrate how, through collaborative care, efforts are being made to assess and address the mental health care needs for pediatric patients, and is furthermore an attempt to share information about implementing a pediatric mental health screening for best practices of the proposed prevention program, “B-HIP.” The investigators applied the Pediatric Symptom Checklist (PSC) as a standard of care for identi ed pediatric patients. Along with anecdotal data of the B-HIP program, an outline of the theory, design, and implementation behind the program’s inception is presented.

Keywords: primary care, family residency, pediatrics, integrated care, pediatric symptom checklist Medical residents, who are training to be- come independent practicing physicians, will often have patients who present with both medical and psychological illnesses. It is, therefore, increasingly important that they un- derstand ways to effectively assess and pro- vide basic care for these patients, and know when it is appropriate to refer these patients on for more in-depth mental health services.

Primary care providers, who are a central part of health care for the majority of patients, are often the rst source of information and guid- ance for patients and their medical and per- sonal needs (Kelleher, Campo, & Gardner, 2006;McDaniel, Campbell, & Seaburn, 1995).More recently, studies have recommended the collaboration of mental health and pri- mary care to provide comprehensive care of pediatric populations with mental disorders, given the unique competencies professionals from these disciplines can offer (American Academy of Pediatrics, 2009;Kelleher et al., 2006). Health professionals in the realm of family medicine and pediatrics are at the fore- front of working with pediatric patients and their families. According to the literature, be- tween 10% and 21% of children who present to primary care of ces have mental health disorders that require treatment (Polaha, Dal- ton, & Allen, 2011). When available, mental health resources are often underused, and communication between providers is lacking (Wissow et al., 2008). Early diagnosis and mul- tidisciplinary management of children who need both medical and psychological management can lead to greater bene ts for children and their fam- ilies (McDaniel et al., 1995).

The “Be Happy, Involved, and Positive (B-HIP)” program involves the practice of inte- grating medical and psychological services co- located in one setting to provide early identi - cation and treatment of pediatric mental health Lorna H. London, Family Medicine Residency Program, Rush-Copley Medical Center, Aurora, Illinois; Erin C. Wat- son and Jared Berger, Adler School of Professional Psy- chology, Chicago, IL.

Correspondence concerning this article should be ad- dressed to Lorna H. London, PhD, Family Medicine Resi- dency Program, Rush-Copley Medical Center, 2000 Ogden Avenue, Aurora, IL 60504. E-mail:lorna.london@ rushcopley.com This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Clinical Practice in Pediatric Psychology © 2013 American Psychological Association 2013, Vol. 1, No. 2, 196 –2002169-4826/13/$12.00DOI: 10.1037/cpp0000014 196 problems. In light of the unique team composi- tion of the Rush-Copley’s Family Medicine Residency Program and in concurrence with the Medical Center’s mission to enhance and share strategies and educational tools, the authors aim to outline the theory, design, development, and implementation of our B-HIP program.

Theory: Why Must We Build This Home?

The B-HIP project was generously funded by the Illinois Children’s Healthcare Foundation and conducted in a Family Medicine Center and Residency Program located in a community hospital in a suburban region. The National Committee for Quality Assurance (NCQA) rec- ognizes the Family Medicine Center as a Pa- tient-Centered Medical Home (PCMH). The PCMH emphasizes individual, organizational, and systemic change, in addition to encouraging providers to participate in advocacy and policy endeavors to optimize primary care collabora- tion (Holtrop & Jordan, 2010). The goals of PCMHs are to integrate patients as active par- ticipants, integrate services and providers, offer the best available evidence-based and appropri- ate interventions, and achieve a comfortable and convenient coordination of treatment for the patient.

The bene ts of mental health and medical care integration have been well documented. In the integrated care model, “providers support improved detection of behavioral health prob- lems through targeted or universal screening, focused assessment, brief interventions, and fol- low-up” (Rowan & Runyan, 2005, p. 11). Our tertiary integrated model positions all of our treatment team as collaborative providers in- cluding primary care physicians at the frontline, mental health providers supporting the primary care providers by bringing their expertise and support, and the patient and his or her commu- nity as collaborators in this population-based care approach (Rowan & Runyan, 2005).

In addition to providing ongoing support for medical professionals, pediatric psychologists are well poised for a role within the integrated care team (Clay & Stern, 2005). They have an existing capacity to assess and provide treat- ment for children with Attention-de cit/ Hyperactivity-Disorder (ADHD), Anxiety, De- pression, and Autism Spectrum Disorders. They are able to provide psycho-education material tocolleagues and patients, and provide consulta- tion to improve patients’ care. As educators, pediatric psychologists can promote effective exchange of information through collaboration and coprecepting to improve medical residents’ con dence in identifying and treating pediatric mental health concerns (American Academy of Pediatrics, 2009). As evidenced by the B-HIP project, pediatric psychologists can write grants and initiate program development to bene t pe- diatric care.

Design: Our Blueprint In an effort to achieve the goals outlined by the NCQA, the B-HIP project promotes the effective identi cation, coordination, and treat- ment of pediatric mental health problems to help children achieve an optimal state of phys- ical and emotional well-being. B-HIP has ve principal objectives:

Curricular enhancements for primary care clinicians (PCCs) and mental health specialists to broaden skill sets to better assess the psycho- logical needs of children in the Family Medi- cine Center.

Implementation of a universal mental health screening to promote early detection, prevention, and intervention among children and adolescents aged 5 to 17.

The development and use of a tiered and individualized treatment based on the severity of symptoms and identi ed needs of patients, using evidence-based interventions and patient and family education.

Utilization of case coordination to manage the needs of patients and families within the clinic and to facilitate linkage to community support services.

Involvement of psychiatric consultation for patients diagnosed with disorders requiring psy- chotropic medication management and/or inpa- tient hospitalization.

Development and Implementation: Building a Strong Foundation B-HIP focuses on training family medicine physicians in child development so that they may be better equipped to identify and assist with the treatment of childhood mental disor- ders. The B-HIP approach to enhancing the 197 HELPING CHILDREN B-HIP! This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. treatment of pediatric mental health involves the following four strategies.

Education for Our Providers The rst step in enhancing the treatment of childhood mental disorders is educating our pri- mary care providers, particularly our family res- idents. Because family residents are often the rst point of contact for our patients, they are provided with the opportunity to screen for mental health issues and facilitate a discussion about treatment goals.

Our pediatric psychologist contributed to ed- ucating our residents by offering weekly lec- tures to residents with topics includingCommu- nication with Families, ADHD School-Based Interventions, Human Development, Suicide Prevention,andBipolar Disorder in Children.

Additionally, residents were required to at- tend the “B-HIP Connections Conference: Inte- grating Primary Care and Pediatric Mental Health,” where experts in mental and medical pediatric health presented on topics including the following:Adolescent Health Issues, ADHD Management in Primary Care,andBiopsycho- social Characteristics of Pediatric Obesity.

PCCs and mental health specialists were re- quired to attend the sessions, and secondary providers were strongly encouraged to also attend.

Lastly, our residents are observed by attend- ing medical faculty, pediatric psychologist, and child psychiatrist via the precepting process.

Immediate feedback is given by attending phy- sicians’ pre-, during, and postvisit process.

Most visits are also recorded via electronic video system and reviewed and evaluated by the pediatric psychologist. Finally, a consulting child psychiatrist is available for case discus- sion. To enhance the process for everyone, psy- chology practicum students are also given the opportunity to precept our family residents as they assess psychosocial symptoms and needs of our primary care pediatric patients.

Screen Our Pediatric Patients Using Valid Measures B-HIP also strives to screen and detect men- tal health issues, so pediatric patients may re- ceive appropriate intervention at an early stage.

Initially, the Pediatric Symptom Checklist(PSC) is used to assess pediatric patients that present with psychosocial issues, whether ob- served by the health care provider or reported by the patient and/or caregiver. The PSC is a 35-item questionnaire designed to improve the recognition and treatment of psychosocial prob- lems in children. Identi ed patients and care- givers were given the option to complete one of several versions of the form: the English or Spanish PSC parent form (PSC), the English or Spanish PSC-Youth Report (Y-PSC), or the pic- torial version (available in both English and Spanish). The Y-PSC can be administered to adolescents ages 11 and up. For children and adolescent ages 6 through 16, a cutoff score of 28 or higher indicates psychological impair- ment. For children ages 4 and 5, the PSC cutoff score is 24 or higher. The PSC is an empirically supported measure with 95% statistical validity (Navon, Nelson, Pagano, & Murphy, 2001). Im- portantly, the PSC tool allows us to screen both child and caregiver, broadening our conceptu- alization of health and demonstrating the impor- tance of collaborative care. Because the PSC is available in both Spanish and English, we are able to respond to the growing needs of the diversity of our patients.

Our patients have mixed psychosocial condi- tions, including ADHD, Anxiety Disorder, De- pressive Disorder, Adjustment Disorder, Au- tism Spectrum Disorders, and V-Codes (e.g., relational or academic issues). Children who, based on their preliminary assessment, fall in the moderate to severe range of psychopathol- ogy are then assigned a mental health specialist.

When necessary, the mental health specialist administers additional assessments and collab- orates with the primary care providers to de- velop an appropriate treatment plan.

After the initial identi cation and assess- ment phase, treatments consist of empirically- based, individualized interventions, to try to address each child’s needs. Treatments in- clude a combination of individual, group, and/or commonly address bullying, con ict res- olution, time management, anger management, trauma/loss,living with ADHD, and self-esteem issues. There is no random assignment to treat- ment groups, nor is there withholding of treat- ment for any identi ed child. Fees associated with the operation of the program were initially covered by the grant. As the conclusion of the grant cycle has come to a close, psychology 198 LONDON, WATSON, AND BERGER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. practicum students supervised by the pediatric psychologist continue services at no cost.

Should the need arise for psychiatric care, the consulting child psychiatrist provides such ser- vices, and is reimbursed from the Family Med- icine Residency budget.

Enhance Multidisciplinary Collaboration and Communication A key component of this program is the mul- tidisciplinary collaboration that is used to pro- vide assessment, education, and intervention.

Our primary care providers consist of 12 resi- dents, four attending physicians, one pediatric psychologist, one consulting child psychiatrist, and four psychology practicum students.

Throughout the last several years, we have also had two community licensed professional coun- selors and consulting community social work- ers. Because many of our patients and their families are Spanish-speaking, we have consis- tently had one or more Spanish-speaking mental health specialists.

Collaboration between providers is facilitated through the educational components just dis- cussed, as well as on-site warm hand-offs, and electronically through the use of All- Scripts—an electronic program used by family physicians to enhance the delivery of integra- tive care. Warm hand-offs consist of a member of the clinical team being invited into the ex- amination room where a plan is coordinated for further care. Having the resident introduce the mental health specialist in a collaborative man- ner further assists the patient. This approach helps the patient understand the supplemental services available, increases compliance, and decreases the myths that often accompany clin- ical therapy (McDaniel et al., 1995).

Importantly, we continue to nd new ways to address the barrier of a high turnover rate in trainees. Because our residents reside with us for three years and our psychology students for one year, we strive to develop a common mis- sion, appreciate respectful professional differ- ences, and promote a caring patient-centered community (McDaniel et al., 1995).

Take It to the Community!

This project coordinates mental health care and medical care, in the primary care setting,while allowing the health care team to also collaborate with schools and community-based organizations as needed. Importantly, the B- HIP project promotes collaboration beyond the professional interaction of medical and mental health professionals, to incorporate community members as part of the treatment team (McDan- iel et al., 1995). In an effort to provide ongoing comprehensive health care to pediatric patients, mental health specialists are able to provide school-based interventions at participating local school districts to monitor and ensure compli- ance of recommendations in alternative settings.

In turn, schools act as a catalyst to minimize stigma associated with mental health concerns and maximize opportunity to serve as a com- munity partner.

Open House: Final Thoughts and Preliminary Results To date, 625 pediatric patients have been screened and 110 have received clinical ser- vices. Preliminary data demonstrate positive outcomes regarding pediatric mental health screenings, utilization of outpatient counseling and psychotherapy services, and the effective- ness of working within the school– community system to enhance children’s medical and psy- chological well-being. The pediatric patients were almost equally male (49%) and female (51%), with a median age of 10 years. The patients self-identi ed as Hispanic (43%), Black (20%), White (20%), Biracial (5%), Asian (2%), or chose not to identify (10%).

Pediatric patients’ visited the clinic mainly for school physicals (58%) or well-child visits (23%). In a matched comparison, youth re- ported signi cantly more symptomatology than their parents at initial screening. In general, parents rated male children with higher symp- tom scores than female children, and youth present for sick child visits rated their own symptomatology higher than other youth.

Further data collection is necessary to dem- onstrate effectiveness and outcomes of the B-HIP project.

Anecdotally it has been reported by our pa- tients that they bene t from receiving care in one location that can effectively coordinate ser- vices,reduce the obstacles in receiving treatment in a timely fashion, and promote early detection and intervention of mental health problems. By 199 HELPING CHILDREN B-HIP! This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. coordinating care with community-basedorgani- zations, we can provide comprehensive services to our youngest, and often most vulnerable pa- tients. To ensure that the mental health needs of our pediatric population are met, we continue to train our physician residents, to assist them in becoming more adept at assessing, diagnosing, and providing brief treatment for common psy- chiatric issues. We, as mental health specialists, create ongoing opportunities to break down the barriers of interdisciplinary collaboration.

We have learned that even with the offer of free mental health services, offered at their medical home, there are still some barriers to overcome, including stigma of mental health services, environmental barriers (e.g., transpor- tation), bilingual services, and access to invalu- able team members (e.g., child psychiatrists, social workers). Additionally, parents who ini- tially express concern about their children’s emotional health are often delayed in seeking treatment, until matters reach a critical level.

Prevention is still something that may not be seen as a priority for some of the participating families. Our future work will explore ways to minimize these barriers and increase opportuni- ties for continued interdisciplinary assessment and intervention.

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doi:10.1542/peds.2007-0418 Received February 14, 2013 Revision received March 6, 2013 Accepted March 10, 2013 200 LONDON, WATSON, AND BERGER This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.