Pediatric Psychiatric Telemedicine: The community feedback period for this project began on 8/8/18 and ended on 10/6/18

What is the problem that needs to be addressed? Please describe how it is related to mental health.

Pediatric mental health care is one of greatest health needs in Orange County. While California is ranked #15 of the 50 states for adult mental health care, it is #38 for pediatric mental health. In California 65% of children diagnosed with depression do not receive treatment and only 20% have the consistent and continued mental health care that they need. Anecdotally we hear that in Orange County unlicensed or nonmedical community providers do not how to link families into needed psychiatric care and medical practitioners are too overwhelmed, undertrained and under-licensed to provide adequate mental health diagnosis and treatment in their offices. Children whose practitioners refer them to Pediatric Psychiatrists face long wait times and many children worsen while awaiting care. These trends are particularly concerning given that 70% of children referred early will access the care that they need compared to only 30% referred later.

Why is this a concern for Orange County? What can Orange County and other counties learn from this project?

We talk extensively about how we do not have enough services for children, particularly those who are seriously ill. But what if we changed the system to allow community providers to refer to pediatricians who can prescribe medication and refer to therapy, help all medical providers care for children in their offices with Pediatric Psychiatric oversight, provide immediate telemedicine conferencing for patients in crisis, and save our intensive services for those in most need? For less than a million dollars annually Orange County can be the first jurisdiction to build a comprehensive network specifically designed to serve every child by need and point of care. The ability to appropriately triage resources on a countywide level can lead to huge mental health gains for children countywide by maximizing what we already have, and identifying future gaps. Metrics for this project would include the levels of appropriate mental health care in medical offices, the average time to connect children with suspected mental health problems to appropriate diagnosis, treatment, and services, and medical and community provider knowledge of and comfort with providing appropriately triaged referrals in real time.

What is currently being done to resolve this problem in our county and throughout the United States? If applicable: Is it working; why or why not?

23 other states and a small pilot program in California have explored providing pediatric psychiatric support to primary care pediatricians via a Child Psychiatry Access Project (CPAP) model. Most of these states offer two critical services: first, a direct telephone line to discuss patient diagnosis and care with a board certified Pediatric Psychiatrist, which is important not just to determine best practices but also to ensure that primary care practitioners have adequate medicolegal coverage when prescribing psychotropic medications. Pediatric Psychiatrists can quickly help pediatricians diagnose illness, prescribe appropriate medications, refer to appropriate psychotherapy, and triage patients that have more severe illness and will need emergent services, either by the pediatric psychiatrist or an emergency room. Second, they offer the services of a case manager who keeps track of all mental services offered by insurance plan, so that the referring pediatrician knows which of the appropriate psychologists or treatment programs function in the area and what their current capacity is.

In jurisdictions that have implemented this model, the results are impressive: in Massachusetts, more than 95% of pediatricians statewide receive detailed case consultation from pediatric psychiatrists through this service. 68% of the time this consultation service allows the pediatrician and his or her staff to provide all appropriate care for the child in their medical office without a referral to more intensive services, as compared to the national average of just 10%. As a result, wait times for intensive services and inpatient stays have decreased from three months to just a few weeks as only the children that need to be seen most emergently are referred to intensive specialty services.
However, there are significant gaps in all of the proposed and existing systems. Many children, particularly those with mental illness, may present first at another medical location, such as emergency rooms, free health clinics, or stand alone Minute Clinics or urgent care centers. In fact, 10% of children 12 and over who came in to the Children’s Hospital of Orange County Emergency Room for a medical complaint were found to be suicidal. And children who present at a nonmedical location such as a community center often receive no referral or a referral to difficult to access resources despite great caring and interest by the community group.

What is new or different about this project idea? Please describe how this differs from what is already being done (Question 6). Please list any research that was done on this topic.

First, the Orange County system would provide immediate telephone or telemedicine support by a board certified Pediatric Psychiatrist for any medical provider who comes into contact with a child and requests assistance. Physicians, Nurse Practitioners and Physician Assistants practicing anywhere from the emergency room to a CVS would have access to this support, making the common denominator the needs of the child, not the professionals being served. In addition to standard phone consultation this project would assist interested practices in setting up telemedicine options to allow for immediate services to children in crisis, for example those in an adult emergency room. Second, it would develop a list of primary care medical practices able to see children with potential mental health issues for each insurance plan, including uninsured, so that critical follow up could be ensured. Third, it would take calls from nonmedical community personnel and do a rapid triage, either providing the same list of medical practices cited above or referring to an emergency room or telemedicine consultation as warranted by the child’s level of distress.

What is the project idea? Please describe how this project will operate.

This project would employ two full time pediatric psychiatrists (approximately $300,000 each for $600,000 total) and four full time program managers (approximately $75,000 each for $150,000 total) to support all health care providers and community workers in getting immediate best practice mental health care for every child in Orange County. Support would be provided primarily by phone at the time of a call; however, resource materials might be created to address common questions as well. An additional start-up fee of $200,000 and minimal annual costs would be set aside to build secure teleconferencing capabilities that would allow for immediate consultation with children in crisis at any location with a compatible system. Initial cost estimates are based on consultation with existing programs along with added resources to support the additional services outlined in this plan.

Additional Information

References by question:

4. Mental Health America, 2017 State of Mental Health in America – Ranking the States
6. data from MCPAP system, private communication and published data; communication from Dr. Huszti, Children’s Hospital of Orange County
8. Discussions with Beacon Health and other MCPAP providers

June 25, 2018

4 comments

The projects below are similar to the Pediatric Psychiatric Telemedicine idea proposed. How is this project different from what is already being done at CHOC Hospital’s Pediatric Psychiatric Consult Line and in Massachusetts with their CPAP Program?

https://www.mcpap.com/About/OverviewVisionHistory.aspx

https://www.choc.org/news/choc-receives-grant-for-countys-first-pediatric-psychiatric-consult-line/

Both of the programs above limit their services to support for pediatricians. By contrast, this proposal would support both other medical providers and community groups who have regular contact with children in crisis yet do not have easy access into the mental health system. In addition, this program would maintain a list of pediatricians who can follow children with mental illness, thus enabling the community providers to connect these high needs children to a pediatric medical home as well as psychiatric and psychological services.

What could we learn from this project that would be new and contribute to learning in this area given that there are already at least two similar programs currently providing pediatric psychiatry consultation services?

Both of the programs cited above limit their services to support for pediatricians. By contrast, this proposal would support both other medical providers and community groups who have regular contact with children in crisis yet do not have easy access into the mental health system. Data indicates that many of the children in more dire need do not have a regular pediatric home, thus they do not benefit from the pediatrician to pediatric psychiatrist link provided by other programs. This project would test whether enabling community providers and healthcare personnel to connect children to mental health and pediatric mental health homes in real time makes an impact in outcomes.

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