Early Childhood Mental Health (ECMH) Integration in Pediatric Primary Care
By Danna Mauch, PhD, President & CEO, Massachusetts Association for Mental Health
Early childhood mental health care matters. One out of every seven children, ages two to eight years, was reported to have a diagnosed behavioral or developmental condition (e.g., depression, anxiety, behavioral or conduct disorder, autism spectrum disorder, developmental delay, etc.) in the National Survey of Children’s Health.[i] Reaching children and families early is critical to optimizing opportunity over the life course, and the pediatric medical home is an effective point of entry for behavioral health as it is a non-stigmatized and trusted source of care.[ii] The Massachusetts Association for Mental Health (MAMH) advocates for widespread adoption of evidence-based models of early childhood mental health (ECMH) integration in pediatric primary care to improve access and outcomes for children and families.
How does ECMH integration in primary care work?
LAUNCH/MYCHILD is one example of an evidence-based model of early childhood mental health (ECMH) integration in pediatric primary care. This model includes both a mental health clinician and a family partner (an adult experienced in navigating the health and social services systems for his/her own child) embedded in the primary care team. The behavioral health clinician and family partner attend regular team meetings and case conferences, participate in daily huddles, receive children and families by way of warm hand offs from primary care clinicians, and are integral in the development of care plans. The goals of this model are to promote healthy relationships between parents/caregivers and their children, prevent concerning behaviors, reduce stress on families, identify behavioral health concerns early and make referrals for therapeutic intervention.
What is the evidence for LAUNCH/MYCHILD?
In my former role as Senior Fellow/Principal Associate at Abt Associates, I led an evaluation of MYCHILD; likewise, the Institute for Urban Health Research at Northeastern University led an evaluation of LAUNCH. As measured by evidence-based tools, LAUNCH/MYCHILD resulted in statistically significant reductions in parental stress and depression symptoms, as well as improved child mental health and social emotional wellness. The Abt research team additionally used Medicaid data to compare health care expenditures for children enrolled in MYCHILD with a matched comparison group in the MassHealth population. Looking at all MassHealth costs over a 12 month period following the index date, we found that MYCHILD costs were $164.21 less per child per month versus children in the control group. Likewise, children enrolled in MYCHILD were also more likely to receive appropriate, non-stigmatizing diagnoses.[iii] Accurate diagnoses are essential to developing effective care and treatment plans.
Are there other evidence-based models of ECMH integration in primary care in Massachusetts?
Yes, there have been additional investments in ECMH integration in pediatric primary care that have further contributed to a body of knowledge in this field. The MetroWest Health Foundation, for instance, supported the Southborough Medical Group in implementing pediatric integrated behavioral health care. The result was improved access to behavioral health services (both timeliness of care and engagement in care). Southborough was also able to address language and cultural barriers to care and document improved communication between families and providers.
Related, the Pediatric Physicians’ Organization at Children’s (PPOC) has successfully integrated mental health care throughout its practices. PPOC also received a grant from the Blue Cross Blue Shield of Massachusetts (BCBSMA) Foundation to integrate substance misuse services in pediatric primary care through a partnership with the Adolescent Substance Abuse Program (ASAP) at Children’s; the Foundation has secured John Snow, Inc. to analyze the impact of the model on access to care. Furthermore, the Richard and Susan Smith Family Foundation’s TEAM UP for Children Initiative is supporting transformation to integrated pediatric primary care at three federally qualified health centers. The Smith Family Foundation is partnering with the Robert Wood Johnson Foundation and Boston University on an evaluation of the initiative to assess real-time cost and quality outcomes.
How can these models be brought to scale?
Despite support for ECMH in primary care from diverse stakeholders, public and private investments in practice transformation and a growing evidence base, integrated pediatric behavioral health care is far from universal. The promotion of widespread adoption, implementation and sustainability requires a multifaceted approach including addressing policy and regulatory barriers; investing in training and technical assistance for practice transformation; promoting sustainability through delivery and payment reform efforts (such as reimbursement for core elements of integrated care and review of ACO certification/reporting requirements); and enforcing state and federal parity laws.
In the past few months, momentum has been building around bringing integrated pediatric care to scale. On March 16, I participated in a panel discussion hosted by the Young Children’s Council – a multi-disciplinary group formed to advise EOHHS and DPH as they implement the two federal grants that support MYCHILD/LAUNCH – on next steps to advance widespread adoption of these models. Just a few weeks later, the Special Commission on Behavioral Health Promotion and Upstream Prevention, chaired by the Honorable James Cantwell, issued its final report with 25 actionable recommendations to advance promotion and prevention among young children in the Massachusetts. Recommendation #17 entails providing outreach and technical assistance to pediatricians and their staff on clinical and administrative steps to achieve behavioral health integration in their practices. MAMH is encouraged by this recent progress and looks forward to ongoing work with our partners to advance integrated ECMH in pediatric primary care to improve access and outcomes for children and their families.
This blog is part of HCFA’s Children’s Mental Health Week series.
[i] Bitsko R.H., Holbrook J.R., Robinson L.R., et al. Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders in Early Childhood — United States, 2011–2012. MMWR Morb Mortal Wkly Rep 2016; 65:221–226.
[ii] Massachusetts Executive Office of Health & Human Services, Massachusetts Department of Public Health, Boston Public Health Commission, Substance Abuse and Mental Health Services Administration. Early Childhood Mental Health Matters… and it Works: Positive Outcomes of ECMH Integration in Primary Care. Available at: http://www.ecmhmatters.org/Pages/ECMHMatters.aspx
[iii] Mauch D. and Allen D. Use of Medicaid Data to Evaluation Effect of Integration of Early Childhood Mental Health into Pediatric Medical Homes through the Massachusetts Young Children’s Interventions for Learning and Development (MYCHILD). (2015 November 4). Lecture presented at the American Public Health Association Annual Conference.