In 2020, the system embedded mental health therapists at 11 primary care sites and four regional support hubs. A study published in November found patients who participated in the program reported a 62% decrease in symptoms of depression, and 44% decrease in symptoms of anxiety.
Benjamin Maxwell, MD, is chief of child and adolescent psychiatry and The Una Davis Family Chair in Behavioral Health at Rady Children’s, and an associate clinical professor of psychiatry at UC San Diego School of Medicine. He sat down with Becker’s to explain how Rady Children’s built the program and how it works.
This conversation has been edited for length and clarity.
Question: How did you go about building this program, and how does it work in practice?
Benjamin Maxwell: I started as an inpatient child psychiatrist working on inpatient units and in the emergency room. So often, when I’d talk with the parents of a 16-year-old, I’d ask a typical question that doctors ask: “When did all of this start?” They’d commonly say, ‘When they were 3, or 4 or 5. We went to the pediatrician and they didn’t know what to do. We looked in the community and couldn’t find any options. We’d hoped it would go away, we hoped it was just a phase, but things just kept getting worse.”
After years and years of asking lots of patients and hearing that same response, it felt like the common sense approach to say, ‘What if we could catch this a lot earlier, and identify things when they’re mild?’ It was my own interest in looking at what’s happening in primary care pediatrics within our system, and having some informal conversations with the leaders of the pediatric group practice. There was real traction immediately in some of those conversations. We started having a monthly lunch with what started as four or five people, and ended up being 10 to 20 people on a regular basis where we started to ask the question of what it would look like to bring mental health expertise into the primary care practice.
We quickly realized the things that a child psychiatrist might think were just completely wrong. It wouldn’t work in that setting. It was great to get pediatricians to say, ‘Look, we’ve got six or seven minutes per patient. Although we’d love to sit and talk with our patients and families for longer than that, the reality is we have to go much quicker.’ That was one of the ideas that very quickly pointed us towards embedding masters level therapists that could take a warm handoff from the trusted pediatrician to have that conversation, and hopefully find ways forward within the primary care setting so these families didn’t have to go to some other clinic.
We talked about it for a while, and we had what we thought was a good plan, but we had no way to think about how it would be financially sustainable. These sorts of services really aren’t reimbursed in a way that a lot of organizations can do it. We fortunately had a philanthropy opportunity come to us, where it gave us a really substantial investment to allow us to pilot this program. That’s what we’ve been doing for the past three, four years. We’ve had better than expected results with the impact that has on getting kids access to care, number one, and number two the impact on reducing symptoms such as anxiety.
Q: What does it look like when a patient comes in needing mental health support?
BM: When a patient or family comes in, if something is identified in that visit, either the parent or kid brings it up, or maybe they screen positive for some psychological symptoms — In our model, the ideal is the pediatrician is able to say ‘That sounds really difficult. Let me walk you down that hall to my co-worker who specializes in treating these sorts of things.’ It’s a same-day, immediate handoff to that mental health therapist.
We leverage the trust that pediatricians have with those families. I think it’s the ultimate way to destigmatize and normalize the conversation around mental health. It’s in the primary care clinic, but everybody has mental health [needs.] We have to find ways to support our mental health and maintain our ability to stay psychologically well.
Q: Why is it difficult to get reimbursement for this kind of program, and what is the path forward to making integrated care financially feasible?
BM: It goes back to what’s reimbursed currently in our healthcare system — complex care to highly acute and challenging patients. This is not that. This is mild to moderate mental health concerns. It’s sitting and talking with the patient, being present. Those sorts of things just aren’t currently reimbursed in our healthcare system.
I think the way forward with that is our ability to demonstrate that there’s a return on investment. When we embed this kind of care into primary care, it prevents not only worsening of mental health conditions, but it also prevents worsening of medical conditions, like type 1 diabetes, or asthma, or any number of things. These things are all intertwined, and we need to care for those simultaneously.
Q: What advice would you give to hospitals and health systems looking to establish something similar?
BM: I think first and foremost it starts with relationships between the different providers, establishing some trust and understanding, the realities of those professionals that come together. Mental health clinicians have to change and adapt to a pediatric clinic. Pediatricians need to change and adapt to having mental healthcare providers in their clinic as well. I think it starts with those relationships, talking about how it might be feasible in the system or location that you’re in, and reaching out to lots of different organizations around that country that are starting to do this. Try to find a way to be a part of that movement to make this standard of care for all kids, no matter where they seek primary care.
