Pediatric integrated primary care (IPC) is an innovative approach to healthcare delivery that seeks to promote comprehensive, coordinated, and cost-effective health services for children. It combines the expertise of both primary care physicians and behavioral health specialists to deliver comprehensive, coordinated, patient-centered healthcare services. This approach helps to ensure that children receive the best possible care by providing access to preventive measures, early diagnosis, and treatment of illnesses, as well as ongoing follow-up visits for both physical and mental health. Although this model can benefit both patients and providers, helping to improve outcomes while reducing overall costs associated with pediatric care, there are also challenges related to its implementation that must be addressed to maximize its effectiveness. The following considers the opportunities and challenges posed by IPC in pediatric settings, strategies to surmount any potential obstacles, best practices for successful implementation, and future directions for enhancing the quality and accessibility of pediatric integrative health services.
The Need for Pediatric Integrated Primary Care
IPC increases access to much-needed care in a safe, comfortable, and destigmatized environment (Lines, 2022). This is critical for ensuring equitable access to high-quality, evidence-based, and trauma-informed care for all patients, including those from underrepresented groups (Lines, 2022). IPC models can provide earlier access to care with shorter wait times, compared to traditional outpatient models, and can often reduce the need for referrals outside of the practice, thus leading to more timely intervention or prevention.
IPC models align with healthcare reform efforts and connect to Quadruple Aim and Value-Based Care (VBC) guidelines (Lines, 2022). The Quadruple Aim is a framework for reducing healthcare costs, improving population health outcomes, improving patient care, and improving provider well-being (Sikka et al., 2015). VBC moves away from a fee-for-service model of care to an approach that rewards providers and health systems for administering preventative care, increasing population health outcomes, and improving the overall quality of care (Lines, 2022). This shift further reinforces the importance of IPC models in providing preventive services as part of primary medical care, which has clear implications for improved treatment outcomes.
Cost-savings in pediatric IPC may not be as evident as in the adult literature. However, its financial impact still has public health implications. Without proper treatment of mental health issues during childhood, costs rise when the individual reaches adulthood. Conversely, some studies have found that pediatric IPC services create short-term cost offsets, potentially impacting long-term savings (Dopp et al., 2018).
Pediatric IPC models have existed for over 40 years but are still relatively less common than adult models. New data suggests that IPC is an effective approach to addressing the growing behavioral health needs of children and young adults, and this model is gaining more traction (Lines, 2022). Mental health issues are among the most common health concerns for children and adolescents in the United States, with 10-20% receiving an official diagnosis yearly (Perou et al., 2013). However, only half of those children ever actually receive the necessary treatment. Minoritized racial and ethnic groups, as well as youth living in poverty, are at a greater risk of mental health challenges but are far less likely to receive behavioral health treatment than other youth their age (Arora et al., 2017). The COVID-19 pandemic and continued racial trauma have caused a surge in youth mental health needs, leading multiple pediatric expert organizations to declare a national emergency regarding child and adolescent mental health, particularly among these underserved populations (American Academy of Pediatrics, 2021). To respond to this urgent situation, policy changes and advocacy must be implemented, adopting pediatric IPC models to meet the critical needs of our youth.
According to the American Academy of Pediatrics, children should receive 12 well-child visits with a primary care provider between the ages of 0-3 years, followed by annual visits until they reach 21 years (Hagan et al., 2018). This consistent relationship and relatively frequent contact make IPC an ideal approach for pediatrics. It reduces access barriers associated with stigma, time, and transportation, increases comfort in seeking treatment, and allows for the focus on prevention that is so important to early child development (Lines, 2022). Pediatric IPC also provides population-level care to more children and expands access to evidence-based practices tailored to their unique cultural needs. In addition, this model also gives children and families access to a continuum of services, from preventive steps to traditional mental health interventions.
Delivery Models of Pediatric Integrated Primary Care
Federal healthcare initiatives have focused on increasing access to services for children with behavioral health issues, making the pediatric primary care setting a prime location (Asarnow et al., 2017). The Patient-Centered Medical Home (PCMH) is a notable example in which a primary health team works to provide holistic and personalized care that is continuously accessible and tailored to the child’s needs. The PCMH is not a physical location but rather an innovative model of healthcare delivery that promotes comprehensive, patient-centered care; coordination among care teams; accessibility to all levels of healthcare services; and quality and safety. It encourages provider-patient relationships built on trust and respect by enabling providers to meet patients where they are – regardless of the complexity or simplicity of their condition (Asarnow et al., 2017). The PCMH model aims to achieve primary care excellence so that patients receive timely, fitting care suited to their specific needs.
Approaches to integrating primary care providers (PCPs) and behavioral health consultants (BHCs) in pediatric IPC services vary widely due to the lack of standard integration. There are three main models of IPC: coordinated, co-located, and integrated care (Njoroge et al., 2016). Coordinated care involves communication and collaboration between the PCP and BHC that may be done in different clinic settings. Co-located care occurs when behavioral health services are available in the same location as the PCP but without significant provider collaboration. Finally, integrated care refers to BHC and PCP working together from a single setting. This allows for “warm hand-offs” (WHOs) in which the patient is introduced to the BHC, who provides psychoeducation and referrals or conducts an intake session. The two clinicians also collaborate to ensure a well-rounded treatment plan incorporating medical and behavioral health interventions (Njoroge et al., 2016).
Research has indicated that co-located and integrated models provide the best access to care (Lilly et al., 2020). In particular, it has been noted that integrated care models are associated with more patients starting and completing their treatment than traditional approaches (Kolko et al., 2014). However, in some cases having a BHC onsite or in full-time integration may not be feasible or cost-effective due to factors such as limited availability of BHCs, physical space constraints in clinics, and small patient capacity within a single clinic (Lilly et al., 2020).
A hub-extension model combines integrated and coordinated models within one health system to address the limitations of having a BHC in every primary care clinic. The hub-extension model is an innovative approach to address organizational barriers such as limited personnel and office space within health systems when exploring options for BHC coverage in primary care clinics (Lilly et al., 2020). In this model, a BHC receives referrals from PCPs at their integrated hub site and from PCPs at extension clinics. Patients referred by extension sites can continue receiving medical care at their current clinic while accessing behavioral health care at an integrated hub clinic within the same organization. PCPs in extension clinics continue communication with BHCs via secure text messaging, phone calls, or electronic medical records to coordinate treatment plans and administrative tasks. Additionally, some providers may operate out of both hub and extension clinics, allowing for contact with the BHC in multiple settings.
There is limited research on which IPC delivery model works best in real-world scenarios and even less research that examines the impact of off-site collaboration on pediatric primary care patients’ access to behavioral health care. Several studies suggest there is no single ‘best way’ to engage children and families, emphasizing the importance of sensitivity to particular clinical populations and settings when devising strategies (Lines & Riley, 2020). More investigation into maximizing the reach of IPC services, including WHOs and other approaches, is necessary. Although best practices for screening, referral, and care delivery may be well-defined, putting them into practice in a fast-paced environment can still be challenging. Knowing the barriers and facilitators to implement evidence-based practices is a key element to ensuring successful integration, requiring the adoption of new and different methodologies.
Benefits of Pediatric Integrated Primary Care
Integrated care models can offer several benefits, including improved patient access to services, increased consistency and continuity of care, better coordination between providers, increased communication between patients and their healthcare teams, and improved health outcomes due to more comprehensive and holistic approaches to treatment (Asarnow et al., 2017). Additionally, integrated care models can often provide extra resources, such as case managers coordinating services for individuals with multiple conditions and needs. This allows for flexibility in efficiently addressing health complexities and with an individualized plan tailored to that patient’s needs.
From the population health perspective, the pediatric PCMH could positively impact morbidity and mortality related to behavioral health problems. Health and health risk behaviors, such as diet, exercise, sleep, behavior, and emotional responses, are formed in childhood and can potentially contribute to long-term health and behavioral health outcomes (Viner et al., 2012). Furthermore, common causes of death in adolescents are accidents, homicide, and suicide, which can be linked to behavioral health problems such as substance use and depression (Asarnow et al., 2017). Therefore, offering preventive services and early intervention is crucial for pediatric populations to reduce the risk of chronic conditions and preventable deaths.
Challenges for Pediatric Integrated Primary Care
Despite the many benefits of pediatric integrated primary care, several challenges must be overcome to implement this model successfully. For instance, some medical centers and hospitals may not have the staff or resources necessary to enact such a system on a large scale. Additionally, as this type of care requires collaboration between medical providers and mental health professionals, cultural differences between these fields may create resistance to working together to ensure an individual’s needs are met. Furthermore, given the complexity of the health care system, new policies or regulations may need to be set in place in order for integrated primary care services to be used effectively. Finally, there is potential for insurance companies and other third-party payers to resist covering increased costs associated with such a model due to its more comprehensive approach to treatment (Burkhart et al., 2020).
One of the main challenges for pediatric IPC is creating a supportive infrastructure to ensure successful implementation. There may be limited access to mental health specialists in certain rural or underserved areas, as well as inadequate resources to support providing such specialized services. In addition, this model often requires more training and resources than traditional models of care to be effective. Additionally, it can be challenging to build trust between medical providers and mental health specialists, which is necessary for successful collaboration. Lastly, additional research is required to understand how best to integrate behavioral health into primary care settings (Burkhart et al., 2020).
Best Practices for Implementing Pediatric Integrated Primary Care
Best practices for implementing an effective, efficient, and sustainable model for pediatric integrated primary care include the following:
- Establishing a team of medical and mental health professionals who can collaborate to provide comprehensive patient care.
- Developing a plan that outlines how integrated services will be delivered and tracked to ensure quality of care.
- Creating policies that encourage efficient use of resources while providing appropriate access to treatments, such as utilizing telemedicine technology when possible.
- Regularly assessing and evaluating the program’s effectiveness to identify improvement opportunities or other sustainability strategies.
- Utilizing community engagement strategies to increase awareness about the importance of integrated primary care amongst families and other stakeholders (Mautone et al., 2021).
Practically, this requires (1) identifying any existing resources that can be utilized to facilitate seamless delivery of services, (2) establishing clear guidelines on how medical and mental health professionals will work together to provide comprehensive care, (3) developing training protocols for healthcare providers to ensure adequate knowledge and buy-in, (4) designing a financial model that covers the cost of integrated treatments while remaining affordable for patients and other payers, and (5) monitoring the progress of the program to continuously evaluate its effectiveness and identify opportunities for improvement or other strategies for sustainability (Mautone et al., 2021).
Implementing IPC requires a commitment from healthcare providers to adjust medical culture, with a resolution towards providing comprehensive, collaborative care. By understanding the value of mutual collaboration, individual performance can improve practice standards and create exceptional patient care that has the potential to change health outcomes significantly.
Future Directions
Substantial evidence supports using IPC models to screen, refer, and treat specific disorders (Njoroge et al., 2016). Less is known about the effectiveness and acceptability of integrated care models and the best way to meet all patient and practice needs. To succeed in the future, integrated models must cover a broader range of conditions and extend beyond current boundaries to better meet the needs of children in pediatric primary care settings. More research is needed to: (a) assess the long-term effects of integrated care models on child and family health outcomes and (b) identify the variables that would predict successful outcomes for children’s health (Njoroge et al., 2016).
To further promote the successful integration of care, several future directions exist to consider. These include (a) training medical and behavioral staff to broaden their skills; (b) implementing universal behavioral health screening; (c) developing a tiered approach to treatment based on the patient’s unique needs; (d) utilizing care coordination and management services; and (e) involving outside consultation to psychiatry when needed for medication management, level of care consultations, or inpatient/hospitalization consultations (Njoroge et al., 2016).
Psychologists specializing in pediatric primary care can help close the access gap by providing integrated behavioral health services. This allows children and adolescents to have quick, effective, and evidence-based treatments available to address their behavioral health needs from the comfort of a pediatric primary care setting. Through integrated behavioral health services, high-quality, prompt, and accessible treatments are made possible.
Conclusion
Pediatric integrated primary care brings numerous benefits to patients and providers by providing comprehensive, coordinated, and cost-effectively delivered healthcare services for children. However, for this innovative model to be fully effective and sustainable, it is essential to identify existing resources that can be utilized, establish clear guidelines on how medical and mental health professionals will collaborate, develop training protocols for healthcare providers, design a financial model that covers necessary treatments while remaining affordable, and monitor progress to continuously evaluate its effectiveness. With the essential strategies in place, pediatric IPC can serve as an invaluable resource for improving the long-term health outcomes of children.
References
American Academy of Pediatrics. (2021, October). Declaration of a national emergency in child and adolescent mental health. https://www.aap.org/en/advocacy/child-and-adolescent-healthy-mental-development/aap-aacap-cha-declaration-of-a-national-emergency-in-child-and-adolescent-mental-health/
Arora, P. G., Godoy, L., & Hodgkinson, S. (2017). Serving the underserved: Cultural considerations in behavioral health integration in pediatric primary care. Professional Psychology: Research and Practice, 48(3), 139–148. https://doi.org/10.1037/pro0000131
Asarnow, J. R., Kolko, D. J., Miranda, J., & Kazak, A. E. (2017). The Pediatric Patient-Centered Medical Home: Innovative models for improving behavioral health. American Psychologist, 72(1), 13–27. https://doi.org/10.1037/a0040411
Burkhart, K., Asogwa, K., Muzaffar, N., & Gabriel, M. (2020). Pediatric integrated care models: A systematic review. Clinical Pediatrics, 59(2), 148–153. https://doi.org/10.1177/0009922819890004
Dopp, A. R., Smith, A. B., Dueweke, A. R., & Bridges, A. J. (2018). Cost-savings analysis of primary care behavioral health in a pediatric setting: Implications for provider agencies and training programs. Clinical Practice in Pediatric Psychology5, 6(2), 129–139. https://doi.org/10.1037/cpp0000231
Hagan, J. F., Shaw, J. S., & Duncan, P. M. (2018). Bright futures. American Academy of Pediatrics. https://brightfutures.aap.org/Pages/default.aspx
Kolko, D. J., Campo, J., Kilbourne, A. M., Hart, J., Sakolsky, D., & Wisniewski, S. (2014). Collaborative care outcomes for pediatric behavioral health problems: A cluster randomized trial. Pediatrics, 133, e981–e992. http://dx.doi.org/10.1542/peds .2013-2516
Lilly, R. G., Meadows, T. J., Sevecke-Hanrahan, J. R., Massura, C. E., Golden, M. E., & O’Dell, S. M. (2020). Hub-extension model and access to pediatric behavioral integrated primary care. Clinical Practice in Pediatric Psychology, 8(3), 220–227. https://doi.org/10.1037/cpp0000358
Lines, M. M. (2022). Pediatric Integrated Primary Care. Delaware Journal of Public Health, 8(2), 6–9. https://doi.org/10.32481/djph.2022.05.002
Lines, M. M., & Riley, A. R. (2020). Introduction to the special issue on integrated pediatric primary care: Placing “how” in the context of now. Clinical Practice in Pediatric Psychology, 8(3), 211–216. https://doi.org/10.1037/cpp0000368
Mautone, J. A., Wolk, C. B., Cidav, Z., Davis, M. F., & Young, J. F. (2021). Strategic implementation planning for integrated behavioral health services in pediatric primary care. Implementation Research and Practice, 2, 10.1177/2633489520987558. https://doi.org/10.1177/2633489520987558
Njoroge, W. F. M., Hostutler, C. A., Schwartz, B. S., & Mautone, J. A. (2016). Integrated behavioral health in pediatric primary care. Current Psychiatry Reports, 18, 106. http://dx.doi.org/10.1007/ s11920-016-0745-7
Perou, R., Bitsko, R. H., Blumberg, S. J., Pastor, P., Ghandour, R. M., Gfroerer, J. C., Hedden, S. L., Crosby, A. E., Visser, S. N., Schieve, L. A., Parks, S. E., Hall, J. E., Brody, D., Simile, C. M., Thompson, W. W., Baio, J., Avenevoli, S., Kogan, M. D., Huang, L. N., & Centers for Disease Control and Prevention (CDC). (2013). Mental health surveillance among children—United States, 2005-2011. MMWR Supplements, 62(2), 1–35.
Sikka, R., Morath, J. M., & Leape, L. (2015). The Quadruple Aim: Care, health, cost and meaning in work. BMJ Quality & Safety, 24(10), 608–610. https://doi.org/10.1136/bmjqs-2015-004160
Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. Lancet (London, England), 379(9826), 1641–1652. https://doi.org/10.1016/S0140-6736(12)60149-4