Where children live plays a large part in the type of health care they receive. In particular, psychiatric services for children are unevenly distributed across the U.S., with children in rural areas experiencing dramatically reduced access. The ratio of child and adolescent psychiatrists per 100,000 youth ranges from 3.7 in Alaska to 31.8 in Massachusetts.
Due to this shortage, primary care providers (PCPs) often have to treat children for behavioral health issues. But because PCPs may not have extensive training in behavioral health treatment or familiarity with evidence-based treatment alternatives, psychotropic medications are often first-line treatment options. Children, particularly those in foster care, often inappropriately receive psychotropic medications, which can cause long-lasting adverse health effects.
Finding opportunities for psychiatric consultation is one way for PCPs to discuss treatment options with child or adolescent psychiatrists to help ensure their young patients receive appropriate treatment. Consultations can be done in-person, over the phone, or, when necessary, via video to observe the child’s behavior. Two psychiatric consultation models — the Oregon Psychiatric Access Line about Kids and the Partnership Access Line used in Washington and Wyoming — offer innovative examples.
Oregon Psychiatric Access Line about Kids
The Oregon Psychiatric Access Line about Kids (OPAL-K) is a collaborative effort between Oregon Health and Science University (OHSU), the Oregon Pediatric Society, and the Oregon Council of Child and Adolescent Psychiatry. Supported by the Oregon Health Authority’s Addiction and Mental Health Services, OPAL-K provides free, same-day, Monday through Friday, child psychiatric phone consultation to PCPs throughout Oregon. OPAL-K is available to all providers serving children and youth in Oregon, regardless of the children’s insurance status.
In addition to consultations, the OHSU webpage also offers care guides, an easy OPAL-K enrollment process for PCPs, and links to resources. PCPs contacting OPAL-K receive an e-mail with a summary of the call, care guidelines, and an invitation to call back as needed.
Although results are not yet available, OSHU is tracking the effectiveness of OPAL-K’s support for PCPs through REDCap, a secure web application for data collection. OHSU collects data on the purpose of the call, questions raised, medication and diagnostic considerations, nonmedical strategies, and any specific recommendations. The application aligns with the Partnership Access Line programs in Washington and Wyoming (outlined below) to allow for regional review of practices and outcomes.
Partnership Access Line in Washington and Wyoming
The Partnership Access Line (PAL) used in Washington and Wyoming provides consultation, continuing medical education conferences related to psychiatric care, and free care guides for PCPs. PAL is funded by state Medicaid dollars. Although PAL serves all children, the type of insurance the child has determines the type of consultation received. Children enrolled in Medicaid are eligible for both telephonic and video consultation.
In Washington, between April 1, 2008 through April 30, 2011, 2,285 calls were received by PAL regarding 1,863 patients. Calls were made by nearly 600 different primary care providers, including 230 who heard about the program from colleagues. Although the program is available for any child regardless of insurance coverage, more than half of the calls were about children with Medicaid coverage. The child and adolescent psychiatrist recommended decreasing medication in eight percent of calls and to stop a medicine in 24 percent of calls.
The PAL program has positively impacted the use of psychotropic medication use among children in Wyoming. From January 2011 until March 2013, there were 229 multidisciplinary team/foster care consults, 125 mandatory medication reviews, and 277 elective phone consultations supporting community providers. As a result, the number of children under age five who were enrolled in Medicaid and who were using psychotropic medication decreased by 42 percent. During this period, phone consultations resulted in the redirection of 60 percent of children identified for a psychiatric residential treatment facility admission to alternative community treatment and placement. These redirections lead to a net savings of more than $1.6 million.
Psychiatric Consultation as a Way to Improve Behavioral Health Care Access
Psychiatric consultation programs increase the capacity of PCPs treating children and youth with serious behavioral health needs. These programs can help PCPs learn about behavioral health treatment and provide a way for states to oversee and address concerning prescribing practices. Psychiatric consultation programs are a valuable and cost-effective tool as states increasingly work toward better monitoring and oversight of psychotropic medications.
Disclaimer: This blog post was produced by CHCS, a partner in the National TA Network for Children’s Behavioral Health, operated by and coordinated through the University of Maryland, under contract with the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Contract #HHSS280201500007C. The views expressed do not necessarily represent the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.