Linking Primary Care to Community-Based Mental Health Resources via Family Navigation and Phone-Based Care Coordination.

Family navigation (FN) and phone-based care coordination may improve linkages from primary care to community-based mental health referrals, but research on their differential impact is limited. This mixed-methods study compared FN and phone-based care coordination in connecting families to mental health services from primary care. Families of children (56.3% male, mean age = 10.4 years, 85.4% Black) were sequentially assigned to either receive FN through a family-run organization or phone-based coordination via the child psychiatry access program (CPAP). Caregiver-reported children's mental health improved in both groups and both groups were satisfied with services. More families in the CPAP group had appointments made or completed (87%) than families in the FN group (71%) though the difference was not statistically significant. Future research with a larger sample that matches family needs and preferences (e.g., level and type of support) with navigation services would be beneficial.

Pediatric advocacy: Advancement in academic institutions.

IMPACT: Children are facing many threats to their health today that require system change at a sweeping level to have real-world impact. Pediatricians are positioned as natural leaders to advocate for these critical community and policy changes. Academic medical center (AMC) leaders recognize the importance of this advocacy and clear steps can be taken to improve the structure to support pediatricians in their advocacy careers through faculty development and promotion, including standardized scholarly measurement of the outcomes.

A Multisystem Approach to Improving Autism Care.

Children with autism face significant barriers to accessing evaluations and intervention services often because of confusing referral processes, lack of centralized coordination across organizations serving children with autism, insurance coverage gaps, multiyear waitlists for diagnostic services, and limited provider knowledge about autism. Racism and systemic inequities exist and persist in autism care across the United States. This article reviews targeted initiatives implemented by a multidisciplinary team to advocate for, and address barriers faced, by autistic children and their families in Washington, DC. We describe initiatives across multiple levels of the health care system including: 1. infrastructure-building initiatives (eg, coalition-building, policy, and advocacy); 2. enabling services (eg, population- and community-level supports that increase provider capacity to serve children's and families' needs); and 3. direct services (eg, innovative, gap-filling programs that directly serve children and families). We review outcomes and describe lessons learned.

DC Mental Health Access in Pediatrics: Evaluating a Child Psychiatry Access Program in Washington, DC.

INTRODUCTION: Child psychiatry access programs (CPAPs) provide primary care providers (PCPs) with assistance in mental health diagnosis, management, and resource navigation. METHOD: Data collected from DC Mental Health Access in Pediatrics (MAP) included PCPs and patient demographics, clinical encounter information, and provider satisfaction. RESULTS: DC MAP consult volume increased 349.3% over the first 5 years. Services requested included care coordination (85.8%), psychiatric consultation (21.4%), and psychology/social work consultation (9.9%). Of psychiatry-involved consultations, PCPs managed patient medication care with DC MAP support 50.5% of the time. Most (94.1%) PCPs said they would recommend colleagues use DC MAP, and 29.6% reported diverting patients from the emergency departments using DC MAP. DISCUSSION: DC MAP grew quickly, highlighting program impact and need. Demand for care coordination required flexible staffing and highlighted the need for coordination in pediatrics. Child psychiatry access programs offer an innovative way to enhance PCP management of their patients' mental health needs.

Making Advocacy Part of Your Job: Working for Children in Any Practice Setting.

Effective child health advocacy is an essential strategy to improve child health, and can improve access to equitable care. It can also be professionally rewarding and improve career satisfaction. However, while advocacy has been a part of pediatrics since its origins as a specialty, many barriers to engaging in health advocacy exist which can be challenging to navigate. There are a wide range of organizational practice settings, which are each accompanied by unique strengths and limitations. No matter the practice setting, pediatricians can be effective advocates for child health through leveraging organizational, professional, and community resources and partnerships.

The Family is the Patient: Promoting Early Childhood Mental Health in Pediatric Care.

Advances in developmental psychology, child psychiatry, and allied disciplines have pointed to events and experiences in the early years as the origin of many adult mental health challenges. Yet, children's mental health services still largely lack a developmental or prevention-focused orientation, with most referrals to mental health professionals occurring late, once problems are well established. An early childhood mental health system rooted in the principles of life-course health development would take a very different approach to designing, testing, and implementing prevention and intervention strategies directed toward early child mental health. Priorities for such a system include supporting healthy family environments, parent-child and family relationships, parents' emotional/behavioral health, and family routines as a means of providing the best possible neurobiological foundation for mental health across the life span. The system would include proactive, trauma-informed, multidisciplinary care, with integrated mental health and social services support embedded in pediatric primary care settings. Novel intervention approaches in need of further research include 2-generational dyadic interventions designed to improve the mental health of parents and children, mental health-oriented telemedicine, and contingency management (CM) strategies. Integral to this Life Course Health Development reformulation is a commitment by all organizations supporting children to primordial and primary prevention strategies to reduce racial and socioeconomic disparities in all settings. We contend that it is the family, not the individual child, that ought to be the identified target of these redesigned approaches, delivered through a transformed pediatric system with anticipated benefits for multiple health outcomes across the life course.

Leveraging E-Learning and Community Assets to "TEACH" Residents to Address Child Poverty.

OBJECTIVE: To evaluate the effectiveness of a multimodal child poverty curriculum for pediatric residents. METHODS: The Trainee Education in Advocacy and Community Health (TEACH) curriculum trains residents to recognize and address the effects of child poverty, utilizing learning objectives modified from the US Child Poverty Curriculum, new interactive web-based modules, experiential learning, and reflection. This mixed-methods evaluation of the first component, "Epidemiology of Child Poverty," includes nearly 2 years of resident participation. Pre/post knowledge and attitudes regarding child poverty were assessed. Behavior change was evaluated in a subset of participants using an Objective Structured Clinical Examination (OSCE), comparing intervention and control groups of residents. Residents' experience with the curriculum was assessed using qualitative analysis of debrief sessions with faculty. RESULTS: Fifty-two residents completed the curriculum between June 2018 and March 2020. Residents increased in knowledge (P < .001) and confidence (P < .0001) in recognizing and addressing poverty. They also self-reported greater preparedness (P < .001) and effectiveness (P < .001) in addressing social determinants of health. Early data from the OSCE have not shown a statistically significant change in skills compared with a control group. Qualitative themes included an increase in empathy for, understanding of, and responsibility to address the effects of poverty in caring for patients. CONCLUSIONS: The multimodal "Epidemiology of Child Poverty" portion of the TEACH curriculum increased resident knowledge, confidence, and empathy. Given the ubiquitous nature of poverty and the generalizability of the online modules, the TEACH curriculum can be a resource for other residency programs.

Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health.

Structural racism-the ways that institutional policies, practices, and other norms operate to create and sustain race-based inequities1-has historically been foundational to the operations of academic medical centers and research institutions. Since its inception, academic medicine has depended on the exploitation of vulnerable communities to achieve medical, educational, and research goals.2 Research practices have long ignored or taken advantage of the individuals purportedly benefiting from the research, a dynamic most manifestly true for Black, Indigenous, and People of Color (BIPOC) communities in the United States. Reflecting current practices in racial justice work, we intentionally use the term "BIPOC" to highlight shared experiences within racially and ethnically minoritized communities, given the history of White supremacy in the United States. We acknowledge limitations of this term, which collapses myriad unique communities and histories into one construct. Specifically, child and adolescent psychiatry has historically been driven by Eurocentric approaches, paradigms, and methodology. These nonparticipatory dominant research practices have contributed to a lack of culturally responsive interventions for BIPOC communities, a paucity of evidence-based practices with demonstrated effectiveness within BIPOC communities, and disparities in access and quality of care.3 Mental health research involving BIPOC communities has been replete with exploitation and inequality.2.

Perinatal Mental Health Task Force: Integrating Care Across a Pediatric Hospital Setting.

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth, with suicide a leading cause of postpartum deaths. PMADs are associated with poor maternal, infant, and family outcomes. Identification and early intervention are imperative for successful treatment. This case study describes the implementation and outcomes of a multidisciplinary Perinatal Mental Health Task Force ("Task Force") at one urban academic children's hospital that was created to promote systems change and health care policy solutions for improved identification and treatment of PMADs. Using the social ecological model as a framework, the Task Force addressed care at the individual, interpersonal, organizational, community, and policy levels. The Task Force applied lessons learned from division-specific screening initiatives to create best practices and make hospital-wide recommendations. This foundational work enabled us to build community bridges and break down internal barriers to shift our pediatric hospital toward prioritizing perinatal mental health. As a result, screening expanded to multiple hospital locations and became a hospital corporate goal, the Perinatal Mental Health Screening Tool Kit was created and disseminated within the community, Task Force members testified in governmental hearings and joined national organizations to inform policy, and Task Force and community collaborations resulted in significant grant funding. Lessons learned have been disseminated nationally. Moving forward, we aim to expand our program and partnerships to ensure that caregivers of infants receive appropriate mental health support to strengthen family well-being. The Task Force can serve as a model for advocates looking to expand and integrate PMAD care.

Pediatric Provider Experiences with Implementation of Routine Mental Health Screening.

OBJECTIVE: Despite the utility of universal screening, most pediatric providers rarely use mental health (MH) screening tools. As such, provider descriptions of their experiences with universal screening are limited. The goal of this study was to describe barriers to, and facilitators of, universal MH screening implementation, the perceived impact of such screening, impressions of a screening-focused quality improvement (QI) Learning Collaborative, and lessons learned. METHOD: We invited primary care clinicians participating in a large-scale QI Learning Collaborative on MH screening (n = 107) to complete postproject interviews. Interviews were transcribed and analyzed using constant comparative qualitative analysis, an inductive, iterative process. RESULTS: Eleven interviews were completed and analyzed. Practice sites included academic health centers, a private practice, and a federally qualified health center. Providers described the positive impact of screening (increased identification of MH concerns) and barriers and facilitators of screening at the practice level (clinic and leadership buy-in and electronic medical record integration), the provider level (provider beliefs about the importance of screening), and the patient level (parent literacy). Challenges of linking families with care after screening included lack of adequate referrals, long wait lists, limited bilingual providers, insurance gaps, and inadequate feedback loops. Access to on-site MH clinicians and participation in the Learning Collaborative were described as beneficial. CONCLUSION: Findings elucidate how universal MH screening can be sustainably integrated into real-world primary care settings and may facilitate the uptake of American Academy of Pediatrics recommendations for best practices in screening for MH concerns.

Interactive Case-Based Childhood Adversity and Trauma-Informed Care Electronic Modules for Pediatric Primary Care.

Introduction: Training health professionals for the skills and capacity to respond adequately to children and adults who have been exposed to adverse childhood experiences is recognized as an essential need in health care. Accessible opportunities to educate physicians and physician-trainees are limited. Methods: Four computer-based e-modules were created focusing on addressing childhood adversity and implementing trauma-informed care in the pediatric primary care setting. These childhood adversity and trauma-informed care (CA-TIC) e-modules were designed as an individualized, self-directed experience to allow for distance learning with flexibility to be embedded into existing coursework. To foster an engaging learning environment, we narrated the modules, prioritized images, and included the opportunity for participant interaction via multiple-choice and short-answer questions. Twenty-eight pediatric residents, two medical students, four attending physicians, and one fellow at Children's National Hospital completed the e-modules. Results: Overall, participants rated the CA-TIC e-modules 4.6 (SD = 0.5) out of 5 for design and quality. Using paired t tests and Wilcoxon signed rank tests, we found statistically significant score increases from presession to postsession for participants' knowledge, attitudes, practice, and confidence related to CA-TIC. The most commonly cited learning points and practice changes included asking about trauma in practice and the seven C's of resilience. Discussion: A trauma-informed, strengths-based approach to care can assist health care providers in mitigating the link between adversity and related poor health outcomes. The CA-TIC e-modules provide an opportunity to train health professionals using an innovative, self-directed, and low-resource mechanism.

Teaching Trauma-Informed Care: A Symposium for Medical Students.

Introduction: A large body of evidence links exposure to childhood trauma with negative health outcomes. Training future physicians to recognize and respond to trauma is paramount, and engaging medical students in the preclinical years affords the opportunity to foster the development of a trauma-informed lens that can then be solidified during clinical clerkships. Methods: We developed and implemented a 4-hour trauma-informed care (TIC) symposium for 179 second-year medical students at the George Washington University School of Medicine and Health Sciences during the Patients, Populations, and Systems course. The symposium included three interactive didactic sessions focusing on the connection between trauma and health and TIC principles. A facilitated small-group discussion allowed students to apply TIC principles to a patient case, followed by reflection and evaluation. Results: The overall rating of the TIC symposium was 4 out of 5. Strengths included integration of a small-group case with discussion on application of TIC in practice, experience of the lecturers and small-group facilitators, and review of research relating adversity to specific health outcomes. Suggestions for improvement included incorporating role-play and standardized patients. Content analysis of student reflections mapped to the domains of physician competency. Discussion: A 4-hour symposium can affect student knowledge and understanding of TIC. Teaching TIC presents an opportunity to prepare medical students for a career in medicine through cultivation of required physician competencies. Next steps include enhanced opportunities to practice TIC and follow-up analysis of participants to determine behavior change during clinical years.

Increasing Mental Health Engagement From Primary Care: The Potential Role of Family Navigation.

Early engagement in mental health intervention is critical, yet the vast majority of children who are experiencing mental health concerns are not receiving needed services. Pediatric primary care clinics have been recognized as an ideal setting in which to identify and address mental health problems early, although engagement in mental health services within primary care and in community-based settings remains low. Navigators, or individuals with experience in navigating the mental health system, have been highlighted as promising partners in efforts to improve engagement in mental health services. Navigation has a growing body of research support among adults and in targeting medical concerns, but there has been limited research on integrating family navigators into pediatric primary care settings to address mental health concerns. Despite this gap in the evidence base, we believe there is significant promise for the use of this model in addressing children's mental health needs. In this report, we discuss factors contributing to high levels of unmet mental health needs and low levels of engagement in mental health services, the role that navigators can play in increasing engagement in mental health care, and implications and recommendations related to integrating mental health-focused family navigators into pediatric primary care settings.

A Primary Care Intervention to Prevent Repeat Pregnancy Among Teen Mothers.

INTRODUCTION: The purpose of this study is to determine the effectiveness of a patient-centered medical home intervention for teen parent families in reducing rates of unintended repeat pregnancy in the first 2 years postpartum. METHODS: A prospective quasi-experimental evaluation was conducted with 98 African American, low-income, teen mother (aged <20 years) participants who received either the intervention or standard pediatric primary care. All participants completed structured interviews at baseline (child aged 2 months) and at follow-ups 12 and 24 months later. Data were collected from 2011 to 2015. Participants reported number of pregnancies, contraception used at last intercourse, depressive symptoms, and romantic status of the relationship with the baby's father. Analyses were conducted from 2015 to 2017. RESULTS: Logistic regression showed that mothers in the intervention group were half as likely as mothers who received standard pediatric primary care to have a repeat pregnancy within 2 years (OR=0.55, p=0.16). The main effect of the intervention on lower rates of repeat pregnancy was mediated by higher rates of contraceptive use. Depression was associated with higher odds of repeat pregnancy, but did not appear to mediate the intervention effect. CONCLUSIONS: This comprehensive and integrated model of care for teen parents may be an effective method to prevent rapid repeat pregnancies in this vulnerable population.

The Advocacy Portfolio: A Standardized Tool for Documenting Physician Advocacy.

Recent changes in health care delivery systems and in medical training have primed academia for a paradigm shift, with strengthened support for an expanded definition of scholarship. Physicians who consider advocacy to be relevant to their scholarly endeavors need a standardized format to display activities and measure the value of health outcomes to which their work can be attributed. Similar to the Educator Portfolio, the authors here propose the Advocacy Portfolio (AP) to document a scholarly approach to advocacy.Despite common challenges faced in the arguments for both education and advocacy to be viewed as scholarship, the authors highlight inherent differences between the two fields. On the basis of prior literature, the authors propose a broad yet comprehensive set of domains to categorize advocacy activities, including advocacy engagement, knowledge dissemination, community outreach, advocacy teaching/mentoring, and advocacy leadership/administration. Documenting quality, quantity, and a scholarly approach to advocacy within each domain is the first of many steps to establish congruence between advocacy and scholarship for physicians using the AP format.This standardized format can be applied in a variety of settings, from medical training to academic promotion. Such documentation will encourage institutional buy-in by aligning measured outcomes with institutional missions. The AP will also provide physician-advocates with a method to display the impact of advocacy projects on health outcomes for patients and populations. Future challenges to broad application include establishing institutional support and developing consensus regarding criteria by which to evaluate the contributions of advocacy activities to scholarship.

Mental Health Screening Quality Improvement Learning Collaborative in Pediatric Primary Care.

BACKGROUND: In the United States, up to 20% of children experience a mental health (MH) disorder in a given year, many of whom remain untreated. Routine screening during annual well visits is 1 strategy providers can use to identify concerns early and facilitate appropriate intervention. However, many barriers exist to the effective implementation of such screening. METHODS: A 15-month quality improvement learning collaborative was designed and implemented to improve screening practices in primary care. Participating practices completed a survey at 3 time points to assess preparedness and ability to promote and support MH issues. Monthly chart reviews were performed to assess the rates of screening at well visits, documentation of screening results, and appropriate coding practices. RESULTS: Ten practices (including 107 providers) were active participants for the duration of the project. Screening rates increased from 1% at baseline to 74% by the end of the project. For the 1 practice for which more comprehensive data were available, these screening rates were sustained over time. Documentation of results and appropriate billing for reimbursement mirrored the improvement seen in screening rates. CONCLUSIONS: The learning collaborative model can improve MH screening practices in pediatric primary care, an important first step toward early identification of children with concerns. More information is needed about the burden placed on practices and providers to implement these changes. Future research will be needed to determine if improved identification leads to improved access to care and outcomes.