Using human-centered design to develop and implement a pediatric mental health care access program.

In 2019, the University of California at San Francisco (UCSF) launched the Child and Adolescent Psychiatry Portal (CAPP), a pediatric mental health care access (PMHCA) program providing remote mental health consultation services to pediatric primary care providers (PCPs) throughout Northern and Central California. The development and implementation of CAPP was guided by Human-Centered Design (HCD), an iterative, rapid-paced innovation process focusing on stakeholders' needs and experiences, which shaped the development of CAPP's programs. The resulting key programmatic elements are designed for pediatric workforce development: (1) PCP consultation with a child and adolescent psychiatrist via a telephone warmline; and (2) training and education for providers. CAPP has grown rapidly since its launch, having enrolled 1,714 providers from 257 practices spread across 36 counties and provided 3,288 consults on 2,703 unique lives as of August 2023. Preliminary evaluation findings indicate high PCP satisfaction with CAPP's services, despite continued challenges of integrating behavioral health into primary care. Throughout the HCD and implementation process, multidisciplinary partnerships have proven critical in providing end-user input to inform and improve program design. This growing network of partnerships, developed through the cultivation of personal relationships and trust over time, has also proven essential for CAPP's rapid growth and sustainability. Overall, this Community Case Study highlights the critical role of partnerships and the importance of taking a people-centered approach, as captured in CAPP's motto, "Connecting for Care."

Systematic Review: Child Psychiatry Access Program Outcomes.

Objective: There has been an increase in Child Psychiatry Access Programs (CPAP) across the United States to address the national child and adolescent psychiatry workforce shortage by supporting pediatric primary care providers (PCPs) in providing mental health services. The objective of this systematic review is to synthesize the expanding literature on CPAPs. Method: A systematic literature search was conducted in PubMed, PsycInfo, Embase, and Web of Science databases to identify articles published from database inception to April 6, 2022, to identify CPAPs, defined as programs with mental health specialists providing rapid remote mental health consultation services to pediatric PCPs. Study outcomes included program adoption, provider experience, patient and caregiver experience, program cost, and patient mental health. Results: None of the 33 included studies were randomized controlled trials. Most of the studies (n = 30) focused on program adoption and provider experience (n = 18). Few studies examined patient and caregiver experience (n = 2), program cost(n = 4), or patient mental health (n = 4) outcomes. CPAPs showed year-over-year growth in adoption and were generally well-received by providers and caregivers. Health care provision costs were quite varied. No articles reported on changes in patient mental health according to validated measures. Heterogeneity in the methodological quality, study design, and outcomes used to evaluate CPAPs hindered comparison among programs. Conclusion: Rigorous research on the impact of CPAPs is lacking. Findings show high provider satisfaction with CPAPs, yet few studies examine patient-level mental health outcomes. CPAPs and funding agencies should consider prioritizing and investing in research to build the evidence base for CPAPs. Diversity & Inclusion Statement: One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote inclusion of historically underrepresented racial and/or ethnic groups in science in our author group. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented sexual and/or gender groups in science. Clinical trial registration information: Child Psychiatry Access Programs: A Systematic Review; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020146410; CRD42020146410.

Pediatric Primary Care Perspectives of Mental Health Services Delivery during the COVID-19 Pandemic.

Due to a national shortage of child and adolescent psychiatrists, pediatric primary care providers (PCPs) are often responsible for the screening, evaluation, and treatment of mental health disorders. COVID-19 pandemic stay-at-home orders decreased access to mental health care and increased behavioral and emotional difficulties in children and adolescents. Despite increased demand upon clinicians, little is known about mental health care delivery in the pediatric primary care setting during the pandemic. This focus group study explored the experiences of pediatric PCPs and clinical staff delivering mental health care during the pandemic. Transcripts from nine focus groups with San Francisco Bay Area primary care practices between April and August 2020 were analyzed using a thematic analysis approach. Providers expressed challenges at the patient-, provider-, and system-levels. Many providers reported increased patient mental health symptomatology during the pandemic, which was often intertwined with patients' social determinants of health. Clinicians discussed the burden of the pandemic their own wellness, and how the rapid shift to telehealth primary care and mental health services seemed to hinder the availability and effectiveness of many resources. The findings from this study can inform the creation of new supports for PCPs and clinical staff providing mental health care.

MRI Insights Into Adolescent Neurocircuitry-A Vision for the Future.

Adolescence is the time of onset of many psychiatric disorders. Half of pediatric patients present with comorbid psychiatric disorders that complicate both their medical and psychiatric care. Currently, diagnosis and treatment decisions are based on symptoms. The field urgently needs brain-based diagnosis and personalized care. Neuroimaging can shed light on how aberrations in brain circuits might underlie psychiatric disorders and their development in adolescents. In this perspective article, we summarize recent MRI literature that provides insights into development of psychiatric disorders in adolescents. We specifically focus on studies of brain structural and functional connectivity. Ninety-six included studies demonstrate the potential of MRI to assess psychiatrically relevant constructs, diagnose psychiatric disorders, predict their development or predict response to treatment. Limitations of the included studies are discussed, and recommendations for future research are offered. We also present a vision for the role that neuroimaging may play in pediatrics and primary care in the future: a routine neuropsychological and neuropsychiatric imaging (NPPI) protocol for adolescent patients, which would include a 30-min brain scan, a quality control and safety read of the scan, followed by computer-based calculation of the structural and functional brain network metrics that can be compared to the normative data by the pediatrician. We also perform a cost-benefit analysis to support this vision and provide a roadmap of the steps required for this vision to be implemented.

Key Components of Effective Pediatric Integrated Mental Health Care Models: A Systematic Review.

Importance: Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined. Objective: To identify and describe the key components of effective pediatric integrated mental health care models. Evidence Review: The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019. Findings: Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment. Conclusions and Relevance: This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.

Cost impact of sobering centers on national health care spending in the United States.

Acute alcohol intoxication is responsible for a sizable share of emergency department visits. Intoxicated individuals without other medical needs may not require the high level of care provided by an emergency department. We estimate the impact on U.S. health care spending if individuals with uncomplicated, acute alcohol intoxication were treated in sobering centers instead of the emergency department. We performed a budget impact analysis from the perspective of the U.S. health care system based on published and gray literature reports. Ninety-five percent confidence intervals (CI) were estimated using Monte Carlo modeling with random variation for three variables (cost of an emergency department visit, cost of a sobering center visit, and start-up costs per sobering center visit) and the percentage of cases diverted from emergency departments to sobering centers. Outcomes were expressed in terms of national savings in 2017 U.S. dollars. Assuming a diversion rate of 50% based on previous studies, national savings range from $230 million to $1.0 billion annually. In the Monte Carlo modeling, we found annual national savings of $99.02 million (95% CI: $95.89-$102.19 million), $792.34 million (95% CI: $767.09-$817.58 million), and $1,185.51 million (95% CI: $1,150.64-$1,226.37 million) with diversion rates of 5%, 40%, and 60%, respectively. Implementing sobering centers as a treatment alternative for individuals with uncomplicated acute alcohol intoxication could yield substantial cost savings for the U.S. health care system.

The role of economic analyses in promoting adoption of behavioral and psychosocial interventions in clinical settings.

In this report, we offer three examples of how economic data could promote greater adoption of behavioral and psychosocial interventions in clinical settings where primary or specialty medical care is delivered to patients. The examples are collaborative care for depression, chronic pain management, and cognitive-behavioral therapy for insomnia. These interventions illustrate differences in the availability of cost and cost-effectiveness data and in the extent of intervention adoption and integration into routine delivery of medical care. Collaborative care has been widely studied from an economic perspective, with most studies demonstrating its relative cost-effectiveness per quality-adjusted life year (QALY) and some studies demonstrating its potential for cost neutrality or cost savings. The success of collaborative care for depression can be viewed as a model for how to promote greater adoption of other interventions, such as psychological therapies for chronic pain and insomnia. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Economic Benefit of "Modern" Nonemergency Medical Transportation That Utilizes Digital Transportation Networks.

OBJECTIVES: To determine the economic benefit of "modern" nonemergency medical transportation (NEMT) that utilizes digital transportation networks compared with traditional NEMT in the United States. METHODS: We used the National Academies' NEMT cost-effectiveness model to perform a baseline cost savings analysis for provision of NEMT for transportation-disadvantaged Medicaid beneficiaries. On the basis of a review of the literature, commercial information, and structured expert interviews, we performed a sensitivity analysis to determine the incremental economic benefit of using modern NEMT. We estimated confidence intervals (CIs) by using Monte Carlo simulation. RESULTS: Total annual net savings for traditional NEMT in Medicaid was approximately $4 billion. For modern NEMT, estimated savings on ride costs varied from 30% to 70%. In comparison with traditional, modern NEMT was estimated to save $268 per expected user (95% CI = $248, $288 per member per year) and $537 million annually (95% CI = $496 million, $577 million) when scaled nationally. CONCLUSIONS: Modern NEMT has the potential to yield greater cost savings than traditional NEMT while also improving patient experience. Public Health Implications: Barriers to NEMT are a health risk affecting high-need, economically disadvantaged patients. Economic arguments supporting modern NEMT are important given decreased support for human services spending.

Childhood Adversities Associated with Poor Adult Mental Health Outcomes in Older Homeless Adults: Results From the HOPE HOME Study.

OBJECTIVE: To examine whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization. METHODS: History of seven childhood adversities (physical neglect, verbal abuse, physical abuse, sexual abuse, parental death, parental incarceration, and child welfare system placement) was gathered through in-person interviews. Multivariate models examined associations between history of childhood adversities and moderate to severe depressive symptoms, lifetime history of suicide attempt, or lifetime history of psychiatric hospitalization. The study enrolled 350 homeless adults, aged 50 and older, in Oakland, California, using population-based sampling methods. Moderate to severe depressive symptoms were measured on a Center for Epidemiologic Studies-Depression Scale (≥22), self-reported lifetime history of suicide attempt, and self-reported lifetime history of psychiatric hospitalization. RESULTS: Participants with exposure to one childhood adversity had elevated odds of reporting moderate to severe depressive symptoms (adjusted odds ratio [AOR]: 2.0; 95% confidence interval [CI]: 1.1-3.7) and lifetime history of suicide attempt (AOR: 4.6; 95% CI: 1.0-21.6) when compared with those who had none; the odds of these two outcomes increased with exposure to additional childhood adversities. Participants with four or more childhood adversities had higher odds of having a lifetime history of psychiatric hospitalization (AOR: 7.1; 95% CI: 2.8-18.0); no increase with fewer adversities was found. CONCLUSION: Childhood adversities are associated with poor mental health outcomes among older homeless adults. Clinicians should collect information about childhood adversities among this high-risk population to inform risk assessment and treatment recommendations.