Integrating Behavioral Health into Pediatric Primary Care: Implications for Provider Time and Cost.

OBJECTIVES: Integrating a behavioral health consultant (BHC) into primary care is associated with improved patient outcomes, fewer medical visits, and increased provider satisfaction; however, few studies have evaluated the feasibility of this model from an operations perspective. Specifically, time and cost have been identified as barriers to implementation. Our study aimed to examine time spent, patient volume, and revenue generated during days when the on-site BHC was available compared with days when the consultant was not. METHODS: Data were collected across a 10-day period when a BHC provided services and 10 days when she was not available. Data included time stamps of patient direct care; providers' direct reports of problems raised; and a review of medical and administrative records, including billing codes and reimbursement. This study took place in a rural, stand-alone private pediatric primary care practice. The participants were five pediatric primary care providers (PCPs; two doctors of medicine, 1 doctor of osteopathy, 2 nurse practitioners) and two supervised doctoral students in psychology (BHCs). Pediatric patients (N = 668) and their parents also participated. RESULTS: On days when a BHC was present, medical providers spent 2 fewer minutes on average for every patient seen, saw 42% more patients, and collected $1142 more revenue than on days when no consultant was present. CONCLUSIONS: The time savings demonstrated on days when the consultant was available point to the efficiency and potential financial viability of this model. These results have important implications for the feasibility of hiring behavioral health professionals in a fee-for-service system. They have equally useful implications for the utility of moving to a bundled system of care in which collaborative practice is valued.

Cumulative Sociodemographic Risk Indicators for Difficult Child Temperament.

Cumulative risk models provide a convenient, parsimonious way to identify outcomes associated with multiple, highly correlated risk factors. In this paper, we explored linkages between a cumulative sociodemographic risk index, which included rurality status, and aspects of temperamental difficulty in an early school age sample of 53 school-aged children from Southcentral Appalachia. Cumulative risk was significantly predictive of temperamental difficulty, as defined by high negative affectivity and low effortful control, but post-hoc analyses revealed this association to be driven primarily by two of the eight risk indicators: rural status and income-to-needs risk. Although rurality status was highly correlated with income-to-needs risk, rurality predicted negative affectivity over and above income-to-needs risk and income-to-needs risk predicted effortful control over and above rurality status. Future models of cumulative risk may benefit from including rurality status as a risk indicator, despite high collinearity with income-to-needs risk.