Speaking of Psychology: Integrated care for kids

Combining mental and behavioral health services with pediatric medical care is a natural fit. But there have been relatively few studies on whether or not it actually works. In this episode, we speak with Joan Asarnow, PhD, who led one of the top studies comparing more traditional care with integrated health care models. She talks about why these studies can help expand integrated care to even more patients.

Joan Asarnow is professor of psychiatry and biobehavioral sciences at the UCLA David Geffen School of Medicine and a clinical psychologist. Asarnow’s work focuses on interventions and service delivery strategies for improving health and mental health in youth, with an emphasis on suicide prevention and depression. She has led efforts to disseminate evidence-based treatments for children and adolescents working across multiple settings including emergency departments, primary care, mental health and schools. Asarnow has received grants from the National Institute of Mental Health, Centers for Disease Control and Prevention, Agency for Healthcare Research and Quality, American Foundation for Suicide Prevention, and MacArthur Foundation. At the UCLA Semel Institute for Neuroscience and Human Behavior, Asarnow directs the Youth Stress and Mood Program, a depression and suicide prevention program.

Audrey Hamilton: Thanks to President Obama’s Affordable Care Act, integrated care has become a major priority within the health care industry. But what is integrated care? How does it affect children, families and older adults? And what are patient-centered medical homes? In this episode, we break down the ins and outs of integrated care with a psychologist who is a leading researcher on integrated care. I’m Audrey Hamilton and this is “Speaking of Psychology.”

Joan Asarnow is director of the Youth Stress and Mood Program and a professor of psychiatry and biobehavioral sciences at UCLA. Her research focuses on strategies for improving health and mental health in youth with an emphasis on suicide prevention and depression. She was also on the American Psychological Association’s task force on patient-centered medical homes. Welcome, Dr. Asarnow.   

Joan Asarnow: Thank you. I’m delighted to be here.

Audrey Hamilton : Your primary area of research focuses on mental health care and prevention for children and teenagers. You’ve also been publishing research on the effect collaborative care settings have on these children. Can you talk about that?

Joan Asarnow: I would be happy to. You know, in the United States we can obtain outstanding medical care and we can obtain outstanding care for behavioral health problems, a broad term that we use to refer to mental health and substance abuse problems and health-risk behaviors. We can get the best mental health and substance abuse care in the world in the United States. But, where we have the problems is in getting that care to people.

From the perspective of kids and mental health, we have some really major problems. First of all, there are very high rates of mental health problems among our kids. Estimates for adolescents indicate that 40 percent of our adolescents suffer from mental health or substance abuse disorders within any year, and in younger kids, it’s one out of eight kids who are estimated to suffer from mental health disorders during a year. This translates to about 16 million children in the United States who suffer from mental health or substance abuse problems.

The second really alarming fact is that over half of those kids with a documented need for mental health care receive no services for those problems. And this unmet need is associated with lack of insurance and minority status and when treated, members of racial and ethnic minority groups and poor children also tend to receive poorer quality of care compared to non-minorities. And this contributes to disparities in care and health outcomes.

We had a study that came out in JAMA Pediatrics in August 2015 that was designed to ask the question “if you put care for behavioral health problems into primary care services, does that lead to improved behavioral health for our kids as compared to usual primary care services?” 

And we did this study because this is a time of dramatic changes for our health care environment and in a time like this it’s really very critical for us as psychologists to look at our scientific base and look at how our science can inform these changes so that we can do our very best to make sure that these changes, which are occurring, can lead to real improvements in the health of our kids.

As you know, there’s recent legislation that’s affected health care, and it’s also affected behavioral health care. The Affordable Care Act aims to achieve a healthier population and improve access to care. Also improve quality of care and the patient experience of care, while reducing costs. And a major part of this is that mental health and substance use services are included as essential health benefits, which means that they must be included in part of a comprehensive package and insurance packages. We have one other piece of legislation that’s had a big impact on behavioral health, and that’s the mental health and addiction parity legislation that was passed in 2008. And that provides increased access to insurance for behavioral health problems.

So one approach to improving access to high quality behavioral health care is to bring that behavioral health care into the settings where kids are already receiving care. And that’s really been one of the things that’s motivated efforts to integrate care for mental health and substance use problems within our primary care settings.

Audrey Hamilton : Right. Do you think that primary care providers are equipped as it is to recognize mental health problems, especially in children, such as depression, anxiety? What can be done better in your view?

Joan Asarnow: Well, I think that that’s what this study was designed to do. First of all, I think we can train and provide resources. We have data that shows this – to help primary care providers to screen behavioral health problems and to help kids to get the care that they need. But there have been a number of studies – in fact, we found 31 of them involving over 13,000 kids where they use different approaches to support primary care in providing care for behavioral health problems.

And the real benefit of this is it brings care to the place where kids are. And that reduces barriers to behavioral health care, like stigma. Kids don’t want to admit often times that they’re suffering from depression or other mental health problems. And there are just practical complications involved in shifting from one doctor to another or one clinic to another and often we see that kids and families aren’t able to follow up with a recommendation to see a specialty mental health provider in a different office.

Audrey Hamilton : Right, so if they’re there the access to care is much easier for everyone involved – the physician, the parent, the child.

Joan Asarnow: Yeah. And in our study, which was a meta-analysis, which means that we looked at results across multiple different studies. This is an approach that’s used increasingly in evidence-based medicine in order to help with clinical decision making so that we know what works and then doctors and other providers are able to match kids to the kinds of treatments that they’re most likely to benefit from.

And in our study where we looked at integrated care programs – and they were really a very diverse range of integrated care programs – what was very exciting is that we found that when you made behavioral health care available through primary care we had a statistically significant benefit for kids’ behavioral health as compared to usual primary care. And that’s a big deal because we looked across multiple different kinds of behavioral health problems and many different kinds of approaches to integrating care.

So the probability was actually 66 percent that a randomly selected child would have a better outcome after receiving integrated care than a randomly selected child after receiving usual care. 

Audrey Hamilton : I want to switch gears a little bit onto when we talked about the Affordable Care Act, the ACA. It’s expanding the use of what are called “patient-centered medical homes” and you participated. You mentioned this in a task force that evaluated research on the role that psychologists play in such places. Can you explain? Because I don’t think a lot of our listeners may know what a patient-centered medical home is. And then can you talk about what you found?

Joan Asarnow: That’s a fabulous question. You know, when I first heard the term “patient-centered medical home” I had this vision of this really comfortable house with comfortable chairs and we were all sitting around a table with a cup of tea and I was talking to my doctor and he was helping me feel better and all was good.

Well, it could be like that. But really the idea of a health home or a patient-centered medical home isn’t a place – it’s not like we’re referring to a place. It’s a philosophy or a model for achieving primary care excellence that’s designed to provide people with care at the right time and the right place and in a way that best meets their needs.

There are five major components of the patient-centered medical home as defined by the Agency for Healthcare Research and Quality. So the first is that the PCMH, I’ll call it PCMH (patient centered medical home) – OK, the PCMH is supposed to be comprehensive. That means it includes both medical care and care for mental health and substance use problems.

Secondly, surprise, surprise, it refers to the need to be patient centered. So that means an active partnership between patients and their doctors and other clinicians that really focuses on things that patients care about and value and really conveys respect for patients and families.

The third is coordination and that means that different doctors and different clinicians talk to each other. So, if I break my toe and I go for an X-ray and I go see somebody to help me with my toe, not only will the person I saw for the toe and the X-ray know about it, but my primary care doctor will know about it, too, so that he could also check on me – he or she could also check on me if they need to.

The fourth component is accessibility – the idea that you can actually get an appointment. Then an appointment is available. And additionally, within the PCMH, approaches are used other than appointments – like telephone coaching or telephone outreach to help get patients the care that they need.

And the fifth (and a very important component) is that care be safe and of high quality. That’s really critical because as we’ve learned, one of the most important things I think in improving care is to closely monitor patients and to see how they’re doing so that if they’re not doing well you can adjust treatment and make sure that their needs are met and if they’re doing well, you can be really happy about it and help them to continue doing what’s working. The other part of that is that health care organizations are encouraged to really engage in quality improvement projects.

Audrey Hamilton : Well, great. Well thank you Dr. Asarnow for speaking with us today.

Joan Asarnow: My pleasure.

Audrey Hamilton : For more information and to see Dr. Asarnow’s work, please go to our website . With the American Psychological Association’s “Speaking of Psychology,” I’m Audrey Hamilton.