Acad Psychiatry DOI 10.1007/s40596-014-0174-z
IN DEPTH ARTICLE: COMMENTARY
From School Health to Integrated Health: Expanding Our Children’s Public Mental Health System Steven Adelsheim
Received: 23 May 2014 / Accepted: 27 May 2014 # Academic Psychiatry 2014
Abstract There is a substantial unmet need for mental health and substance abuse services in the USA. In 2009, the Institute of Medicine recommended increased early identification and intervention for young people with mental, emotional, and behavioral disorders. With the expansion of integrated models in primary care settings, we now have the chance to improve outcomes for young people with mental health conditions, just as we have by improving the early identification and treatment of other preventable and/or treatable conditions such as obesity, asthma, or HIV. This is a moment of great opportunity to fundamentally change how young people access mental health care in our country. Through strategic integration of care, we can increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; we can identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; and we can purposefully embed integration into provider training programs for both primary care and mental health providers to ensure sustainability. Keywords Systems . Mental health integration . Health disparities In the school-based health center (SBHC), we all noticed that it was usually by the third primary care visit that students would start to raise any underlying mental health issues. Those initial visits with the nurse practitioner, pediatrician, or family practice resident for a headache, stomachache, or sports physical would provide a certain comfort in a nonstigmatizing environment for the student and his or her
S. Adelsheim (*) Stanford University School of Medicine, Stanford, CA, USA e-mail: [email protected]
provider to start a conversation about mental health. Because we had one common waiting area, students generally did not know why the others were there, but they could see which provider took each person into an exam room. For many of the students, it seemed easier somehow to have that person be a primary care provider (PCP), but we all knew that many would need mental health care. We integrated a health screen for the PCP to use with several mental health questions. Positive responses led to a specific mental health screen. If that screen revealed positive indicators, it was time for a shared visit with the PCP and the mental health specialist or at least a warm handoff between the two. I came to school mental health work as a trainee. I began as a first-year child psychiatry fellow on a school consult rotation with a student assistance team at an elementary school. In my second year, I was able to have weekly clinical time in a high school SBHC. My primary on-site supervisor at the SBHC was the director of the family and community medicine training program, who would sometimes pull me into the room to jointly interview students who were having suicidal thoughts or possible hallucinations. Most of the primary care residents on site from family medicine or pediatrics had not been trained how to ask questions about suicide or homicide risk or paranoia or auditory/visual hallucinations. I realized while at the SBHC that my time was best spent seeing patients with PCPs and that if I spent time one-on-one with students, I would only be able to serve a few young people. The individual-care model lacked potential for on-site capacity building for the PCPs and did not feel sustainable beyond my personal involvement. Over time, I saw that seeing students with primary care colleagues optimized access to care, increased continuity, and improved provider skills for both primary care and mental health providers. Over time, the PCPs, both the residents and faculty, began to feel more comfortable asking critical mental health-related questions and expressed gratitude for the shared experience. There had not been any other setting where the
Acad Psychiatry
opportunity arose for PCPs to learn how to interact with adolescents around mental health questions in the same way [1]. For me, I had learned the value and practical application of working with an integrated team and seen how significantly the stigma of seeking out mental health care reduced access. As our nation shifts to a model of integrating mental health supports into primary care, these lessons I learned in SBHCs seem to take on additional importance. We have significant work to do to successfully integrate care in this country. We know that there is substantial unmet need for mental health and substance abuse services in the USA. In fact, while one in every five people reports having experienced a mental illness within the past year, most will not receive care [2]. This lack of access starts with young people. Half of all mental health conditions have their onset before age 14, and 75 % by age 24 [3]. Early symptom development is itself a risk factor for increasing the time an individual takes to access mental health services [4]. In 2009, the Institute of Medicine recommended increased early identification and intervention for young people with mental, emotional, and behavioral disorders. With the expansion of integrated models in primary care settings, we now have the chance to improve outcomes for young people with mental health conditions, just as we have by improving the early identification and treatment of other preventable and/ or treatable conditions such as obesity, asthma, or HIV. This is a moment of great opportunity to fundamentally change how young people access mental health care in our country. Through strategic integration of care, we can (1) increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; we can (2) identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; and we can (3) purposefully embed integration into provider training programs for both primary care and mental health providers to ensure sustainability.
Increasing Access Any effort to increase access will need to have a populationbased public health approach. Until now, there have been many barriers to shifting the current system of mental health care in this direction. Public health and primary care systems have generally not seen support for mental health issues as part of their primary role. Until recently, reimbursement models have not led to sufficient payment for screening or treatment of mental health problems in primary care settings. Schools have been increasingly focused on meeting educational testing requirements and, as a result, have had less educational and financial resources available for ensuring that children with mental health issues are recognized and treated early. Ironically, research indicates that SBHCs might lead to
improved test scores [5]. Children’s state mental health systems have generally focused scarce resources on those in state custody through foster care or juvenile justice systems as well as those children with serious emotional disorders. Few, if any, state public health systems or agencies focus specifically on increasing mental health awareness, screening, preventive intervention, and/or early treatment for young people. Although our national mental health policy statements have increasingly promoted a movement toward a public health framework for mental health care, we are just now putting the components in place to make this vision a reality. With new policies and changes in insurance comes a potential shift in the structure of reimbursement from a fee-forservice to a covered-lives model. This shift has the potential to support an integrated public mental health system. Cost savings through prevention, early identification, and treatment become essential to a covered-lives health care business plan. As such, there is increasing emphasis on and support for integrated care models [6]. The nationally recognized Four Quadrant Clinical Integration Model ensures both mental health and primary care access from any entrance into the health care system [7]. This whole person approach understands that each individual will have physical and behavioral health needs to varying degrees and lays the foundation for the development of systems that can extend services to those with differing needs in a systematic manner.
Early Identification and Treatment A move toward expansion of integrated care models opens up the potential to build this sorely needed public mental health system for young people. And yet, to optimize care, we will need to build in strategies to identify those individuals who need services as early as possible and then link them directly to the services they need. Many of the necessary components of an early screening and intervention model have been developed as parts of various separate programs, and the time has come to bring them together into a cohesive integrated care framework. Early screening for young people for mental health conditions is a critical aspect of any integrated care model. Back in 2003, the President’s New Freedom Commission on Mental Health recommended screening in multiple settings for mental health conditions in young people, including primary care and school settings [8]. Programs such as Columbia’s TeenScreen, focusing on depression and suicide, targeted screening in schools and primary care clinics. The US Preventive Task Force recommended screening for depression in primary care settings for adolescents when access to appropriate diagnosis, psychotherapy, and followup was available. An effective framework would broaden screenings to include identifying young people who are at risk for multiple mental health conditions. As integrated care
Acad Psychiatry
models create co-located and coordinated care services, immediate follow-up by a mental health provider becomes available when a PCP has concerns or after a positive screen. Until these systems are more firmly established in primary care settings for young people, the ongoing shortage of child mental health providers may require systems to provide a more targeted screening approach. Focused and gated screening for high-risk individuals, rather than broad clinic-wide screening, may make sense for now to ensure a provider is available to evaluate each young person with a positive screen. As children are screened, systems need to be in place to link those needing support for mental health conditions to appropriate interventions. In primary care settings, such support could come through models such as the Massachusetts Child Psychiatry Access Project (MCPAP) (www.mcpap.org), which provides immediate mental health backup and support for PCPs identifying and treating young people with mental health issues in their practice [9]. This model ensures rapid consultation for primary care with a mental health team including a case manager, master’s trained provider, and child psychiatrist. The MCPAP model has now expanded to over 27 states in an effort to build access to mental health care while expanding the capacity of PCPs to manage young people with mental health needs in their own practices (www.nncpap.org). In rural and remote areas, a telehealth consultation model, like those being implemented in New Mexico and through the Indian Health Service, could also be effective in a similar structure to MCPAP (https://sites.google. com/site/ihstbhce/). Using a telehealth model allows the child and family to be supported both on site through management in the PCP setting and remotely through televideo backup by a child mental health specialist as indicated. Several other countries have developed integrated care sites specifically geared toward and marketed to young people who might be at risk for the onset of mental health problems. In Australia, the headspace program stands out for its focus on providing multiple services for young people ages 12–25 in standalone sites. Each headspace site provides both primary care and mental health services as well as links to social services, housing supports, and peer support. In addition, headspace provides online support for young people with mental health concerns, and the headspace school program provides suicide prevention programming across the country (www.headspace.org.au). The initial 50 headspace sites have proven to be quite successful, leading to a national commitment to expand to 100 sites over the next few years. The headspace model is currently being replicated in Denmark and Israel, and similar models are in place in Ireland. This growing international focus on specifically orienting mental health systems to the needs of young people has led to an International Declaration on Youth Mental Health, which calls for decreasing preventable
mortality due to mental health conditions while improving access to services, increasing youth and family involvement and improving mental health literacy and recognition of youth mental health conditions and needs.
Training Early identification and intervention must be recognized as critical components for the prevention of high-risk, potentially lethal problems such as suicide, substance abuse, youth violence, and accidents. And yet, the lack of a well-trained workforce with expertise in child mental health remains a limiting factor in making these interventions available and successful. Training our residents and child psychiatry fellows in integrated care settings remains critical. The tendency for many psychiatrists in primary care settings is to independently see patients referred by the office PCPs. Unfortunately, this model quickly leads to having a psychiatrist in a primary care office that is unavailable to the PCPs around him or her for immediate support, with a long list of patients to be scheduled and seen. Even though financial mechanisms incentivizing alternative models are still in development, it is clear our trainees need exposure now to models of primary care partnerships where they can learn to be members of an integrated, multidisciplinary care team. It is important for our trainees to learn how to best support our primary care and other behavioral health professional partners in a collaborative way that expands the capacity of our PCP colleagues to handle increasingly complex psychiatric situations. Providing these opportunities in schools or other community settings where young people are continues to be important. This critical training needs to be part of child and adolescent psychiatry training programs. Several years after completing my child psychiatry fellowship, I was hired as a faculty member by the same family medicine department to be the director of school mental health programs for the university’s SBHCs. As I worked to create a similar integrated care experience for our child psychiatry fellows, we also worked to build opportunities for trainees to learn about school culture into our training model. Ultimately, the fellows’ SBHC experience came to not only include seeing students regularly with the primary care team members but also include meeting with the school principal, teaching classes for students, and providing on-site training for the school health professionals. Certain critical moments stand out as important supervisory experiences. One was the time the medical student came out of an exam room looking quite frightened to tell the pediatric resident and then me that he thought the student he was just speaking to might be suicidal. After briefly discussing how to handle the next steps in the interview, we made our way back to the student together only to arrive at an empty exam room. The next few minutes were a wild search across the
Acad Psychiatry
school grounds that fortunately turned out well because the student had heard the bell and simply gone to his next class. We ultimately found him there. After a brief interview, we saw that he was not actually at risk and a follow-up appointment was scheduled for later that day. Everyone involved, from school health professionals to SBHC staff, learned that day the importance of never leaving alone a person for whom one had safety concerns. Ultimately, our university SBHC team had the opportunity, as additional state and federal grant funds became available, to expand this integrated SBHC model statewide throughout our Division of Public Health. What followed was the development of an integrated state and regional infrastructure for school health and mental health, which include SBHCs at the core. As our state provided funds for SBHC expansion throughout our rural and frontier communities, each was required to have parity in mental health and primary care hours. Gated screening models for early signs of mental health conditions in SBHCs became the norm, without the question of what to do for those who screened positive, because there were mental health providers on site in each SBHC where the screening was taking place [10]. Over time, multisite telehealth and telephone check-ins became the way to back up school health/mental health professionals and SBHC staff for the complex situations requiring child psychiatry support and consultation [11]. The programs focused both on early identification of young people with mental health conditions through integrated care and building the capacity of our primary care and school-based providers to handle complex mental health issues of the students in their schools and community settings. We have a tremendous opportunity through our expanded integrated care systems to improve health for our young people. Providing mental health care in integrated settings whether in schools, standalone sites, or primary care clinics builds the possibility for improved access in de-stigmatized environments. With the recognition of improved outcomes through early intervention for many mental health conditions, including psychosis, the importance of screening and early recognition becomes more urgent [12]. Furthermore, additional training for psychiatry residents in multiple integrated care clinical settings must be expanded so trainees develop expertise and comfort with additional roles as real-time consultants and multi-disciplinary team members. As the USA moves forward in building opportunities for integrated care programs linking mental health with primary care, we must utilize this
moment of opportunity to develop a public mental health care system that will ensure our young people stay healthy and productive as they lead us into the future. Acknowledgments The author thanks Melina Salvador for her support in the development of this piece. Disclosure The author has no conflicts of interest.
References 1. Pacheco M, Adelsheim S, Davis L, Mancha V, Aime L, Nelson P, et al. Classroom outreach from a school-based clinic: addressing felt needs in a school community. J School Health. 1991;61(8):367–9. 2. Substance Abuse and Mental Health Services Administration: 2012. National Report Finds One-in-Five Americans Experienced Mental Illness in the Past Year. http//www.samhsa.gov/newsroom/ advisories/1201185326.aspx. Accessed 6 May 2014. 3. Kessler R, Berglund P, Demler O, Jin R, Walters E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:593–602. 4. Wang P, Berlund P, Olfson M, Pincus H, Wells K, Kessler R. Failure and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:603–13. 5. Jennings J, Pearson G, Harris M. Implementing and maintaining school-based mental health services in a large, urban school district. J Sch Health. 2000;70:201–5. 6. Substance Abuse and Mental Health Services Administration: Integrated Care Models. http://www.integration.samhsa.gov/ integrated-care-models. Accessed 6 May 2014. 7. Center for Integrated Health Solutions (SAMHSA-HRSA). http:// www.integration.samhsa.gov/integrated-care-models/13_June_ CIHS_Integrated_Care_System_for_Children_final.pdf. Accessed 6 May 2014. 8. New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003. 9. Sarvet B, Gold J, Bostic J, Masek B, Prince J, Jeffers-Terry M, et al. Improving access to mental health care for children: the Massachusetts child psychiatry access project. Pediatrics. 2010;126(6):1191–200. 10. Adelsheim S, Carrillo K, Coletta E. Developing school mental health in a rural state: the New Mexico School Mental Health Initiative. Child Adolesc Psychiatr Clin N Am. 2001;10(1):151–9. 11. Kriechman A, Salvador M, Adelsheim S. Expanding the vision: the strengths-based, community-oriented child and adolescent psychiatrist working in schools. Child Adolesc Psychiatr Clin N Am. 2010;19(1):149–62. 12. Lieberman J, Dixon L, Goldman H. Early detection and intervention in schizophrenia: a new therapeutic model. JAMA. 2013;210(7): 689–90.
IN DEPTH ARTICLE: COMMENTARY
From School Health to Integrated Health: Expanding Our Children’s Public Mental Health System Steven Adelsheim
Received: 23 May 2014 / Accepted: 27 May 2014 # Academic Psychiatry 2014
Abstract There is a substantial unmet need for mental health and substance abuse services in the USA. In 2009, the Institute of Medicine recommended increased early identification and intervention for young people with mental, emotional, and behavioral disorders. With the expansion of integrated models in primary care settings, we now have the chance to improve outcomes for young people with mental health conditions, just as we have by improving the early identification and treatment of other preventable and/or treatable conditions such as obesity, asthma, or HIV. This is a moment of great opportunity to fundamentally change how young people access mental health care in our country. Through strategic integration of care, we can increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; we can identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; and we can purposefully embed integration into provider training programs for both primary care and mental health providers to ensure sustainability. Keywords Systems . Mental health integration . Health disparities In the school-based health center (SBHC), we all noticed that it was usually by the third primary care visit that students would start to raise any underlying mental health issues. Those initial visits with the nurse practitioner, pediatrician, or family practice resident for a headache, stomachache, or sports physical would provide a certain comfort in a nonstigmatizing environment for the student and his or her
S. Adelsheim (*) Stanford University School of Medicine, Stanford, CA, USA e-mail: [email protected]
provider to start a conversation about mental health. Because we had one common waiting area, students generally did not know why the others were there, but they could see which provider took each person into an exam room. For many of the students, it seemed easier somehow to have that person be a primary care provider (PCP), but we all knew that many would need mental health care. We integrated a health screen for the PCP to use with several mental health questions. Positive responses led to a specific mental health screen. If that screen revealed positive indicators, it was time for a shared visit with the PCP and the mental health specialist or at least a warm handoff between the two. I came to school mental health work as a trainee. I began as a first-year child psychiatry fellow on a school consult rotation with a student assistance team at an elementary school. In my second year, I was able to have weekly clinical time in a high school SBHC. My primary on-site supervisor at the SBHC was the director of the family and community medicine training program, who would sometimes pull me into the room to jointly interview students who were having suicidal thoughts or possible hallucinations. Most of the primary care residents on site from family medicine or pediatrics had not been trained how to ask questions about suicide or homicide risk or paranoia or auditory/visual hallucinations. I realized while at the SBHC that my time was best spent seeing patients with PCPs and that if I spent time one-on-one with students, I would only be able to serve a few young people. The individual-care model lacked potential for on-site capacity building for the PCPs and did not feel sustainable beyond my personal involvement. Over time, I saw that seeing students with primary care colleagues optimized access to care, increased continuity, and improved provider skills for both primary care and mental health providers. Over time, the PCPs, both the residents and faculty, began to feel more comfortable asking critical mental health-related questions and expressed gratitude for the shared experience. There had not been any other setting where the
Acad Psychiatry
opportunity arose for PCPs to learn how to interact with adolescents around mental health questions in the same way [1]. For me, I had learned the value and practical application of working with an integrated team and seen how significantly the stigma of seeking out mental health care reduced access. As our nation shifts to a model of integrating mental health supports into primary care, these lessons I learned in SBHCs seem to take on additional importance. We have significant work to do to successfully integrate care in this country. We know that there is substantial unmet need for mental health and substance abuse services in the USA. In fact, while one in every five people reports having experienced a mental illness within the past year, most will not receive care [2]. This lack of access starts with young people. Half of all mental health conditions have their onset before age 14, and 75 % by age 24 [3]. Early symptom development is itself a risk factor for increasing the time an individual takes to access mental health services [4]. In 2009, the Institute of Medicine recommended increased early identification and intervention for young people with mental, emotional, and behavioral disorders. With the expansion of integrated models in primary care settings, we now have the chance to improve outcomes for young people with mental health conditions, just as we have by improving the early identification and treatment of other preventable and/ or treatable conditions such as obesity, asthma, or HIV. This is a moment of great opportunity to fundamentally change how young people access mental health care in our country. Through strategic integration of care, we can (1) increase access to care for those who would not seek out mental health services because of the stigma or inconvenience of reaching out to a mental health provider; we can (2) identify those who need care earlier and reduce the impact of mental illness on individuals, family, and community through early identification and treatment; and we can (3) purposefully embed integration into provider training programs for both primary care and mental health providers to ensure sustainability.
Increasing Access Any effort to increase access will need to have a populationbased public health approach. Until now, there have been many barriers to shifting the current system of mental health care in this direction. Public health and primary care systems have generally not seen support for mental health issues as part of their primary role. Until recently, reimbursement models have not led to sufficient payment for screening or treatment of mental health problems in primary care settings. Schools have been increasingly focused on meeting educational testing requirements and, as a result, have had less educational and financial resources available for ensuring that children with mental health issues are recognized and treated early. Ironically, research indicates that SBHCs might lead to
improved test scores [5]. Children’s state mental health systems have generally focused scarce resources on those in state custody through foster care or juvenile justice systems as well as those children with serious emotional disorders. Few, if any, state public health systems or agencies focus specifically on increasing mental health awareness, screening, preventive intervention, and/or early treatment for young people. Although our national mental health policy statements have increasingly promoted a movement toward a public health framework for mental health care, we are just now putting the components in place to make this vision a reality. With new policies and changes in insurance comes a potential shift in the structure of reimbursement from a fee-forservice to a covered-lives model. This shift has the potential to support an integrated public mental health system. Cost savings through prevention, early identification, and treatment become essential to a covered-lives health care business plan. As such, there is increasing emphasis on and support for integrated care models [6]. The nationally recognized Four Quadrant Clinical Integration Model ensures both mental health and primary care access from any entrance into the health care system [7]. This whole person approach understands that each individual will have physical and behavioral health needs to varying degrees and lays the foundation for the development of systems that can extend services to those with differing needs in a systematic manner.
Early Identification and Treatment A move toward expansion of integrated care models opens up the potential to build this sorely needed public mental health system for young people. And yet, to optimize care, we will need to build in strategies to identify those individuals who need services as early as possible and then link them directly to the services they need. Many of the necessary components of an early screening and intervention model have been developed as parts of various separate programs, and the time has come to bring them together into a cohesive integrated care framework. Early screening for young people for mental health conditions is a critical aspect of any integrated care model. Back in 2003, the President’s New Freedom Commission on Mental Health recommended screening in multiple settings for mental health conditions in young people, including primary care and school settings [8]. Programs such as Columbia’s TeenScreen, focusing on depression and suicide, targeted screening in schools and primary care clinics. The US Preventive Task Force recommended screening for depression in primary care settings for adolescents when access to appropriate diagnosis, psychotherapy, and followup was available. An effective framework would broaden screenings to include identifying young people who are at risk for multiple mental health conditions. As integrated care
Acad Psychiatry
models create co-located and coordinated care services, immediate follow-up by a mental health provider becomes available when a PCP has concerns or after a positive screen. Until these systems are more firmly established in primary care settings for young people, the ongoing shortage of child mental health providers may require systems to provide a more targeted screening approach. Focused and gated screening for high-risk individuals, rather than broad clinic-wide screening, may make sense for now to ensure a provider is available to evaluate each young person with a positive screen. As children are screened, systems need to be in place to link those needing support for mental health conditions to appropriate interventions. In primary care settings, such support could come through models such as the Massachusetts Child Psychiatry Access Project (MCPAP) (www.mcpap.org), which provides immediate mental health backup and support for PCPs identifying and treating young people with mental health issues in their practice [9]. This model ensures rapid consultation for primary care with a mental health team including a case manager, master’s trained provider, and child psychiatrist. The MCPAP model has now expanded to over 27 states in an effort to build access to mental health care while expanding the capacity of PCPs to manage young people with mental health needs in their own practices (www.nncpap.org). In rural and remote areas, a telehealth consultation model, like those being implemented in New Mexico and through the Indian Health Service, could also be effective in a similar structure to MCPAP (https://sites.google. com/site/ihstbhce/). Using a telehealth model allows the child and family to be supported both on site through management in the PCP setting and remotely through televideo backup by a child mental health specialist as indicated. Several other countries have developed integrated care sites specifically geared toward and marketed to young people who might be at risk for the onset of mental health problems. In Australia, the headspace program stands out for its focus on providing multiple services for young people ages 12–25 in standalone sites. Each headspace site provides both primary care and mental health services as well as links to social services, housing supports, and peer support. In addition, headspace provides online support for young people with mental health concerns, and the headspace school program provides suicide prevention programming across the country (www.headspace.org.au). The initial 50 headspace sites have proven to be quite successful, leading to a national commitment to expand to 100 sites over the next few years. The headspace model is currently being replicated in Denmark and Israel, and similar models are in place in Ireland. This growing international focus on specifically orienting mental health systems to the needs of young people has led to an International Declaration on Youth Mental Health, which calls for decreasing preventable
mortality due to mental health conditions while improving access to services, increasing youth and family involvement and improving mental health literacy and recognition of youth mental health conditions and needs.
Training Early identification and intervention must be recognized as critical components for the prevention of high-risk, potentially lethal problems such as suicide, substance abuse, youth violence, and accidents. And yet, the lack of a well-trained workforce with expertise in child mental health remains a limiting factor in making these interventions available and successful. Training our residents and child psychiatry fellows in integrated care settings remains critical. The tendency for many psychiatrists in primary care settings is to independently see patients referred by the office PCPs. Unfortunately, this model quickly leads to having a psychiatrist in a primary care office that is unavailable to the PCPs around him or her for immediate support, with a long list of patients to be scheduled and seen. Even though financial mechanisms incentivizing alternative models are still in development, it is clear our trainees need exposure now to models of primary care partnerships where they can learn to be members of an integrated, multidisciplinary care team. It is important for our trainees to learn how to best support our primary care and other behavioral health professional partners in a collaborative way that expands the capacity of our PCP colleagues to handle increasingly complex psychiatric situations. Providing these opportunities in schools or other community settings where young people are continues to be important. This critical training needs to be part of child and adolescent psychiatry training programs. Several years after completing my child psychiatry fellowship, I was hired as a faculty member by the same family medicine department to be the director of school mental health programs for the university’s SBHCs. As I worked to create a similar integrated care experience for our child psychiatry fellows, we also worked to build opportunities for trainees to learn about school culture into our training model. Ultimately, the fellows’ SBHC experience came to not only include seeing students regularly with the primary care team members but also include meeting with the school principal, teaching classes for students, and providing on-site training for the school health professionals. Certain critical moments stand out as important supervisory experiences. One was the time the medical student came out of an exam room looking quite frightened to tell the pediatric resident and then me that he thought the student he was just speaking to might be suicidal. After briefly discussing how to handle the next steps in the interview, we made our way back to the student together only to arrive at an empty exam room. The next few minutes were a wild search across the
Acad Psychiatry
school grounds that fortunately turned out well because the student had heard the bell and simply gone to his next class. We ultimately found him there. After a brief interview, we saw that he was not actually at risk and a follow-up appointment was scheduled for later that day. Everyone involved, from school health professionals to SBHC staff, learned that day the importance of never leaving alone a person for whom one had safety concerns. Ultimately, our university SBHC team had the opportunity, as additional state and federal grant funds became available, to expand this integrated SBHC model statewide throughout our Division of Public Health. What followed was the development of an integrated state and regional infrastructure for school health and mental health, which include SBHCs at the core. As our state provided funds for SBHC expansion throughout our rural and frontier communities, each was required to have parity in mental health and primary care hours. Gated screening models for early signs of mental health conditions in SBHCs became the norm, without the question of what to do for those who screened positive, because there were mental health providers on site in each SBHC where the screening was taking place [10]. Over time, multisite telehealth and telephone check-ins became the way to back up school health/mental health professionals and SBHC staff for the complex situations requiring child psychiatry support and consultation [11]. The programs focused both on early identification of young people with mental health conditions through integrated care and building the capacity of our primary care and school-based providers to handle complex mental health issues of the students in their schools and community settings. We have a tremendous opportunity through our expanded integrated care systems to improve health for our young people. Providing mental health care in integrated settings whether in schools, standalone sites, or primary care clinics builds the possibility for improved access in de-stigmatized environments. With the recognition of improved outcomes through early intervention for many mental health conditions, including psychosis, the importance of screening and early recognition becomes more urgent [12]. Furthermore, additional training for psychiatry residents in multiple integrated care clinical settings must be expanded so trainees develop expertise and comfort with additional roles as real-time consultants and multi-disciplinary team members. As the USA moves forward in building opportunities for integrated care programs linking mental health with primary care, we must utilize this
moment of opportunity to develop a public mental health care system that will ensure our young people stay healthy and productive as they lead us into the future. Acknowledgments The author thanks Melina Salvador for her support in the development of this piece. Disclosure The author has no conflicts of interest.
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