Acad Psychiatry DOI 10.1007/s40596-014-0137-4
IN BRIEF REPORT
Training in Integrated Mental Health-Primary Care Models: A National Survey of Child Psychiatry Program Directors Matthew D. Burkey & David L. Kaye & Emily Frosch
Received: 8 January 2014 / Accepted: 7 April 2014 # Academic Psychiatry 2014
Abstract Objective The objective of this study was to assess current trainee exposure to integrated mental health/primary care models in US child and adolescent psychiatry fellowship programs. Methods In June 2013, an electronic survey was sent to all US child and adolescent psychiatry fellowship program directors (N=123). Results Fifty-two responses were obtained from the 120 eligible participants (43 %). The majority of the program directors who responded (63 %) indicated that fellows in their programs regularly participate in clinical care and/or consultation within an outpatient pediatric primary care setting. Program directors identified barriers to increasing training exposure to integrated care delivery as competing clinical demands and challenging financial models for indirect consultation in primary care settings. Discussion Many child psychiatry fellowship program directors view training in integrated care models as an important part of their teaching and service mission, and are creating novel avenues for exposure. Current funding models, however, may limit the widespread implementation of these opportunities.
Keywords Primary care: pediatrics . Subspecialty: child and adolescent
M. D. Burkey (*) : E. Frosch The Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] D. L. Kaye University at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, NY, USA
Despite the high rates of mental health problems in youth, fewer than 40 % of those with psychiatric diagnoses receive treatment, often following a delay of several years [1, 2]. The current treatment gap is expected to widen as the shortage of child psychiatrists expands over the next decade [2, 3]. To address the burden of mental illness and the limited subspecialty resources available, the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Academy of Pediatrics (AAP) have proposed integrating mental health services into pediatric primary care delivery systems [4]. While programs are beginning to integrate mental health services into primary care, there is not yet consensus about how to train pediatricians or child psychiatrists to effectively practice in such models. In June, 2012, AACAP issued a report [4] highlighting the critical need for integrated care models to meet the mental health needs of youth and families. Integrated care models seek to overcome low rates of problem identification in primary care and follow through on referral to stand-alone mental health clinics [5] through a variety of means, including colocation of services, formal collaboration and consultation mechanisms, and/or multidisciplinary team approaches [6]. The success of integrated care models relies on supportive funding mechanisms, coordinated infrastructure, and trained personnel in order to succeed [7]. Despite the recommendations for greater care integration [4, 8], the Accreditation Council on Graduate Medical Education’s (ACGME) current training guidelines for child psychiatry fellowships do not offer detailed guidance about integrated care exposure or require outpatient experience in integrated care settings [9]. With the advent of the Affordable Care Act and Accountable Care Organizations, the move toward integrated care is expected to accelerate. Recognizing that integrated care models involve complex systems of coordination and represent a deviation from traditional practice models, AACAP leaders and membership recently identified
Acad Psychiatry
preparing child psychiatrists to practice in new models of healthcare delivery as one of the key issues facing child psychiatry in the next decade [10]. Therefore, this study aimed to establish a baseline understanding of current models for and exposure to training in integrated mental health/primary care delivery among US child and adolescent psychiatry (CAP) fellowship programs through a nation-wide survey of fellowship program directors. We also aimed to identify the opportunities and barriers in the implementation of these programs in order to inform the next iteration of program development in the training of America’s child mental health workforce.
Methods After receiving IRB approval, an anonymous online survey was emailed to all 123 US CAP program directors. Four separate requests for participation were sent to each program director over the course of 12 weeks; returned requests were individually reviewed by the authors who then sought out alternative contact information on program websites and through program assistants. Of the 123 available e-mail addresses, 3 (2.4 %) were found to be nonfunctional, with no identifiable alternative, leaving 120 eligible participants. The survey consisted of 23 questions, including 21 multiple choice questions and 2 open-ended response options. Program directors were asked to indicate the types of exposure fellows have to integrated behavioral health models, the perceived acceptability of the identified exposures, fellows’ future career plans related to integrated care, and perceived barriers to a greater training exposure. The survey results were compiled and summary statistics evaluated using Stata 12.0.
Results A total of 52 responses were obtained from the 120 eligible participants (43 %). The majority of the respondents represented programs that were urban (73 %), affiliated with academic centers (88 %), and had affiliated pediatric residency programs (98 %). The mean number of total fellows per program was 7.4 (SD=3.4); the mean number of full-time (equivalent) CAP faculty members per program was 8.0 (SD=5.2). Integrated Care Training Models The majority of the program directors who responded to the survey (n=46 out of 52 respondents (88 %)) indicated that fellows in their programs regularly participate in teaching,
clinical care, or consultation in an outpatient pediatric primary care setting (see Table 1). Twenty-three programs (44 %) reported that fellows regularly provide psychiatric consultation to primary care providers (“indirect” consultation, i.e. without direct patient contact); 16 (31 %) reported that fellows regularly provide face-to-face (“direct”) consultations with patients and/or families within an outpatient primary care setting; and 7 (13 %) reported that fellows regularly provide ongoing psychiatric care for patients in a primary care setting as part of their training. Nineteen programs (37 %) reported that at least one integrated care rotation was required as part of their program, while others were conducted as elective rotations. Eighteen programs (35 %) reported that fellows spent at least one fulltime equivalent month on integrated care rotations during CAP training. The majority of the program directors reported that fellows evaluate integrated care rotations as being of “about the same value” as or “more valuable” than other rotations. In addition to providing consultation and care in primary care settings, child psychiatry fellows are also engaged as teachers in integrated settings with pediatrics. Thirty-three program directors (63 %) reported that child psychiatry fellows engage in didactic and/or case-based teaching to pediatric residents as part of a larger curricular or didactic effort. Most program directors (40 out of 52 respondents (77 %)) reported that fellows receive at least some didactic teaching related to providing mental health care in primary care settings with an emphasis on integration and collaboration of care delivery, with 12 programs providing at least 10 h of instruction over 2 years of CAP training. Program directors were also asked to identify other ways their training programs are integrating mental health into primary care using free text responses. A variety of novel strategies were shared and themes included: (1) conducting Table 1 Clinical and didactic exposure to integrated care in child psychiatry fellowships Integrated care exposure
Number of programs (%)
Any didactic or clinical training offered Didactics offered >10 h didactics offered Clinical experience in outpatient pediatrics clinic Indirect consultation Direct consultation Ongoing patient care Clinical rotation in integrated care is required in program Plans to increase exposure to integrated care in next 3 years
46 (88 40 (77 12 (23 33 (63
%) %) %) %)
23 (44 16 (31 7 (13 19 (37
%) %) %) %)
32 (62 %)
Acad Psychiatry
joint case conferences for Child Psychiatry and Pediatrics; (2) integrating CAP faculty and fellows into pediatric residents’ outpatient clinics, specialty pediatrics clinics (e.g., HIV clinics), and federally qualified health centers; (3) CAP faculty and fellows providing consultation to primary care physicians as part of state-wide initiatives; and (4) partnering with community mental health systems that have already initiated integrated care delivery (some utilizing telemedicine technology) (see Table 2). Finally, program directors also noted that pediatrics residents and CAP fellows both benefit from providing joint care during “guest” rotations (e.g., pediatrics residents joining psychiatry rotations). Careers and Future Plans Despite the current didactic and rotation exposures, most program directors surveyed (77 %) either disagreed or strongly disagreed that, as a field, CAP training programs are already preparing graduates for upcoming changes in mental health care delivery with respect to new practice models and do not need to make additional changes in curricular structure. Only one program director (2 %) strongly agreed that graduates are prepared to practice in integrated practice models. Skills for delivering integrated care emerged as a priority for preparing trainees for future careers: the majority of the programs surveyed (56 %) reported that at least one of their current fellows plans to work in an integrated outpatient care setting following graduation. Most program directors surveyed (62 %) reported that their training
programs have plans in place for the next 3 years to increase exposure to integrated mental health care provision and none reported plans to decrease exposure. Barriers to Integrated Care Training Several barriers were also noted to increasing fellows’ participation in integrated mental health delivery in outpatient pediatric primary care settings. The most common barriers endorsed in the survey were competing clinical service demands (40 %), lack of child psychiatry faculty interest or availability (17 %), and lack of support or interest from key departmental administration and leadership (16 %). In a free text response question, program directors also noted additional barriers to increasing training exposure (see Table 2). The most commonly cited barrier was the lack of existing funding mechanisms (GME support and insurance reimbursement) to pay for faculty and residents to provide indirect consultations/care in primary care settings. Respondents also reported that some psychiatry and pediatrics departments provided limited support for integrated care training. Program directors indicated that the lack of support was due to different departmental priorities or mission, existing access by pediatrics to psychiatric consultation in academic settings, and the preference of some pediatricians to transfer psychiatric care completely to a psychiatrist rather than provide integrated care. Finally, program directors reported that providing training experiences was impeded by working between multiple, independent institutions with potentially divergent missions.
Table 2 Strategies for and barriers to increasing integrated care exposure: results from open-ended questions Strategies for increasing exposure: Formal mechanisms: • Joint case conferences with pediatrics, adolescent medicine • Fellows provide consultations (to patients and/or providers) in pediatrics resident clinics, HIV clinics, federally qualified health centers, rural clinics in-person, or via telemedicine technology • Fellows provide consultation to primary care physicians via statewide telephone access line Informal mechanisms: • Interactions with pediatricians joining psychiatry rotations and when CAP residents are on developmental pediatrics rotations Barriers to increasing exposure: • Not perceived as part of mission or priority by pediatrics and/or psychiatry department leaders or affiliated patient care institutions • Pediatrics already have ready access to psychiatric consultation in academic setting; lack of interest from pediatrics in sharing responsibility for ongoing patient care • Lack of financial support (e.g., insurance reimbursement, graduate medical education budget, or university budget) for faculty supervision and/or resident time to work across departments
Discussion Key Findings Despite the absence of specific training guidelines or supportive funding mechanisms, many CAP fellowship program directors are creating novel avenues for integrated outpatient care training exposure. Our study provides a conservative estimate that at least one third of US CAP programs are already providing didactic teaching and/or clinical exposure to integrated care models. However, the form and intensity of existing training models varies widely according to institutional and state/regional needs and available resources. The lack of consistent funding mechanisms appears to be a major barrier to implementing integrated care training in many programs, despite faculty and fellow interest. To the best of our knowledge, this study is the first to examine integrated care exposure and training models among child psychiatry fellowship programs in the USA.
Acad Psychiatry
Limitations The findings of our survey should be interpreted within the context of low to moderate response rate and possible response bias, which may limit the representativeness of our data. Response bias may have been introduced by overrepresentation among responders of programs with an interest or current curriculum in integrated care. Nevertheless, our study has the strength of sampling from a nationwide database and thus presents the most comprehensive view to date of current training practices in integrated care training among US CAP programs. To reduce the risk of misinterpretation of our findings as representative, we have emphasized the responses about programs as count (rather than proportion) data. This approach to presentation has the benefit of producing a minimum estimate of the number of programs currently providing training exposure to integrated care. The largely multiple choice question format employed in this study to minimize respondent burden precluded gathering in-depth data on novel program practices. However, we attempted to add information depth by including two openended questions, which, in line with qualitative research methodology, have the aim of hypothesis generation (rather than hypothesis testing) and thus are not dependent upon representativeness. By including both closed- and open-ended questions, our study provides an up-to-date snapshot of what programs are doing to train CAP fellows to deliver integrated care in a time of rapid health care change. Implications and Future Directions The results of our national survey demonstrate that a critical mass of child psychiatry program directors view integrated care as an important domain for training and have already begun to pilot integrated care training in outpatient care settings. However, most existing integrated care training curricula are confined to single institutions and are dependent upon idiosyncratic funding models, calling into question their sustainability and scalability without systematic reform efforts. If the next generation of child psychiatrists is to fulfill the promise of integrated care to meet the mental health needs of children in the USA, serious attention must be given to address the shortcomings of existing funding mechanisms and training curricula. Developing models for teaching about integrated care is of great importance now and will be increasingly so as healthcare changes unfold, emphasizing collaborative models of care. Future studies and educational efforts should now focus on disseminating results from pilot
programs, developing model curricula, and addressing systems-level barriers to widespread implementation.
Implications for Educators & In recognition of the changing nature of healthcare delivery, many child psychiatry fellowship programs now offer didactic and/or clinical training emphasizing various models of integrated care. & Educators are called on to share model curricula and advocate for greater funding/support to meet the growing demand for child psychiatrists prepared to practice effectively in a wide range of integrated care settings.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Merikangas KR, He J-P, Burstein M, Swendsen J, Avenevoli S, Case B, et al. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey– Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32–45. 2. Surgeon General. Mental health: a report of the surgeon general. Bethesda: Surgeon General; 1999. 3. US DHHS Health Resources and Services Administration. Physician supply and demand: projections to 2020. October 2000. Retrieved from http://bhpr.hrsa.gov/healthworkforce/supplydemand/medicine/ physician2020projections.pdf 4. American Academy of Child and Adolescent Psychiatry. Best Principles for Integration of Child Psychiatry into the Pediatric Health Home. 2012. Retrieved from https://www.aacap.org 5. Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med. 2002;156(6):592. 6. Foy JM, Kelleher KJ, Laraque D. Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics. 2010;125(Supplement 3):S87–S108. 7. Mauer B. Background paper: Behavioral health/primary care integration–models, competencies and infrastructure. Rockville: National Council for Community Behavioral Healthcare (NCCBH); 2003. 8. Dickinson WP, Miller BF. Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Fam Syst Health. 2010;28(4):348. 9. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Child and Adolescent Psychiatry; 2007. Retrieved from https://www. acgme.org 10. American Academy of Child & Adolescent Psychiatry. Back to project future: Plan for the coming decade. 2014. Retrieved from http://www.aacap.org
IN BRIEF REPORT
Training in Integrated Mental Health-Primary Care Models: A National Survey of Child Psychiatry Program Directors Matthew D. Burkey & David L. Kaye & Emily Frosch
Received: 8 January 2014 / Accepted: 7 April 2014 # Academic Psychiatry 2014
Abstract Objective The objective of this study was to assess current trainee exposure to integrated mental health/primary care models in US child and adolescent psychiatry fellowship programs. Methods In June 2013, an electronic survey was sent to all US child and adolescent psychiatry fellowship program directors (N=123). Results Fifty-two responses were obtained from the 120 eligible participants (43 %). The majority of the program directors who responded (63 %) indicated that fellows in their programs regularly participate in clinical care and/or consultation within an outpatient pediatric primary care setting. Program directors identified barriers to increasing training exposure to integrated care delivery as competing clinical demands and challenging financial models for indirect consultation in primary care settings. Discussion Many child psychiatry fellowship program directors view training in integrated care models as an important part of their teaching and service mission, and are creating novel avenues for exposure. Current funding models, however, may limit the widespread implementation of these opportunities.
Keywords Primary care: pediatrics . Subspecialty: child and adolescent
M. D. Burkey (*) : E. Frosch The Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] D. L. Kaye University at Buffalo, School of Medicine and Biomedical Sciences, Buffalo, NY, USA
Despite the high rates of mental health problems in youth, fewer than 40 % of those with psychiatric diagnoses receive treatment, often following a delay of several years [1, 2]. The current treatment gap is expected to widen as the shortage of child psychiatrists expands over the next decade [2, 3]. To address the burden of mental illness and the limited subspecialty resources available, the American Academy of Child and Adolescent Psychiatry (AACAP) and the American Academy of Pediatrics (AAP) have proposed integrating mental health services into pediatric primary care delivery systems [4]. While programs are beginning to integrate mental health services into primary care, there is not yet consensus about how to train pediatricians or child psychiatrists to effectively practice in such models. In June, 2012, AACAP issued a report [4] highlighting the critical need for integrated care models to meet the mental health needs of youth and families. Integrated care models seek to overcome low rates of problem identification in primary care and follow through on referral to stand-alone mental health clinics [5] through a variety of means, including colocation of services, formal collaboration and consultation mechanisms, and/or multidisciplinary team approaches [6]. The success of integrated care models relies on supportive funding mechanisms, coordinated infrastructure, and trained personnel in order to succeed [7]. Despite the recommendations for greater care integration [4, 8], the Accreditation Council on Graduate Medical Education’s (ACGME) current training guidelines for child psychiatry fellowships do not offer detailed guidance about integrated care exposure or require outpatient experience in integrated care settings [9]. With the advent of the Affordable Care Act and Accountable Care Organizations, the move toward integrated care is expected to accelerate. Recognizing that integrated care models involve complex systems of coordination and represent a deviation from traditional practice models, AACAP leaders and membership recently identified
Acad Psychiatry
preparing child psychiatrists to practice in new models of healthcare delivery as one of the key issues facing child psychiatry in the next decade [10]. Therefore, this study aimed to establish a baseline understanding of current models for and exposure to training in integrated mental health/primary care delivery among US child and adolescent psychiatry (CAP) fellowship programs through a nation-wide survey of fellowship program directors. We also aimed to identify the opportunities and barriers in the implementation of these programs in order to inform the next iteration of program development in the training of America’s child mental health workforce.
Methods After receiving IRB approval, an anonymous online survey was emailed to all 123 US CAP program directors. Four separate requests for participation were sent to each program director over the course of 12 weeks; returned requests were individually reviewed by the authors who then sought out alternative contact information on program websites and through program assistants. Of the 123 available e-mail addresses, 3 (2.4 %) were found to be nonfunctional, with no identifiable alternative, leaving 120 eligible participants. The survey consisted of 23 questions, including 21 multiple choice questions and 2 open-ended response options. Program directors were asked to indicate the types of exposure fellows have to integrated behavioral health models, the perceived acceptability of the identified exposures, fellows’ future career plans related to integrated care, and perceived barriers to a greater training exposure. The survey results were compiled and summary statistics evaluated using Stata 12.0.
Results A total of 52 responses were obtained from the 120 eligible participants (43 %). The majority of the respondents represented programs that were urban (73 %), affiliated with academic centers (88 %), and had affiliated pediatric residency programs (98 %). The mean number of total fellows per program was 7.4 (SD=3.4); the mean number of full-time (equivalent) CAP faculty members per program was 8.0 (SD=5.2). Integrated Care Training Models The majority of the program directors who responded to the survey (n=46 out of 52 respondents (88 %)) indicated that fellows in their programs regularly participate in teaching,
clinical care, or consultation in an outpatient pediatric primary care setting (see Table 1). Twenty-three programs (44 %) reported that fellows regularly provide psychiatric consultation to primary care providers (“indirect” consultation, i.e. without direct patient contact); 16 (31 %) reported that fellows regularly provide face-to-face (“direct”) consultations with patients and/or families within an outpatient primary care setting; and 7 (13 %) reported that fellows regularly provide ongoing psychiatric care for patients in a primary care setting as part of their training. Nineteen programs (37 %) reported that at least one integrated care rotation was required as part of their program, while others were conducted as elective rotations. Eighteen programs (35 %) reported that fellows spent at least one fulltime equivalent month on integrated care rotations during CAP training. The majority of the program directors reported that fellows evaluate integrated care rotations as being of “about the same value” as or “more valuable” than other rotations. In addition to providing consultation and care in primary care settings, child psychiatry fellows are also engaged as teachers in integrated settings with pediatrics. Thirty-three program directors (63 %) reported that child psychiatry fellows engage in didactic and/or case-based teaching to pediatric residents as part of a larger curricular or didactic effort. Most program directors (40 out of 52 respondents (77 %)) reported that fellows receive at least some didactic teaching related to providing mental health care in primary care settings with an emphasis on integration and collaboration of care delivery, with 12 programs providing at least 10 h of instruction over 2 years of CAP training. Program directors were also asked to identify other ways their training programs are integrating mental health into primary care using free text responses. A variety of novel strategies were shared and themes included: (1) conducting Table 1 Clinical and didactic exposure to integrated care in child psychiatry fellowships Integrated care exposure
Number of programs (%)
Any didactic or clinical training offered Didactics offered >10 h didactics offered Clinical experience in outpatient pediatrics clinic Indirect consultation Direct consultation Ongoing patient care Clinical rotation in integrated care is required in program Plans to increase exposure to integrated care in next 3 years
46 (88 40 (77 12 (23 33 (63
%) %) %) %)
23 (44 16 (31 7 (13 19 (37
%) %) %) %)
32 (62 %)
Acad Psychiatry
joint case conferences for Child Psychiatry and Pediatrics; (2) integrating CAP faculty and fellows into pediatric residents’ outpatient clinics, specialty pediatrics clinics (e.g., HIV clinics), and federally qualified health centers; (3) CAP faculty and fellows providing consultation to primary care physicians as part of state-wide initiatives; and (4) partnering with community mental health systems that have already initiated integrated care delivery (some utilizing telemedicine technology) (see Table 2). Finally, program directors also noted that pediatrics residents and CAP fellows both benefit from providing joint care during “guest” rotations (e.g., pediatrics residents joining psychiatry rotations). Careers and Future Plans Despite the current didactic and rotation exposures, most program directors surveyed (77 %) either disagreed or strongly disagreed that, as a field, CAP training programs are already preparing graduates for upcoming changes in mental health care delivery with respect to new practice models and do not need to make additional changes in curricular structure. Only one program director (2 %) strongly agreed that graduates are prepared to practice in integrated practice models. Skills for delivering integrated care emerged as a priority for preparing trainees for future careers: the majority of the programs surveyed (56 %) reported that at least one of their current fellows plans to work in an integrated outpatient care setting following graduation. Most program directors surveyed (62 %) reported that their training
programs have plans in place for the next 3 years to increase exposure to integrated mental health care provision and none reported plans to decrease exposure. Barriers to Integrated Care Training Several barriers were also noted to increasing fellows’ participation in integrated mental health delivery in outpatient pediatric primary care settings. The most common barriers endorsed in the survey were competing clinical service demands (40 %), lack of child psychiatry faculty interest or availability (17 %), and lack of support or interest from key departmental administration and leadership (16 %). In a free text response question, program directors also noted additional barriers to increasing training exposure (see Table 2). The most commonly cited barrier was the lack of existing funding mechanisms (GME support and insurance reimbursement) to pay for faculty and residents to provide indirect consultations/care in primary care settings. Respondents also reported that some psychiatry and pediatrics departments provided limited support for integrated care training. Program directors indicated that the lack of support was due to different departmental priorities or mission, existing access by pediatrics to psychiatric consultation in academic settings, and the preference of some pediatricians to transfer psychiatric care completely to a psychiatrist rather than provide integrated care. Finally, program directors reported that providing training experiences was impeded by working between multiple, independent institutions with potentially divergent missions.
Table 2 Strategies for and barriers to increasing integrated care exposure: results from open-ended questions Strategies for increasing exposure: Formal mechanisms: • Joint case conferences with pediatrics, adolescent medicine • Fellows provide consultations (to patients and/or providers) in pediatrics resident clinics, HIV clinics, federally qualified health centers, rural clinics in-person, or via telemedicine technology • Fellows provide consultation to primary care physicians via statewide telephone access line Informal mechanisms: • Interactions with pediatricians joining psychiatry rotations and when CAP residents are on developmental pediatrics rotations Barriers to increasing exposure: • Not perceived as part of mission or priority by pediatrics and/or psychiatry department leaders or affiliated patient care institutions • Pediatrics already have ready access to psychiatric consultation in academic setting; lack of interest from pediatrics in sharing responsibility for ongoing patient care • Lack of financial support (e.g., insurance reimbursement, graduate medical education budget, or university budget) for faculty supervision and/or resident time to work across departments
Discussion Key Findings Despite the absence of specific training guidelines or supportive funding mechanisms, many CAP fellowship program directors are creating novel avenues for integrated outpatient care training exposure. Our study provides a conservative estimate that at least one third of US CAP programs are already providing didactic teaching and/or clinical exposure to integrated care models. However, the form and intensity of existing training models varies widely according to institutional and state/regional needs and available resources. The lack of consistent funding mechanisms appears to be a major barrier to implementing integrated care training in many programs, despite faculty and fellow interest. To the best of our knowledge, this study is the first to examine integrated care exposure and training models among child psychiatry fellowship programs in the USA.
Acad Psychiatry
Limitations The findings of our survey should be interpreted within the context of low to moderate response rate and possible response bias, which may limit the representativeness of our data. Response bias may have been introduced by overrepresentation among responders of programs with an interest or current curriculum in integrated care. Nevertheless, our study has the strength of sampling from a nationwide database and thus presents the most comprehensive view to date of current training practices in integrated care training among US CAP programs. To reduce the risk of misinterpretation of our findings as representative, we have emphasized the responses about programs as count (rather than proportion) data. This approach to presentation has the benefit of producing a minimum estimate of the number of programs currently providing training exposure to integrated care. The largely multiple choice question format employed in this study to minimize respondent burden precluded gathering in-depth data on novel program practices. However, we attempted to add information depth by including two openended questions, which, in line with qualitative research methodology, have the aim of hypothesis generation (rather than hypothesis testing) and thus are not dependent upon representativeness. By including both closed- and open-ended questions, our study provides an up-to-date snapshot of what programs are doing to train CAP fellows to deliver integrated care in a time of rapid health care change. Implications and Future Directions The results of our national survey demonstrate that a critical mass of child psychiatry program directors view integrated care as an important domain for training and have already begun to pilot integrated care training in outpatient care settings. However, most existing integrated care training curricula are confined to single institutions and are dependent upon idiosyncratic funding models, calling into question their sustainability and scalability without systematic reform efforts. If the next generation of child psychiatrists is to fulfill the promise of integrated care to meet the mental health needs of children in the USA, serious attention must be given to address the shortcomings of existing funding mechanisms and training curricula. Developing models for teaching about integrated care is of great importance now and will be increasingly so as healthcare changes unfold, emphasizing collaborative models of care. Future studies and educational efforts should now focus on disseminating results from pilot
programs, developing model curricula, and addressing systems-level barriers to widespread implementation.
Implications for Educators & In recognition of the changing nature of healthcare delivery, many child psychiatry fellowship programs now offer didactic and/or clinical training emphasizing various models of integrated care. & Educators are called on to share model curricula and advocate for greater funding/support to meet the growing demand for child psychiatrists prepared to practice effectively in a wide range of integrated care settings.
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References 1. Merikangas KR, He J-P, Burstein M, Swendsen J, Avenevoli S, Case B, et al. Service utilization for lifetime mental disorders in US adolescents: results of the National Comorbidity Survey– Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2011;50(1):32–45. 2. Surgeon General. Mental health: a report of the surgeon general. Bethesda: Surgeon General; 1999. 3. US DHHS Health Resources and Services Administration. Physician supply and demand: projections to 2020. October 2000. Retrieved from http://bhpr.hrsa.gov/healthworkforce/supplydemand/medicine/ physician2020projections.pdf 4. American Academy of Child and Adolescent Psychiatry. Best Principles for Integration of Child Psychiatry into the Pediatric Health Home. 2012. Retrieved from https://www.aacap.org 5. Rushton J, Bruckman D, Kelleher K. Primary care referral of children with psychosocial problems. Arch Pediatr Adolesc Med. 2002;156(6):592. 6. Foy JM, Kelleher KJ, Laraque D. Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics. 2010;125(Supplement 3):S87–S108. 7. Mauer B. Background paper: Behavioral health/primary care integration–models, competencies and infrastructure. Rockville: National Council for Community Behavioral Healthcare (NCCBH); 2003. 8. Dickinson WP, Miller BF. Comprehensiveness and continuity of care and the inseparability of mental and behavioral health from the patient-centered medical home. Fam Syst Health. 2010;28(4):348. 9. Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Child and Adolescent Psychiatry; 2007. Retrieved from https://www. acgme.org 10. American Academy of Child & Adolescent Psychiatry. Back to project future: Plan for the coming decade. 2014. Retrieved from http://www.aacap.org
