Pediatric Integrated Collaborative Care: An Advocacy Victory for NJ Children and Youth

Debra E. Koss, MD, FAACAP

NJPA Senior Vice President

One in five youth experience mental illness severe enough to impact normal development. Half of all lifetime cases of mental illness begin by age 14 and three-quarters by age 24. The data is compelling and points to the importance of early intervention and treatment. Yet one in four parents report it’s difficult to find mental health services for their child.

Despite the evidence for safe and effective treatments, nearly 80% of youth with mental illness do not receive treatment. Stigma, the lack of equal insurance coverage of mental health and substance abuse disorders as promised under the Mental Health Parity and Addiction Equity Act of 2008, and a shortage of mental health care providers are just some of the barriers to care. Delay or interruption of mental health care leads to devastating consequences for youth, including academic failure, involvement in the juvenile justice system, substance use, and tragically suicide. In addition to the direct impact on children, untreated mental illness is also associated with a fiscal toll. The cost of childhood mental illness is estimated at over $200 billion annually in mental health and health services and related costs.

In the face of these challenges, many families turn to their primary care providers for help. Seventy five percent of children with mental health disorders are now treated in primary care settings. One in five primary care appointments are for a behavioral health disorder. Primary care providers also prescribe the majority of psychotropic medications. Advantages to delivering care in the primary care setting include decreased stigma, access to information about family and developmental history, and trust associated with a longstanding doctor-patient relationship.  However, barriers to treatment in the primary care setting do exist. These include, insufficient time, lack of expertise and comfort in treating mental illness, lack of knowledge about local mental health resources, and insufficient reimbursement.

To overcome these barriers and ensure delivery of evidence-based care, primary care physicians and child and adolescent psychiatrists have come together to develop effective collaborative partnerships. The integrated care model essentially creates opportunities for timely access to consultation with a child and adolescent psychiatrist, education for the primary care provider on mental health care, family access to a care coordinator, and direct psychiatric assessment when needed. These pediatric integrated care teams now exist in more than 24 states and data collection spans more than ten years. 

Efforts to bring the collaborative care model to NJ began in 2009 with a grant from the American Academy of Child and Adolescent Psychiatry Campaign for America’s Kids. This grant supported the development of a coalition of mental health advocates who hosted the first ever Forum on Children’s Health. In 2010, with a second grant from AACAPs Campaign for America’s Kids, the group reconvened, hosted the second annual Forum on Children’s Health, and ultimately developed a proposal for a statewide collaborative care program.

Since that time, the NJ Psychiatric Association has been steadfast in its efforts to advocate for a statewide pediatric integrated collaborative care program. NJPA members have served as consultants in collaborative care pilots and have provided trainings on children’s mental health for primary care providers. Members have also organized meetings with lawmakers and policy makers to review the evidence supporting this model of mental health care delivery.

Advocacy efforts prevailed. In July 2014, the NJ Legislature approved $1.2 million in state funds for a pediatric collaborative care pilot. Funded through the New Jersey Department of Children and Families, Office of Child and Family Health, the Collaborative Mental Health Care Pilot Program was initiated by Meridian Health in partnership with Cooper University Health Care. Best practice standards ensured appropriate screening, assessment, diagnosis and treatment of children, youth and young adults presenting in pediatric primary care settings with emotional and behavioral health concerns.

The pilot originally covered four counties (Monmouth, Ocean, Camden, and Burlington). In its second year, it expanded to seven additional counties (Middlesex, Mercer, Atlantic, Cape May, Cumberland, Gloucester, and Salem).  The pilot project ultimately enrolled 233 primary care providers across 11 counties, screened 34,494 patients for behavioral health disorder, and provided mental health consultation to 1,746 patients.

In July 2017, with both national and state data supporting the efficacy of the model, the NJ legislature approved $5 million for a statewide pediatric integrated collaborative care program. Funds will support the expansion of collaborative care hubs throughout the state. Child and adolescent psychiatrists will continue to serve as physician team leaders, providing consultation to primary care providers and other members of the health care team, as well providing direct patient evaluation as needed. Ultimately, children and youth with emotional and behavioral health disorders will have more timely access to direct evaluation and treatment.