Literature Collection

The integration of behavioral health and serious mental illness assessment and treatment into primary care remains a challenge. While the increase in telehealth usage due to the COVID-19 pandemic helped reduce a key barrier to access, other challenges remain including a shortage of trained providers and an increased demand for services. A collaboration between ECHO-Chicago and Americares established a unique virtual medical education program that provided training and telementoring using the Project ECHO model with the integration of clinic-wide quality improvement (QI) projects. In this paper, we outline the process of adapting the existing Project ECHO(®) (Extension for Community Health Outcomes) series on behavioral health integration and serious mental illness to fit the needs of Free and Charitable Clinics (FCCs). This project highlights the process and organizational-wide outcomes of creating a partnership between an ECHO hub and a national cross-section of FCCs to create a telehealth program to improve mental healthcare delivery within the FCC space that can be replicated and scaled more broadly. Through this process, we highlight evaluation methods to examine the impact of ECHO series beyond the individual to the clinic-wide level.

INTRODUCTION: Individuals with single ventricle congenital heart disease and Fontan circulation are at high risk for mental health problems. There is a lack of information about potential care models to address these common challenges. This study describes the innovative integration of psychology consultations into a multidisciplinary clinic for pediatric patients with Fontan circulation. Findings from emotional/behavioral and quality-of-life measures are reported and relationships between these variables are explored. METHOD: The Fontan Rehabilitation, Wellness and Resilience Development (FORWARD) Program at Children's Hospital of Philadelphia is a multidisciplinary clinic for individuals with Fontan circulation. A psychologist provides behavioral health consultations to all clinic patients. The psychologist engages in real-time care coordination and treatment planning with the multidisciplinary team. Families are administered standardized screening questionnaires assessing child emotional/behavioral functioning (Behavior Assessment System for Children-3) and quality-of-life (Pediatric Cardiac Quality of Life Inventory). The psychologist provides brief behavioral intervention and recommendations for follow up care. Patient data were gathered by chart review. Correlations explored the relations between selected screening measures. RESULTS: 158 patients (mean age = 12.5 years) were seen between January 2019 - June 2022. 92% completed a psychology consultation. Most had hypoplastic left heart syndrome (54%), were male, White, and had commercial insurance. A majority completed at least one of the screening measures. Elevated symptoms were found for 23% of the sample for depression/anxiety, 37% for inattention, and 22% reported school problems. Findings from the quality-of-life measure showed mild to moderate impairment for the sample. Greater inattention, depression/anxiety, and school problems correlated with lower quality-of-life scores. DISCUSSION: This study demonstrates the feasibility of innovatively implementing regular psychology consultations into a multidisciplinary clinic for children and adolescents with Fontan circulation. Greater emotional/behavioral problems were associated with poorer quality-of-life. Fully integrated care models that include including behavioral screening measures are optimal to address emotional/behavioral challenges in this population. Less resource intensive models could be implemented as pilot programs to establish feasibility and utility. Research is needed to evaluate efficacy of such programs and examine potential links between medical and psychological variables.

Rates of mental health, emotional, and behavioral (MEB) problems in the United States continue to rise, with current estimates of 13% to 20% of children having an MEB disorder and an additional 19% with problems causing impairment or distress that do not meet diagnostic criteria for a specific disorder. This clinical report incorporates and expands on recommendations from the 2019 American Academy of Pediatrics policy statement "Mental Health Competencies for Pediatric Practice" as well as "Recommendations for Preventive Pediatric Health Care." It addresses the rising MEB needs of youth since the previous clinical report, "Promoting Optimal Development: Screening for Behavioral and Emotional Problems," was published in 2015. This report outlines specific guidance for MEB screening, identification, and care of children in pediatric primary care. Screening, as part of regular health supervision visits and surveillance, begins within the first month of life to identify postpartum depression in caregivers. Child-focused screening for MEB problems begins at 6 months of age and continues at 12-, 24-, and 36-month health supervision visits, alternating with recommended developmental and autism spectrum disorder screenings at every visit in the Bright Futures Periodicity schedule and additionally when clinically indicated. After age 3, MEB screening continues annually. This report also 1) reviews updated information on prevalence of MEB problems; 2) articulates the current state of detection of these problems in pediatric primary care; 3) addresses how to manage a positive screen; 4) describes barriers to screening, including special population needs, and potential models to address those barriers; and 5) discusses potential changes at a practice and systems level that facilitate successful MEB screening.