Children’s mental health needs are widespread and treatment is often limited and inadequate. Epidemiologic studies report that 20% of children and adolescents have a psychiatric disorder, and 10% have severe impairment. This translates to 1 million children and adolescents in New York State with a disorder, and 500,000 with severe impairment. Despite the prevalence and impact, less than 50% get any kind of treatment and fewer get mental health treatment. Of those who get treatment it is generally of low intensity and duration. Many of these children could benefit from child psychiatric services and yet there is a dearth and maldistribution of child and adolescent psychiatrists, making access extremely difficult in most situations.
In New York State, child and adolescent psychiatrists are concentrated in urban regions. Out of 62 counties, 26 have no child and adolescent psychiatrists (CAPs) and 9 more have only one. Even in New York City it is difficult to get appointments with CAPs and many do not accept insurance, limiting access further. This story is similar, or worse, in the rest of the Country.
What to do? One prominent solution has been to look to primary care to pick up more of the responsibility for assessing and managing patients with mild to moderate mental health issues. Currently, PCPs prescribe the vast majority, perhaps as much as 85%, of the psychotropics prescribed in the pediatric population. Despite this, PCPs generally feel ill-equipped to assess and manage these conditions. Residents in pediatrics and family medicine receive limited training in child mental health during residency and enter modern day practice needing further training and support, clinically and administratively.
For the past several years several states have developed child & adolescent psychiatry access programs to meet this need. The State of New York Office of Mental Health, under the umbrella Project TEACH, funded two programs (CAP PC and CAPES, child and adolescent psychiatric education service) beginning in 2010. The larger of these programs, Child and Adolescent Psychiatry for Primary Care (CAP PC) has been funded for the past 5 years and recently was renewed for 5 additional years through 2020. CAP PC covers the upstate, New York City, and Long Island, while CAPES covers the eastern part of the state. Each Program aims to provide education and consultation services to PCPs in their catchment regions, although the programs differ in their approach and process. CAP PC has been the 2nd largest child & adolescent psychiatry access program (CPAP) nationally in terms of phone consultations and the largest provider of formal education for PCPs. CAP PC has provided over 15,000 CME hours to over 1000 PCPs.
The goals and vision of CAP PC have been to improve the public health of children and adolescents across New York State by addressing the unmet need for mental health services by (1) Bolstering PCPs’ ability to assess and manage mild-moderate mental health problems, and (2) Promoting collaboration and integration of health and mental health services.
CAP PC has done this by providing formal education to PCPs together with phone consultation support, assistance with linkage/referrals, and face-to-face evaluations in selected situations. CAP PC is unique in its collaboration among 5 university-based child & adolescent psychiatry divisions at the University at Buffalo, University of Rochester, Columbia University Medical Center/NYS Psychiatric Institute, SUNY Upstate Medical University in Syracuse, and Hofstra Northwell School of Medicine. The 5 collaborating sites each have a site team with 2-3 senior CAPs and 1 Liaison Coordinator, who assists with the program broadly, and specifically is responsible for appropriate linkage and referral support for PCPs. The program has one toll-free phone line (1-855-227-7272) and rotates coverage among the 5 teams, with each team covering one day per week. Beginning in 2015 the program expanded to accept calls from all pediatric prescribers, including psychiatrists and child psychiatrists. The phone consultation and linkage/referral support occurs in real time Monday-Thursday 8am-7pm and Friday 8am-5pm. Calls from a CAP are returned on average within one hour. The numbers of calls have increased over time and last year there were over 1600. From inception almost 1900 PCPs have registered for the program and have called to consult about nearly 6000 children and adolescents. One-time face-to-face consultations with Program CAPs are available for selected cases, and are scheduled within 2 weeks. The CAP PC Team works closely together to coordinate planning and assure communication and consistency across the Program in clinical cases.
CAP PC has partnered with the REACH Institute (www.thereachinstitute.org) in the delivery and development of educational programs. The flagship education program has been the REACH-developed Mini-Fellowship in Child and Adolescent Mental Health. This interactive, adult learning, 28-hour CME program focuses on the most common child mental health problems (ADHD, anxiety, depression, and aggression) and was specifically developed for primary care physicians. CAP PC has delivered the REACH training to nearly 600 PCPs in New York. Our internal evaluations as well as an external evaluation have confirmed the success of the program. Beginning in 2013, in order to reach more PCPs, CAP PC began to produce several shorter education programs to PCPs, including teleconferences, webinars, and “core trainings”, a 5-hour on-site program at PCP offices that cover the basics of assessment and management of common problems. All CAP PC programs are provided free of charge to PCPs and include CME credit.
The program has a website you can visit at (www.cappcny.org) that archives many of the educational programs and houses commonly used rating scales and questionnaires, vetted annotated websites, a quarterly newsletter, and other public domain articles. The website has had over 30,000 unique users and over 200,000 hits in the past 3 years.
From the beginning CAP PC has worked closely with the leaders of the New York State and regional Chapters of the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) to evolve the Program. CAP PC has also worked closely with the New York State Office of Mental Health, as well as many other mental health and primary care leaders to promote knowledge of the program.
CAP PC has been extremely well received by PCPs. Overall, 93.4% of consultations were thought to be very helpful or extremely helpful, and 99.2% would recommend the program to other PCPs. These numbers have been consistent from year-to-year. The Program has also conducted annual surveys of PCP participants, and the State has organized 2 external evaluations, all of which strongly support its effectiveness.
In summary, child & adolescent psychiatric access programs are gaining ground nationally as a way to address the dearth of CAPs and expand access to services for children with mental health needs. CAP PC is a collaborative consultation program covering 80% of New York State that is nearly six years old and is uniquely a collaboration of 5 university-based divisions of child & adolescent psychiatry. CAP PC represents a step forward for CAP access programs by combining substantial and robust formal education along with CAP consultation support. By emphasizing formal education, the goal has been to “teach PCPs to fish” rather than to give them fish. Increasing PCP geographic penetration, calls, and awareness of the Program is evident. CAP PC further demonstrates that large-scale collaborative consultation models for primary care are popular with PCPs, feasible to implement, and provide access to child & adolescent psychiatric expertise for patients who would otherwise have none. Outcomes evaluation projects have supported their value, although more are needed.
Dr. Fornari is the Director of Child and Adolescent Psychiatry at the Zucker Hillside Hospital and Professor of Psychiatry and Pediatrics at the Hofstra Northwell School of Medicine. Dr. Kaye is Professor of Psychiatry and Vice Chair for Academic Affairs at the University of Buffalo Jacob School of Medicine. He is the Medical Director of the CAP PC program.