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Development of Integrated Mental Health Services within Pediatric

Ambulatory Settings across an Academic Medical Center:

A Beginners Guide to Getting

Started with Integrated Care

James Waxmonsky, M.D.

Associate Professor,
Child and Adolescent Psychiatry,
Penn State Hershey College of
Division Chief of the Child and
Adolescent Psychiatry
Hershey Medical Center

Lidija Petrovic-Dovat , M.D.

Assistant Professor,
Child and Adolescent Psychiatry,
Penn State Hershey College of Medicine
Associate Director of Pediatric Behavioral
Health Collaborative Care Program
Hershey Medical Center

Presenters Disclosure

Consultant Advisory



(past 3 years)

Speakers Research




Dr. Petrovic-Dovat has no disclosures

Revised Integration Framework

(Heath 2013)

Coordinated Care: Levels 1&2 (minimal/at a distance)

Co-located Care (physical proximity)

Level 3 Basic Onsite: same facility but may not share same
practice space or records; still separate systems

Level 4 Close Collaboration: shared space and systems with

an embedded BH provider but still practice independently
Integrated Care (practice change/merging cultures)

Level 5 Approaching an Integrated Practice: team problem

solving with frequent communication and modified practice
structure to promote integration but some separate parts

Level 6 Merged Practice: single system treating the whole


Collaboration: bringing resources together

Integration: how services are delivered and organized

What We Had: Walls and Obstacles

Two Separate Systems: mental health services at HMC and Pinnacle

merged to form PPI (was level 3)
No longer any inpatient outpatient psych care at HMC campus other than
inpatient CL that didnt cover emergency department
Different staff, different EHR, and largely different patient populations
Long waits for HMC patients to receive mental health services with low
levels of satisfaction from primary care teams
We were level 1

Jackpot: Changes to our System

New Hospital CEO, & Pediatrics Chair who valued

mental health services
Vice Chair for Clinical Services in Pediatrics with a
mental health background
New Director of Outpatient Pediatrics who felt primary
care needs to treat mental health issues
Three general pediatrics clinics with largest on main
campus with 36,000 annual visits,18 providers and 75%
private insurance but short on space
Two satellite pediatric clinics within 30 miles (30 mins)
whose patients frequently come to main campus

Our Institutional Requests

Bringing back outpatient clinic under the Penn

State umbrella with same EHR
Targeted hires for CL and outpatient staffing to
provide services to HMC
License Pediatrics Clinics to be credentialed for
behavioral health services
Adjustment to internal billing so BH retains staff
generated revenues and recognition that some
IC components dont generate revenue
Short Term Goal: get to Level 4 in one year
Two years: Level 5

General Pediatrics Needs Assessment

Priority was guidance on psychopharmacology and

linkage to psychiatry services for complicated cases
Next was providing diagnostic clarity
They were willing to prescribe initial treatments
Felt like they could get their patients linked to
psychosocial services in the community and had
methods to handle emergency assessment
Barriers: limited space, not licensed for BH, limited
nursing staff, linking to on-call system, PCCs werent
going to fill out lengthy intake forms


(AACAP 2010)

Patient, PCC and CAP satisfaction (Kolko 2014, Richardson 2015)

Wait times for behavioral health service in primary care
and psychiatry
Use of EBPs in primary care (Kolko 2014, Richardson 2015, Silverstein 2015)
Improved initiation and persistence of treatment

(Kolko 2014, Richardson 2015, Silverstein 2015)

Symptom, impairment and caregiver strain measures

(Kolko 2014, Richardson 2015, Silverstein 2015)

Usage of high intensity medical services and behavioral

health treatments (Pitt Childrens Data AACAP 2015)
Costs ????

Program Expansion
September 2014

December 2014
Two Clinics per
month focus
Disorders ages
8+ (1 BHC)

Added phone
consults 5
days a week

February 2015
Four clinics per
month with Int
and Ext focus;
ages 4+; added
brief psych

May 2015
Added therapy
services in
specialty peds,
joint initiatives, GI
clinic (4 BHCs)

Our Communication Protocol

Use of EHR is default
Created peds psych message pool with rotating
clinician coverage for it (level 5)
PCC clinic note addresses acute mental health issue
IC team advises as to what level of service needed
PCC selects specific BH service via HER
Patients can be referred for any service from any site
Regular meetings with clinician and intake coordinator
to identify cases stuck in pipeline
PCC feedback-

Easier to refer
Scheduling on site makes a differences
Knowing the people scheduling makes it easier
E-messaging is much easier than making phone call or filling out forms

Program feedback; Providers satisfaction survey at the Penn State

Hershey: Please rate the process of ease of referral to the
Collaborative Care Clinic

Very easy






Very Hard

Providers satisfaction survey: Average wait time for

the initial BH assessment at the Gen Peds Clinic

Shorter than


What I expected




Went from 12 weeks + to under 4 weeks for BH clinic
Show rates for PC visits were 90%+

Longer than
Much longer

The Experience of the BH Providers

Similar to data reported by Norfleet et al., 2016

Bumps on the way

PCCs balked at 1 page referral form

Getting everything referred

Solution: ?? Psych bills brought back to psych admin staff vs having peds submit them (level 3)

Archaic and Idiosyncratic MH site licensure approval process

Solution: Peds clinic to expand with new therapy rooms (move towards level 6)

Billing issues: dont have integrated bill

Solution (pending): sign out PCC that psychiatrist meets with that clinic day

Workspace limitations

Solution: in house PC champions for the program, institutional push that mental health starts in PC

Delay between consult and treatment initiation

Solution: point person at PC clinic quit; identified new one and started IC EHR review team

Resistant PCCs

Solution: EHR review by BHC teams and expansion of groups as initial treatment options

2 month decrease in fill and show rates

Solution: Dropped for 2-3 line EMR based consult with inclusion of completed screeners and verification
that not emergent or in clear need of long term BH care; BHC reviews last note in EHR

Appealing to the State of PA

Increasing wait times at PC clinic

Solution: increased phone consult services; add more consult slots; care managers in primary care

Program Expansion: from Primary Care to


Most youth receiving specialty services dont have a HMC PCC

Specialty peds mostly located in one suite that was licensed for BH
Specialists were not comfortable managing any med outside of
their primary domain
Most of their cases were not linked with therapy and had no care
management to assist with this
Standard case: mid grade anxiety/mood symptoms with recurrent
physical symptoms and issues with adherence
Solution: created similar review team for specialty care and
embedded MSW therapist at site who also works in BH clinic
MSW hired through psychiatry for this position with PhD
supervising and developing programming
Focuses on short term therapy level 4 integration
Free 15 minutes of every hour to meet patients/engage providers

Approaching Level 6: Peds GI

Initial step: psychiatry faculty attend Peds GI rounds

Peds GI pilot funded a project to embed PhD to perform brief
assessments of screen positive mood/anxiety cases once a month
PhD time billed using Health and Behavior Assessment and Intervention
(96150/151) Codes
Developed group CBT program for children with anxiety with chronic
medical illness (housed at BH clinic)
At same time, MSW hired for specialty peds where GI is located so can do
warm handoff 3 days a week
PhD verified screen positive cases now sent to

Anxiety group at BH clinic (25%)

Individual short term therapy with embedded MSW at Specialty Peds (25%)
Community based services (10%)
Psychiatry assessment at BH clinic (5%)
To HMC PMD to start psychotropic (10%)
Individual therapy with PhD at BH clinic (most challenging cases) (25%)

Under 1 in 3 cases coming back to BH clinic for individual services despite

increase in detection

Penn State Hershey Experience

Essentials: champion and administrative point

person in Primary Care and BH, shared EHR,
willingness to absorb some up front costs,
faculty interested in model
Critical step: clinic based needs assessmentevery clinic is different
Maintenance: regular meetings and replace lost
point people
Managing flow: clinical expertise for screening
process and implement stepped care models

Penn State Hershey Pediatric Integrated Care Program

Department of Psychiatry, Division of Child and Adolescent Psychiatry

James Waxmonsky, M.D. Director

Division of Child and Adolescent Psychiatry

Lidija Petrovic-Dovat M.D.

Associate Director of Pediatric Behavioral Health Collaborative Care Program

Timothy Zeiger, PsyD

Jolene Hilwig Garcia, M.D.
Jasmine Marini, LPC
Stephanie Ebersole BA

Department of Pediatrics

Sarah Iriana, M.D. Associate Division Chief

Ben Fogel, M.D. Medical Director Primary Care Hope Drive Clinic
Rachelle Jones, BA