The Michigan Child Collaborative Care Program: Building a Telepsychiatry Consultation Service

Approximately 13% of youths in the United States have a behavioral health condition, and most do not receive effective treatment (1). Inadequate treatment is associated with school failure, unstable employment, substance use, violence, and co-occurring mental disorders (2). There is a shortage of child and adolescent psychiatrists, and the vast majority of counties in Michigan have no child and adolescent psychiatrists (see map in the online supplement). Thus, many pediatric behavioral health problems are diagnosed and treated within primary care practices (3–5). Primary care providers (PCPs) report gaps in training in mental health and may lack the resources to detect and manage these conditions (6). In the state of Michigan, psychosocial risk factors are considerably elevated, with 1 in 5 children growing up in poverty (7). The mismatch of significant risk and need with limited treatment resources results in a high risk of unaddressed childhood mental illness and increasing risk of morbidity, poor functioning, and poor quality of life.

Phone and telepsychiatry consultations enhance access to child behavioral health specialists and are currently promoted through the National Network of Child Psychiatry Access Programs (www.nncpap.org) (8, 9). These programs are cost-effective, well accepted by families and PCPs, and enable PCPs to consult with a panel of child and adolescent psychiatrists.

This column describes the Michigan Child Collaborative Care (MC3) program at the University of Michigan Department of Psychiatry. This program differs from previously described telepsychiatry programs in several ways (8–10). First, the program provides consultation to PCPs treating youths and perinatal women. Second, the program involves strategic partnerships with the Michigan Department of Health and Human Services (MDHHS), the Michigan Department of Education, and local community mental health agencies throughout the state, and leverages other state and university networks. Third, the program handles referrals from school-based primary care clinics, providing consultation in the care of rural youths who receive primary care services within their schools. Fourth, because of extreme specialist shortages in Michigan, the symptoms of the children discussed are frequently moderate to severe. Finally, the behavioral health consultants provide operations-related consultation to assist PCPs in establishing workflow processes to integrate MC3 services and mental health screening within their primary care practices.

Program Description

The MC3 program is a phone and video-based telepsychiatry consultation program for PCPs and their patients, serving youths through age 26 years and pregnant and postpartum women of all ages. Prescribing PCPs in clinics and school-based child and adolescent health centers are eligible for enrollment in MC3. Behavioral health consultants provide regional coverage to primary care practices, facilitating phone consultations and connection to local resources. They form a statewide phone network to ensure rapid responses to calls each day.

The BHCs are masters-level mental health professionals who are funded by the grant but recruited, hired, and supervised by the local community mental health services programs. They receive ongoing supervision and participate in relevant continuing education from the MC3 team. Behavioral health consultants may be embedded part-time and provide brief interventions and care coordination and referral. They also work with the PCPs’ administrative and practice staffs to develop a tailored, clinical workflow for patients.

To better evaluate youths and perinatal women with complex mental health needs, the BHC, psychiatrist, and PCP may consider whether a video consultation is appropriate. The psychiatrist does not prescribe in either the phone or video consultation, but makes recommendations for evidence-based medications, psychotherapy, and/or additional testing to the PCP. Discussions may also entail family interventions, school-based interventions, and review of other systems of care. Additional consultations are encouraged if medication adjustment or further diagnostic clarification is needed. PCPs may also schedule group case consultations to allow their staff members to learn together using case-based and didactic formats.

Strategic Partnerships

Prior to the program’s inception and throughout its development, the MC3 team worked with key state and university partners to guide programmatic priorities and geographic expansion. These partnerships have been critical to the growth and success of the program and to MC3’s broad acceptance and promotion throughout Michigan. The MC3 team met initially with leadership at the MDHHS Mental Health Services to Children and Families Division, which provided inroads to the state’s community mental health system. Strong relationships between the community mental health agencies and MC3 were critical for collaborative planning and to enable patients with moderate to severe illness covered by Medicaid to readily access the community mental health system. The MDHHS provided introductions to community mental health leadership in key areas, and local behavioral health consultants were hired by the community mental health agencies. The relationship with MDHHS has also fostered culturally competent educational programs which meet the needs of the state’s diverse population, which includes African-American, Hispanic, Arab-American, and Native-American populations.

The MDHHS has also been instrumental in enabling the MC3 team to appear before key legislators and in facilitating joint meetings with state Medicaid payers, who work with MC3 program leadership on sustainability strategies, including development of billing codes that might cover components of services provided.

Partnership with the Michigan Department of Education was key to developing arrangements with school-based health centers to provide individual and group consultations to their nurse practitioners. Michigan also has a well-defined Children’s Trauma Network, and there has been a reciprocal relationship between MC3 and the network, providing MC3 clinicians with advanced training in trauma-informed care and a referral source for clinicians trained in trauma-focused cognitive-behavioral therapy.

Additionally, MC3 has forged relationships with other University of Michigan programs serving the mental health needs of the state’s population. These linkages have been instrumental in decreasing the “silos” that often exist within large programs and allowing MC3 to function as a central hub providing access to other programs and networks. For example, the Michigan Opioid Collaborative, which provides consultations to clinicians caring for patients with opioid use disorders, has been modeled after MC3. The PCPs treating adolescents and young adults with co-occurring disorders can now receive consultations across programs.

Relationships with pediatricians in various regions of Michigan who were early adopters and champions of the program helped shape components of the program, including delivery of didactic presentations, to appropriately meet the needs of PCPs in rural and urban areas. These relationships resulted in partnerships with the Michigan chapter of the American Academy of Pediatrics, whose endorsement of MC3 further contributed to the program’s success. Inclusion of MC3 leadership on key committees also promoted education of the academy’s membership on behavioral health topics.

These partnerships took time to develop and, in many cases, delayed decision-making and program launch in some geographic areas. However, the resulting stakeholder buy-in and assistance with implementation were invaluable and continue to be critical to program success and sustainability and as well as to the health of youths and pregnant and postpartum women with moderate to severe mental health disorders.

Provider Enrollment and Engagement

The MC3 team expands its geographic service areas by following guidance from strategic partners (MDHHS and regional community mental health leadership), estimating the percentage of behavioral health consultant effort required to serve the new region, and coordinating hiring as needed. With the behavioral health consultant in place, the team approaches local PCP offices by phone, e-mail, and in-person visits, often leveraging relationships with physician champions in the area. An informational breakfast or luncheon meeting for the PCP’s clinical staff is scheduled with an MC3 psychiatrist and the behavioral health consultant. Interested PCPs can enroll in the program at that time or later. After enrollment, behavioral health consultants meet with the PCP’s administrative and clinical staff to enhance mental health screening for common conditions and to discuss optimal integration of the MC3 program into the primary care practice. Participating PCPs receive access to MC3 Web-based educational modules on common mental health conditions. Regular visits from the behavioral health consultant and ongoing communications from the MC3 program, including notices of new educational modules and webinars, facilitate sustained engagement. A laminated psychopharmacology card deck developed by MC3 psychiatry faculty provides PCPs with pharmacotherapy guidance and is an easily viewed program reminder.

Funding, Equipment, and Documentation

The MDHHS underwrites the costs for the behavioral health consultant effort and psychiatry clinical effort for phone consultation, with matching funds for administrative efforts provided through the MDHHS’s Medicaid match program. MC3 purchased a HIPAA-compliant videoconferencing platform (Polycom, Inc.), and mobile units were installed at local community mental health offices. Laptops and tablet computers were purchased for the video sessions in PCP offices. The Blue Jeans video conferencing platform (Blue Jeans Network, Inc.) is commonly used for enrollment meetings and group case consultations when in-person meetings are not possible.

MC3 psychiatrists and behavioral health consultants document consultations in a HIPAA-compliant and secure electronic record that can be remotely accessed on multiple mobile devices. The behavioral health consultant records the presenting concern and relevant clinical information. The psychiatrist reviews the record, contacts the PCP, and documents the conversation with the PCP, which includes providing guidance on how the psychiatric differential diagnosis was made and recommendations in the following domains: pharmacotherapy, psychotherapy, community resources, testing, self-help, follow-up instructions for the behavioral health consultant, and the need for higher levels of care or additional MC3 consultations. The behavioral health consultant conveys the recommendations to the PCP after adding community and psychotherapy resources conforming to the patient’s insurance.

From 2012 to 2018, the MC3 program enrolled 2,121 PCPs in 519 clinics across 63 counties and 33 community mental health regions in Michigan. Of the 842 PCPs (40%) who have enrolled in MC3 for services, the majority (97%) reported being satisfied and/or very satisfied with MC3 services.

There have been 10,445 service requests for 9,007 patients. Patients have ranged in age from 0–45 years (see online supplement). Service requests were for psychiatrist-to-PCP diagnostic and psychopharmacology consultations (39%), direct services to patients by BHC embedded in the PCP’s practice (43%), and information-only services (referral, triage, local information, and payer questions) provided by the BHC (14%). Other requested services included embedded psychiatry services (2%), group case consultations (2%), and video evaluations (<1%).

Of 4,103 psychiatrist-to-PCP consultations, a range of diagnoses was considered by the consulting psychiatrist. The most common diagnoses were anxiety, attention-deficit hyperactivity disorder, and major depressive disorder, but other disorders were also discussed (see online supplement), including autism and other developmental concerns and substance abuse. Trauma was perceived to be a co-occurring concern by the psychiatrists in 9% of cases. Perinatal women accounted for 10% of the consultations, with depressive and anxiety disorders most prevalent. Most youths and women discussed in the program (97%) had not seen a psychiatrist for the presenting concern, and the consultation through their PCP constituted their sole access to a child, adolescent, or perinatal psychiatrist. The majority of patients (67%) were taking pharmacotherapy at the time of the initial call, with an average of 1.8 prescribed medications per patient; medication use varied according to age group (see online supplement). All categories of psychotropic medications were discussed during the consultations, with stimulants and alpha−2 agonists commonly discussed for young children, stimulants and selective serotonin reuptake inhibitors (SSRIs) discussed for children ages 6 to puberty and adolescents, and SSRIs and mood stabilizers for adolescents. Patient symptom severity, assessed by the psychiatrists, was often moderate to severe (58%). The MC3 psychiatrist team responded to medication requests with comprehensive recommendations regarding dosage, titration schedule, monitoring practices, and other safety caveats (e.g., suicidality, agitation with SSRIs).

A cost analysis of program services is underway, including an effort to establish cost per unit of service by examining average times spent by type of provider for specific MC3 components. We are continuing to explore best methodologies to determine true costs.

Conclusions

PCPs are often the first-line providers in the evaluation and management of treatment of youths and pregnant and postpartum women with behavioral health issues, particularly in underserved areas. Programs such as MC3 provide PCPs with access to support for patients with mental health issues, effectively leveraging scarce child and perinatal psychiatry resources. PCPs have reported high levels of satisfaction with this program, which supports them across a spectrum of patient illness severity. Partnerships with state leadership and regional community mental health agencies have been critical to the program’s success and expansion.