Recognizing the shared challenges facing pediatric providers for serving the health of AI/AN and rural communities, a joint AAP Indian Health and Rural Health SIG Listserv® discussion was launched on 1/23/06 by Dr. Steve Holve, Indian Health Service Chief Clinical Consultant in Pediatrics.  The following excerpts were presented in the invitation:

“Through this Listserv® discussion, we would like to explore the difficulties and frustrations as well as satisfaction with model programs that are being experienced by primary pediatric care providers encountering mental and behavioral illness among AIAN children and youth, as well as children and youth who reside in rural settings.

• How are mental and behavioral health services being delivered in your various clinical and community settings?
• What works, and what else is needed to address these problems?
• What triumphs are experienced? What programs out there that could be generalized more widely to meet the challenges?
• Do you have any suggestions for improving cross-specialty consultation processes?
• Any ideas regarding optimal electronic medical record (EMR) strategies for serving AI/AN youth?
• Does your clinic utilize telemedicine/telepsychiatry supports? Perils and promises?
• Do you have experiences or resources to share, such as the Massachusetts Child Psychiatry Access Project (MCPAP)?
• Does your program have links to community-based projects and/or traditional/complementary healing practices (such as the Circles of Care projects)?”

 

The following is a summary of the Listserv® Dialogue.

We want to commend the thoughtful perspectives provided by our respondents Drs Wegehaupt, Greenberg, Handal, Ratmeyer, Campbell, Byron, Fatimi, Jarvis, Oski, Holve, Gold, Poinsett, Rushton, Blaschke, and Kairys, Novins and Levenson. We offer special thanks for guidance from Sunnah Kim, MS, CPNP –AAP CONACH Coordinator and Linda Paul, MPH – AAP Manager, Mental Health Initiatives.

Listserv® Discussion themes included:

• The pressing need by pediatricians for consultation on problems more complex than “routine” ADHD – problems such as Aspergers disorder, bipolar disorder, and severe post-traumatic stress disorder.
• A call for the development of training modules for competencies in child mental health – there was a call for a two-day intensive training curricula at national meetings.
• Sharing strategies for surviving low rates of funding for mental health services.
• The need for AAP and other support for provision of networks of psychiatric specialty consultants who have access to telemedicine.
• The necessity and complexity of building relationships with local social service and school organizations.
• The challenges of fostering community-centered approaches to mental health problems.
• Training and retaining professionals who hail from the community and thereby have intrinsic cultural competence.
• Laments over the difficulties of recruiting and retaining pediatric psychiatrists to rural and underserved areas.
• Support for more training for such specific therapies as Trauma-focused Cognitive Behavioral Therapy, Motivational Interviewing, and guides such as Bill Coleman's book Family-Focused Behavioral Pediatrics.
• Improvements in utilization of pediatric psychiatrists so as to balance direct service and individual/group consultation to more efficiently serve community needs (and, for the psychiatrists, to foster their resilience and serenity).
• Encouragement for restructuring elements of pediatric residency training so as to better prepare residents for providing care for seriously distressed kids.
• Developing models of pediatric clinic-flow/pediatric practice to allow more time for some kids or more time-per-kid for some clinics (such as school clinics) as well as foster support for home-based services including, selectively, home visits by pediatricians.
• Lobbying for a US health care system that is more focused on prevention of psychosocial distress (and less driven by crisis-driven service and acute care funding).
• Facilitating pediatrician awareness of up-to-date trends in pediatric psychopharmacology.
• The need for a clearinghouse/website for useful questionnaires and tools for pediatric mental health.
• Bolstering strategies for improving third party reimbursements.
• Tapping into current AAP projects such as the Community Pediatrics Training Initiative, the Task Force on Mental Health (TFOMH), the Improving Mental Health in Primary Care Through Access, Collaboration, and Treatment (IMPACT) grant, and such websites as www.pediatricsinpractice.org; www.brightfutureseducation.org.
• Establishing Listserv follow-up conference calls to coalesce interests/expertise among Indian Health and Rural Health SIG and selected pediatric psychiatrists.
• Augmentation of electronic medical recordkeeping to allow for more efficient continuity and contact between providers across rural/urban, state/state, boarding school placements, etc.

In response to many of the above comments and concerns, we would like to list a series of possible strategies that could be adopted to address the identified systemic deficiencies regarding mental health services in rural and AI/AN communities.  These strategies could be initiated locally, regionally, or nationally by various agencies and groups.  Some are already underway.

1. calling for national (or preferably regional) consultation lines (something akin to a "crisis hotline") for providers to get immediate perspective on a specific mental health treatment quandry. Could IHS help sponsor something like this? Initial inquiries have been made to the Massachusetts Child Psychiatry Access Project (MCPAP).
2. beginning planning for an AAP NCE or other national meeting focusing on behavioral health skills for the primary care provider. . .including some of the above topics and more.
3. highlighting existing success stories and model treatment programs from communities that are solving their challenges.
4. enhancing efforts to orient psychiatrists who provide consultation and/or direct service to AI/AN and rural settings, to methods of consultation that are most useful for primary clinicians.
5. developing a position statement that encourages more extensive pediatric primary mental health care training in pediatrics/family medicine residencies.
6. pressing the American Academy of Child and Adolescent Psychiatry (AACAP) and other guilds to augment their efforts to help recruit/encourage psychiatrists and ARNP's and other mental health providers to practice in AI/AN and rural communities.
7. fostering enhanced collaboration between the Indian Health Service and the Bureau of Indian Affairs in an effort to better serve the daunting health care needs of the nearly 10,000 AI/AN youth in boarding schools.
8. increasing the presence of Physical/Occupational/Speech and Language Therapists in AI/AN and rural communities where there exists a critical shortage.
9. recommending increased support of the AAP Task Force on Mental Health (TFOMH) to hasten accomplishment of the goals and activities of the Improving Mental Health in Primary Care Through Access, Collaboration, and Treatment (IMPACT) grant (please refer to the contribution to the Listserv discussion entered by the AAP's Linda Paul for the exciting details).

Thank you all for participating in and following this interesting and revealing Listerv discussion. Hopefully we will soon see movement onmany of the issues that were raised and experience significant improvement in our ability to serve the mental health needs of our AI/AN and rural communities. We look forward to our collaborations along the way!

Mick Storck, MD, AACAP Liaison to the CONACH
Douglas H. Esposito, MD, MPH, FAAP