Promising Practices: Goldsboro Pediatrics – North Carolina

A History of Integrated Pediatric and Mental Health Services

In the late 1990’s, pediatricians in the practice engaged in professional development through the National Institute for Children’s Health Quality (NICHQ) to better understand attention deficit disorder and the role of mental health services in supporting child development. Simultaneously, the practice began the school health program integrating health centers within local school system through the Wayne Initiative for School Health (the WISH program) and engaged mental health providers to work with children at risk within the school system. Using these experiences, the practice began to explore an integrated mental health services model during the early 2000’s. Through connections with the University of North Carolina School of Medicine, the practice hired a child psychologist to ensure patients’ access to mental health services. Additionally, the practice integrated a clinical social worker onsite and a child and adolescent psychiatrist who provides telepsychiatry services.

Psycho-Social and Mental Health Screening and Developmental Monitoring

Goldsboro Pediatrics provides care for the approximately 1,500 babies born each a year in the local hospital in Wayne County, North Carolina. Several tools are used to gather information about family well-being, including mental health. After birth, practice staff use the Edinburgh Postnatal Depression Scale (EPDS) at 2 weeks, 2 months, 4 months and 6 months during health supervision visits. Staff also use Parents Evaluation of Developmental Status (PEDS) while partners in the local Early Head Start/Head Start use the Ages and Stages Development Screener which can be shared with the practice. Additionally, a psycho-social screening is conducted by public and private sector prenatal care clinic staff who partner with Goldsboro Pediatrics as a component of the pregnancy medical home model. This tool gathers in-depth information on social drivers of health that is available when patients begin services through the practice. This is possible through a collaborative American Academy of Pediatrics (AAP)-funded project, Community Access to Child Health (CATCH), focused on ensuring information traveled with the patient so all perinatal providers working with families could access the information to improve perinatal outcomes. The practice ensured the psycho-social screening process is uniform across private and public perinatal care settings, and that paths of communication involving prenatal clinics, labor/delivery hospital staff, and Goldsboro Pediatrics staff were optimal.

Health Department Care Coordinators funded through Medicaid (Care Management of At-Risk Children (CMARC)), along with community-based Medicaid care coordinators (Community Care of NC Program) also serve as partners in identifying and providing for family needs. The care coordinators share information and referrals with providers who work with families. Family health histories are gathered within the Goldsboro Pediatrics electronic health record (EHR) so that all providers can access this information. Additionally, providers connect with families during health visits to understand family needs, gathering information within the EHR about social drivers of health and mental health needs. When providers refer families for additional services, they can follow up on these recommendations, identifying whether referrals lead to services for children and families.

Collaboration to Identify and Address Mental Health and Psycho-Social Needs

Goldsboro Pediatrics has long-standing relationships with mental health and community services programs throughout Wayne County. As a member of several local projects including CATCH and the WISH Project, staff from Goldsboro Pediatrics engage in strategic planning to address mental health and psycho-social needs of children and families. Participants in these projects include representatives from the local Early Head Start/Head Start, Women, Infants, and Children (WIC), home visiting, early intervention, local health department, maternal and child health, obstetricians/gynecologists, social workers from the hospital and local department of social services, agencies serving people who are homeless, the public schools, the Wayne County Partnership for Children, and organizations addressing food insecurity, housing, transportation, and mental health/substance use needs.

Working together, these groups focus directly on the social drivers of health in the community they serve, identifying challenges families are facing and creating systemic solutions to problems. One example of a solution was a collaboration initiated by Goldsboro Pediatrics’ lactation consultant with a local mental health counselor interested in perinatal health. Parents who had elevated scores on the EPDS met monthly for peer-support and guidance. Several community organizations have contact points where information could be gathered and shared with service providers. As a part of enrollment in services, these community organizations include forms to ask parent/legal guardian consent to share information, streamlining coordination to comply with the Health Insurance Portability and Accountability Act (HIPAA) and the Family Education Rights and Protections Act (FERPA) requirements.

Most importantly, collaborative activities have reinforced relationships between Goldsboro Pediatrics’ providers and community organizations. Through ongoing communication and coordination, providers enhance the rate of follow up and improve service delivery to ensure families’ needs are met. Many of these partners can access the practice’s EHR so that they are all working from the same data systems to share information and conduct follow-up easily.

Professional Development and Scheduling Systems to Support Mental Health Services and Address Social Drivers of Health

An integral component of the practice’s success is a systemic professional development forum (Category I Continuing Medical Education Program) conducted on most Tuesday evenings. Mental health topics are integrated throughout these sessions, engaging staff, consultants, and partners to promote awareness of and solutions to mental health and other psychosocial problems. Offering these sessions ensures staff have the skills needed to identify and address concerns. All providers and essential community partners are invited to these sessions; the practice offers flexibility to allow providers to focus on their interests and specializations. Monthly provider meetings also include care coordination to identify needs and solutions for children and families.

Because certain providers are more deeply engaged in mental health and social drivers of health, schedulers and nurses often will direct patients to specific physicians for visits and services. Being a close-knit practice allows administrative staff the ability to direct specific patients to the physicians best suited to their needs. Using information from the EHR, including screening information and family history, staff can pinpoint family needs and ensure that providers with expertise are available to provide services. Often families will see more than one provider, but services always are available to support families due to the depth of expertise within the practice and the integrated mental health approach.

Lessons Learned

There is a deep connection between social drivers of health and optimal health and developmental outcomes for children. Advocacy for integrated mental health services is a critical piece of success. Because current systems do not offer parity for mental health services, Goldsboro Pediatrics collaborates with state systems and community partners to deliver quality mental health services and meet needs of patients and families. Additionally, existing screeners for social drivers of health may not capture all the information needed to address concerns. Deep collaborations with partners and ongoing support of families in health supervision visits are some of the best ways to identify and address these needs. Additionally, education and awareness campaigns regarding community resource systems (such as the 2-1-1 system) need to be more prevalent in communities with high need to increase access to food, housing, transportation and mental health/substance use services. In order to enhance the 2-1-1 telephone system, North Carolina is implementing the NCCARE360 on-line two-way communication platform for assisting families needing services related to Social Determinants of Health. Families needing assistance meeting needs such as food, transportation, housing, and those dealing with domestic violence, substance abuse, and mental health disorders can log onto www.NCCARE360.org to seek assistance.

When primary care providers want to assure patient access to behavioral health services, an integrated service model can improve productivity of the primary care providers, adherence of families to treatment, and lessen time/cost associated with finding referrals for families. However, practices might face challenges in implementing this model, including hiring mental health professionals to work in their practices, credentialing providers with payers, filing accurately coded claims with payers and being fairly paid for services provided by mental health professionals. To address these challenges, Goldsboro Pediatrics modified the model in the school-based health centers so that the centers provide consultation space, assistance with parental permission for mental health services, help scheduling appointments and access to third party payer information for the mental health professionals to bill for services from their private offices.

Ultimately, physicians need to identify payment and administrative policies that work best for them in an integrated model, including knowing how to document and bill for services to address mental health and social drivers of health. The August 18, 2022 Center for Medicaid and CHIP Services (CMCS) Informational Bulletin reiterated requirements for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefits. The bulletin provides recommendation on how states can support provision of behavioral health services through Medicaid, CHIP, and other federal funding sources. Further reading: AAP Coding Fact Sheets.