Academic-Community Partnership to Improve Pediatric Mental Health Access: Missouri Child Psychiatry Access Project

Enrollment, utilization, and PCP satisfaction data are used to evaluate implementation of MO-CPAP. By May 2021, MO-CPAP had enrolled more than 500 PCPs statewide and had fielded more than 600 calls for psychiatric and/or care coordination consultation. The geographical distribution of enrolled providers reflects MO-CPAP’s phased implementation approach as well as early engagement and recruitment efforts that prioritized prescribing providers: two-fifths of enrolled providers practice in the eastern region (one of eight MO-CPAP regions in the state) and about 80% of all providers are physicians, and the majority of other enrollees are credentialed as nurse practitioners. In terms of utilization of consultation support, about 40% of enrolled providers have called to collaborate with a CAP and/or care coordinator on patient care. Satisfaction data suggest PCPs believe MO-CPAP helps them meet the needs of children with mild-to-moderate behavioral health challenges and improves patient care in the local setting.

The triad of MO-CPAP resources—consultation, care coordination, and education—is intended to improve support for PCPs in providing behavioral health care and to increase PCPs’ knowledge of, comfort with, and use of evidence-based practices in behavioral health care for children and adolescents, including with screening and prescription of psychotropic medications. PCPs complete a baseline assessment at enrollment and are surveyed at least annually thereafter to evaluate perceived gains. In addition, call data that include patient characteristics, referral questions, diagnoses, potential next steps, teaching points, and referrals are tracked. Preliminary evaluation by PCPs has suggested that MO-CPAP increases access to psychiatric consultation and behavioral health support. Initial findings indicate that MO-CPAP may be supporting PCPs in managing patient behavioral health care in their practices, without need for higher levels of intervention. As shown by CAP disposition documentation after each consultation, the sole disposition of about 60% of all calls is continued care by the PCP (i.e., referral to CAP for consultation and/or transition of care to CAP is not indicated). Investigations are underway to better understand the impact of MO-CPAP on PCPs, patient care, and patient outcomes, but these initial results are promising. Early challenges include recruiting rural providers in some parts of the state and navigating calls about patients who need support outside the scope of primary care settings. Outreach and engagement efforts are evolving in this state’s rural and medically underserved areas, which vary more in terms of available provider types.

The main vehicle for adoption of MO-CPAP is partnerships with diverse stakeholder entities spanning academic institutions, community providers, advocacy organizations, and professional trade organizations. Leveraging existing collaborations and capacity has been particularly important because of the relatively rapid scale-up of the project from a regional pilot project focused on only 15 counties to a statewide program in just over 2 years.

Project advisory or steering committees were initially convened regionally to support pilot and statewide expansion and are now transitioning into a single multidisciplinary statewide entity consisting of PCPs, CAPs, health care leadership, community and advocacy groups, professional organizations, and other committed stakeholders. Steering committee members monitor implementation efforts, recommend refinements to the program, provide valuable and realistic feedback on products (e.g., marketing, practice guides, data collection methods), and guide decision making on processes and outcomes.

MO-CPAP was initially conceptualized as a program offering CAP consultation and ongoing PCP educational opportunities and was subsequently expanded to incorporate care coordination support. MO-CPAP evolution is characterized by rapid iterations informed by need, ongoing quality improvement efforts, and input via steering committee stakeholders. At the outset, CAP consultation was defined as a one-time conversation between a PCP and a CAP to discuss a case. Over time, PCPs have increasingly made multiple calls for support for the same patient. However, the CAP responding may not have fielded the original call and therefore may have no background on the previous consultation. MO-CPAP staff recognized the opportunity for quality improvement in tracking follow-up calls, shifting some cases from the level of a single consultation to a process of ongoing collaboration. Provision of a deidentified case consultation summary outlining the discussion between the CAP and PCP, as well as educational “teaching points” after the consultation, have been received positively by enrolled providers. MO-CPAP has developed a parallel, complementary documentation process for care coordination that is similarly intended to facilitate communication, access to MO-CPAP support, and continuity of patient care. Ongoing MO-CPAP promotion efforts include community outreach to PCP offices, onsite and virtual lunch-and-learn opportunities, and newsletters published every 2 months. In addition to the educational modules, enrolled providers have access to behavioral health toolkits, including medication algorithms, practice parameters from the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry, and evidence-based screening instruments.

The MO-CPAP Sustainability Committee uses data to identify and advocate for funding sources and braided funding strategies and to navigate additional funding opportunities. Three subcommittees (legislative, insurance, and foundation support) were established. The legislative subcommittee’s objective is to develop a strategy to obtain endorsement and support from the Missouri legislature to support ongoing implementation, build awareness of children’s mental health needs, and advocate for a future state budget allocation. The insurance subcommittee’s goal is to develop a strategy for cost sharing and to support managed care organizations and commercial payers in driving systems change to better support PCPs in providing appropriate behavioral health care to pediatric patients. With collaboration and support from state advocacy organizations and professional trade organizations, the project is exploring how families can advocate for MO-CPAP services that are directly available from their PCPs. Marketing and advocacy messaging efforts are aimed at families to increase access to care, decrease stigma, and address parental behavioral health concerns.