This article is part of State of Health, a series examining integrated care and its potential to improve Michiganders' health. It is made possible with funding from the Michigan Health Endowment Fund.
A new trend in pediatric care – offering behavioral health care at the pediatrician’s office – could not only cut costs but also create healthier, happier communities in the future.
“We know children eventually grow up and become adults,” says Michelle Duprey, director of integrated healthcare at Inkster-based Starfish Family Services. “Children with undetected medical and behavioral needs become adults who have more extensive and expensive medical and behavioral needs.”
The costs communities incur as a result aren’t limited to providing care. Adults with untreated mental health issues may find it difficult to hold onto family or relationships, and even harder to hold down a job. Communities not only lose productive members but also experience escalating costs associated with covering social services, substance abuse treatment, and, in some cases, court and incarceration costs.
One of Starfish Family Services’ newest integrated care projects, “One Location, One Visit: Pediatric Integrated Health Care in Wayne County,” is transforming two existing pediatric primary care practices. Using its Pediatric Integrated Health Care model (PIHC), Starfish integrates behavioral and medical care for children by deploying Behavioral Health Consultants (BHCs) to primary care, pediatric, and OB/GYN practices.
“When it comes to programming for behavioral health and mental health, a lot of times our system makes rules and programs for adults and forgets the kids. Well, when we do the same thing for the kids (as for adults), it doesn’t work,” Duprey says. “Children have many developmental stages between (age) 1 and 21 and so many different risk factors. … (Mental health issues) you see in an adult started in childhood most of the time.”
Duprey is a national subject matter expert who literally wrote the book on PIHC: the "Pediatric Integrated Health Care Manual". The focus of her career has been integrating mental and behavioral health into primary care, pediatric, and obstetric practices. It hasn’t been an easy task. For one, neither public nor private health insurance systems have developed fair payment systems for integrated care. Starfish Services’ projects have had to seek grant funding in order to keep integrated practices afloat.
Second, medical doctors often feel their role is solely to do medical work. They may fear that lack of time, training, and resources for referrals will make adding mental health services cumbersome and impractical. Duprey says she had to “pound the pavement” to find two pediatric practices to join the new program. One of the pediatricians was skeptical, but relented and let her give it a try.
“After a year, he said, ‘I don’t think I can practice without you. You’ve transformed my viewpoint of whole-person care and whole-family care,’” Duprey says.
Pediatricians who do give it a try find that integrating behavioral health into their practices creates efficiencies. When a patient makes a behavioral health need known, the pediatrician can hand the patient off and move on to their next appointment.
“The behavioral health worker provides resources, action plans, and brief interventions,” Duprey says. “If a client is identified as needing more help, we help them navigate that (mental health) system because we know it.”
Vice versa: Judson Center
With services in Wayne, Washtenaw, Oakland, Genesee, and Macomb counties, Judson Center is integrating care the other way around. Historically a provider of behavioral health services, its latest project, launched in February 2019, adds primary care to its menu of services. Using the Patient Centered Medical Home Model (PCMH), the new clinic addresses patients’ needs holistically with consideration for their social determinants of health. In addition to medical and mental health, patients benefit from adjuncts like nutritional counseling, educational programming, and introduction to other community resources.
“We knew it was important to have a clinic that could provide whole-person care, most specifically to a behavioral health population,” says Susan Salhaney, chief operating officer of Judson Center. “We have our largest behavioral health clinic in Macomb County. 50% of those folks refer through community mental health. Two-thirds of them are children. Based on our surveying, many were not routinely getting the primary care they needed. Sometimes we think of children as little adults, but children’s behavioral health needs are distinct and impacted by stages of development.”
Susan Salhaney at Judson Family Center in Warren.Judson Center is partnering with healthcare management organization MedNetOne Health Solutions for the primary care piece of its practice. The partnership is a truly integrated model that allows for both practitioners to engage with a patient during the same visit. Patients with challenges like finding childcare or transportation are more likely to receive all the care they need when they don’t have to schedule additional appointments at another, potentially unfamiliar practice. Community health workers on Judson’s staff remove barriers to health by helping patients find transportation, food, or needed items – in one case, a vacuum cleaner.
In addition, this integration allows the staff at Judson Center to address issues like anxiety and depression that often accompany medical conditions, or to discover a child’s ADHD has been misdiagnosed and is really the result of having experienced trauma.
Susan Salhaney and Ewa Matuszewski at Judson Family Center in Warren.
“When behavioral care with a child or family is addressed in a team environment, you can identify the condition with the behavioral health and primary care providers and see them both at the same time. It’s not, ‘We’ve identified this and now they have to make an appointment and travel five miles to see someone else,’” says Ewa Matuszewski, CEO of MedNetOne. “We’re looking at making primary care available at the point of care and establishing great relationships with the family or caregiver.”
Lunchtime chat yields transformational partnership
Alexandros Maragakis, assistant professor in Eastern Michigan University’s (EMU) psychology department; and Blake Lancaster, assistant professor at University of Michigan (U-M) Medicine, met one day for lunch. Both were working on integrating mental health care into medical care practices – a pediatric setting, in Lancaster’s case. Both saw integrated health settings as the future of behavioral health care, and both agreed that traditional training didn’t properly prepare psychologists for that future.
So they decided to begin addressing that by creating the Michigan Medicine/EMU Integrated Pediatric Behavioral Health Training Collaborative. The collaboration will provide specialty training in integrated behavioral health for doctoral trainees in psychology during their practicum, internship, and post-doctoral studies.
“(We decided that) if we started people at the practicum level and (continued) throughout their progress through the training pipeline, not only would they be more skilled but they’d … be able to go out into the field and start their own integrated health clinics,” Maragakis says.
Alex Maragakis.The collaborative received a $326,000 Michigan Health Endowment Fund grant to get the program started. Maragakis says EMU will cover the practicum side of the programming, while U-M will handle intern and post-doctoral programming. He says the collaboration has led him to spend a lot of time at U-M, “creating new clinics and testing new methods of service delivery that otherwise would have been impossible for us to do.”
“We are creating a nice bridge between the university training side of things and the hospital training side of things,” he says.
Maragakis says the goal is to not only train practitioners for Michigan Medicine systems but to also equip a new wave of behavioral health professionals who will serve other medical systems throughout the state or open their own integrated practices — and reach the many underserved Michigan children who need behavioral health care.
“We know that the sooner we address behavioral health in children, the less likely it will impact them later on in life,” Maragakis says. “There is a lot of benefit to addressing problems as soon as possible for the child and family. The faster we can do that, the higher the chances (are that their) family follows through and the child gets access to care they need — and the more likely we can create an overall healthy community in the future.”
A freelance writer and editor, Estelle Slootmaker is happiest writing about social justice, wellness, and the arts. She is development news editor for Rapid Growth Media, communications manager for Our Kitchen Table, and chairs The Tree Amigos, City of Wyoming Tree Commission. Her finest accomplishment is her five amazing adult children. You can contact Estelle at [email protected] or www.constellations.biz.
All photos by Nick Hagen except Michelle Duprey photo courtesy of Michelle Duprey.