Expanding Mental Health Access for Children and Youth Through System Change, Human-Centered Design, and Community Partnership

Summary

Suicide is the second-leading cause of death for youth ages 10 to 14 years and the third for 15 to 24-year-olds.¹ According to the Youth Behavioral Risk Factor Survey, nearly one in five high school students have had suicidal thoughts, and 8.9% have attempted suicide.² The COVID-19 pandemic further increased mental health distress among youth. Recognizing this growing issue, in 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in children’s mental health.

Pediatric providers identified several barriers to addressing this emergency, including a lack of time, inadequate mental health training, provider burnout, clinic system inefficiencies, limited resources for youth and their families, and the lack of a robust mental health system. Despite these barriers, pediatricians reported being committed and willing to screen patients for mental health issues and suicide risk. However, they expressed wanting more support to offer individuals who screened positive. In response to these challenges, this project focused on achieving the following system change goals: (1) increase access to community-based mental health services for youth and families during times of distress, (2) provide practice facilitation support to pediatric providers, and (3) build a more robust system for youth mental health.

Our research team used a Human Centered Design (HCD) workshop, focus group, and survey input from multiple community partners, youth, families, and pediatric clinicians to identify projects to improve youth mental health. HCD aims to align system design with the needs of users.^{3, 4} During the workshop, participants were given an overview of youth mental health and suicide epidemiology. They then engaged in activities to generate ideas for systemic changes to improve youth mental health. Through this process, our team chose to focus on enhancing a follow-up care coordination role through Missouri’s Child Psychiatry Access Project (MO-CPAP).⁵ This master’s level behavioral health clinician role identifies needed resources while supporting families’ linkage to mental health services over a 90-day period and communicates information back to the referring pediatric clinician.

Through collaboration and feedback, further improvements were made to the MO-CPAP follow-up care coordination service, including easier online intake forms and improved follow-up communication. The Washington University Pediatric and Adolescent Ambulatory Research Consortium (WU PAARC), a practice-based research network of more than 60 pediatric primary care practices caring for over 175,000 patients, completed additional provider outreach, education, coaching and programmatic updates to promote follow-up care coordination.⁶ Preparation for this effort involved several steps, including creating a one-pager for families describing follow-up care coordination, making the online service request link more prominent on MO-CPAP’s website, and then adding the link to WU PAARC’s website. Refinement of flow charts for providers and updated protocols for follow-up were also completed.

Significance

This project made it easier for pediatric providers to connect patients who screened positive for mental health issues to appropriate follow-up care. Previously, the MO-CPAP follow-up care coordination service was only accessible by phone. Busy clinicians identified this time-consuming process as a barrier to using the service. Our work supported the development and implementation of an easy-to-use online form. Providers can now submit referrals asynchronously and request psychiatry consultation or follow-up care coordination. Resource materials explaining the process were created and shared with pediatricians, youth, and families. Pilot testing with a smaller group of providers ensured system effectiveness and improved communication between clinicians and families regarding the follow-up care coordination process, specifically informing caregivers on what to expect once referred. The usage of both follow-up care coordination and the online form significantly increased, benefiting families and increasing access to youth mental health services statewide in Missouri.

This collaborative approach strengthened our mental health system for children, enhanced community partnerships, and led to an increase in service use by providers. Early usage data from statewide providers shows nearly 70% of requests for assistance come through an online mechanism, and 70% of all MO-CPAP requests now include follow-up care coordination.

This project also had important equity impacts. The follow-up care coordinator service is now available to every child and family in Missouri through their pediatric clinician. This means rural patients and children of diverse racial and ethnic backgrounds have access to this support, and the service is free of charge.

Benefits

Demonstrated benefits are those that have been observed and are verifiable.

Potential benefits are those logically expected with moderate to high confidence.

Expanded the follow-up care coordination services throughout the state of Missouri through MO-CPAP. demonstrated.

Community

Community health services

Increased usage of follow-up care coordination by pediatric providers to give greater access to mental health services for youth and their families. demonstrated.

Community

Health care accessibility

Enhanced a follow-up care coordinator role to effectively refer and link families to mental health services. demonstrated.

Community

Health care quality

Increased access to community health services and provided additional outreach, education, and programmatic updates to promote follow-up care coordination. demonstrated.

Community

Health education resources

Strengthened our mental health system for children, potentially increasing life expectancy and quality by reducing the risk of suicide and improving emotional distress. potential.

Community

Life expectancy & quality of life

Provided free referral services to providers and families through MO-CPAP. demonstrated.

Economic

Cost savings

This research has community and economic implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.⁷

Community

This project increased access and linkage to needed care, added funding resources, redesigned an available resource for greater use by pediatric clinicians, and enhanced partnerships for future work in children’s mental health. The referral coordination system was improved based on user needs and preferences and now utilization has increased, thanks to the collaborative nature of MO-CPAP and Behavioral Health Response (BHR) staff and the trust and shared values among all entities. Among the 21 pilot requests including care coordination, 10 families (48%) were connected with resources.

Economic

MO-CPAP referral services are free for providers and families. WU PAARC helped secure federal and state funds for this free care coordination service by sharing provider feedback and committing to partner with MO-CPAP to develop an easier online process for psychiatric consultation and care coordination. WU PAARC data gathered around needs and pediatric clinician feedback strengthened a HRSA grant proposal, which ultimately led to greater funding for MO-CPAP to expand and bolster these care coordination services.

Lessons Learned

This project strengthened our mental health system for children, enhanced community partnerships, and led to an increase in service use by providers.  Advocacy and system change work increased access and linkage to needed care, added funding resources, redesigned an available resource for greater use by pediatric clinicians, and deepened partnerships for future work in children’s mental health. Building strong relationships around shared goals can lead to important system change that can strengthen mental health access for youth. The collaborative relationships between MO-CPAP, BHR, WU PAARC, parents, youth, community agencies, and pediatric clinicians are critical. The referral coordination system was improved based on user needs and preferences and utilization has increased. This project demonstrates that system change can occur through collaborative efforts among partners managing different aspects of the system. The HCD process helped identify opportunities that aligned with desirability, feasibility, and acceptability, while fostering trust and mutual understanding. The project began with achievable system changes and evolved into sustained and enhanced efforts through deepened partnerships.