Across the three regions, PCPs surveyed were more comfortable providing mental health assessment and referral than psychoeducation or direct interventions. However, PCPs reported difficulty finding therapists and CAPs for their patients. These findings are in line with prior work, which has found that PCPs view their role in mental health care as limited to screening and diagnosis, with the exception of ADHD treatment—about which providers still report discomfort initiating medication, particularly with more severe cases or when comorbidities are present [13, 14]. However, consistent with PCP perceptions in this study, there remains a significant shortage and maldistribution of behavioral health providers, particularly CAPs, and this shortage is more pronounced in rural/remote communities, like those surveyed in this study, where delays in access to care may result in poor patient outcomes . This lack of access necessitates that PCPs serve as default mental health providers despite insufficient training . Of note, there were regional differences in this study, with more providers in Southern Maryland reporting discomfort prescribing psychiatric medications compared to the other regions. This may be due to the over-representation of nurse respondents in that region, who are not able to prescribe psychiatric medications. Additionally, nearly all respondents in Southern Maryland and 80% in Western Maryland reported difficulty finding CAPs, which is consistent with workforce data indicating significant shortages (i.e., ~3 CAPs/10,000 children) in these regions .
Like many child psychiatry access programs, BHIPP has taken steps to address gaps in pediatric mental health services by providing standalone 1- to 3-hour trainings, consultation, and resource/referral services to Maryland PCPs. Results of this needs assessment align with recent BHIPP warmline utilization; referral calls reflect a higher proportion of calls to BHIPP in each of the last 2 years compared to calls for consultation, and medication evaluation/change has been the most common reason for consultation. Results underscore the importance of expanding the mental health workforce and access to specialty mental health care. In particular, results highlight the need for additional longitudinal training and consultation from CAPs and psychologists to expand PCPs’ mental health treatment capacity, as well as the urgent need for increased access to direct mental health treatment provided by specialists (e.g., CAPs, psychologists) through use of promising integrated care models, such as in-person evaluation/treatment with mental health providers co-located with PCPs or at an agency partnering with the primary care site, and tele-mental health services (e.g., telepsychiatry) . Of note, data from this study were collected prior to March 2020 and do not reflect mental health service access during the COVID-19 pandemic. COVID-19 is expected to increase the need for mental health care, underscoring the importance of child psychiatry access program services to support pediatric PCPs and their patients .
There were some limitations to this study. Although 107 providers participated, respondents represented just under half of practices in target regions, with variation in the proportion of participating providers per practice leading to underrepresentation from some practices and overrepresentation from others. Thus, findings may not be representative of all PCPs or practices in these regions and should be interpreted cautiously due to possible selection bias . Although the total number and demographic characteristics of all providers practicing at each practice in these regions is currently unknown, BHIPP continues to identify PCPs within the target regions, and has been able to reach a substantial proportion of the pediatric primary care workforce. However, the lack of information about non-responders limits our ability to evaluate the extent of selection bias in this study. Additionally, results may not generalize to other regions and states as the target regions reflect three high-need, rural regions with very limited access to mental health providers, particularly CAPs . Unique geographic differences in these regions affect access to mental health services, with the Appalachian Mountains passing through one and the Chesapeake Bay separating the others. It is notable, however, that the sample, which is majority White and female, is representative of the larger pediatric primary care workforce and those contacting child psychiatry access programs [11, 19].
Guided by needs assessment results, BHIPP aims to increase availability and accessibility of pediatric behavioral health treatment through the provision of tele-mental health services, care coordination, and web-based longitudinal training using the Project ECHO® (Extension for Community Healthcare Outcomes) model . Tele-mental health services will include consultation and direct service delivery provided to patients within primary care sites across Maryland via real-time videoconferencing . These services will be provided by CAPs and social workers based on patient needs, allowing for a broad range of mental health services over real-time videoconferencing. Care coordination will also be available to providers and families for resource/referral assistance and follow-up over the phone. Project ECHO is a widely used telementoring model that aims to address the inadequate supply of specialty care in rural and underserved areas through case-based learning and didactic education via videoconferencing to front-line health care workers in those regions to increase their capacity to provide best-practice care . BHIPP’s ECHO didactic curriculum and case-specific guidance will be directly informed by the mental health practices identified as areas of discomfort (e.g., prescribing psychotropic medication) by respondents in this study. Through these expanded services, BHIPP aims to increase PCP knowledge and comfort with a broader range of mental health practices as well as augment access to specialty mental health care through tele-mental health services. Future work will evaluate the impacts of these expanded services on provider and patient outcomes to guide best practices for increasing access to pediatric mental health services.