Designing a Referral Network to Address the Youth Mental Health Crisis

March 27, 2023 - The US is staring down a youth mental health crisis that’s more than getting out of hand. And with mental healthcare access demand outpacing supply, healthcare providers are finding themselves at a loss for how they can meet pediatric patient needs.

For John Straus, MD, the founding director of the Massachusetts Child Psychiatry Access Program (McPAP) and the president of the National Networks for Child Psychiatry Access Programs (NNCPAP), this is more than a once-in-a-generation emergency.

McPAP was conceived of nearly two decades ago to help even out the supply and demand problem in mental healthcare access. Behavioral and mental healthcare access has long left much to be desired, and the issue of social stigma, plus provider shortages and patient navigation hiccups, often get in the way.

“We have, on the one hand, the provider community being small,” Straus said in an interview with PatientEngagementHIT. “And the other hand—particularly this part of the problem's gotten worse—the need is growing.”

McPAP in Massachusetts and its peers across the country that are part of NNCPAP fill in some of those gaps by building a referral network for primary care providers seeking a psychiatry consult.

The program doesn’t solve every problem in youth mental and behavioral health access, Straus is careful to emphasize, but it presents an effective model for at least chipping away at patient care access challenges.

Snapshot of today’s youth mental health crisis

In 2021, more than a third (37 percent) of high schoolers said their mental health deteriorated during the COVID-19 pandemic, and 44 percent said they’d felt persistently sad or hopeless, according to figures from the Centers for Disease Control and Prevention (CDC).

The US is finding itself in crisis mode, separate CDC data showed. A February 2022 Morbidity and Mortality Weekly Report revealed that the proportion of pediatric emergency department visits for mental health conditions increased in 2020.

Indeed, pediatric mental health visits in the ED are becoming such a problem for overcrowding that some states, like Massachusetts, are putting in place funds to divert patients to other healthcare resources rather than the ED.

But the problem is, the upstream resources needed to prevent an ED visit aren’t there. Kids need mental health intervention before they end up in the ED, but according to Straus, those interventions aren’t always able to happen.

Pinpointing primary care as a mental health access site

Upstream mental health interventions—the early interventions that ideally prevent mental health emergencies—are hard to come by because the clinicians who helm them (psychiatrists) are hard to come by.

“There are a limited number of child behavioral health providers, particularly psychiatrists, and access to them is tough,” he explained during an interview with PatientEngagementHIT.

Data from the Association of American Medical Colleges confirms this. In 2022, AAMC said the nation will the short between 14,280 and 31,109 psychiatrists within a few years.

But where pediatric healthcare access is doing comparatively well is in the primary care space. The Kaiser Family Foundation says that, as of 2021, around half of kids have a medical home, which far outpaces pediatric healthcare access in other specialties.

McPAP and NNCPAP capitalize on that pediatric primary care access and operate on the principle that kids should be able to get mental healthcare access within the primary care setting.

“But those folks, generally, have not been well-trained and can feel uncomfortable in managing behavioral health conditions,” Straus said of primary care providers, pediatricians, and family medicine clinicians. “We can't increase the number of specialty providers, particularly psychiatrists, so we had to make it so that the primary care folks would be more comfortable managing behavioral health issues.”

Straus set to work in 2003 to develop McPAP and rolled out the program in 2004 to create a referral system for primary care providers and psychiatrists. When pediatricians meet with patients they believe need a mental or behavioral health intervention, they can call a psychiatrist within the McPAP network for a consultation.

This process, which was manual during McPAP’s early days but has since embraced telehealth models, usually took around 30 minutes, a far quicker process than getting a kid in for an in-person visit with a psychiatrist using a traditional model.

The McPAP model works well because it leverages a pediatrician’s prescribing power. After the consult with the psychiatrist, the pediatrician can prescribe any necessary medication and help with medication management and adherence plans.

“So that's really avoiding the need of the psychiatrist,” Straus said, reiterating that psychiatric care access is hard to come by. “Now, obviously, many of these kids need therapy, and we'll help them access therapy.”

McPAP quickly grew into NNCPAP, and by 2015, there were around 20 programs across the country. The programs got their funding through state legislatures and grant funding, and soon proved very economical. According to Straus, the Massachusetts program enrolls around 1.5 million kids and costs $3.4 million each year. That shakes out to around $2.30 per kid per year.

Around 2015, NNCPAP started getting attention at the federal level, with Massachusetts Representative Katherine Clark bringing the program to the House floor to create federal funding. That funding came as part of the 21st Century Cures Act, and since then, the bipartisan Safe Communities Act has also created some funding mechanisms. The Health Resources and Services Administration (HRSA) has also provided funding to 50 programs.

That’s allowed NNCPAP to grow and touch other populations. McPAP for Moms, for example, is tailored for people who are pregnant and post-partum in Massachusetts. This is important for obstetricians and midwives who are now required to screen for mental and behavioral health and want to be able to offer a referral when issues arise.

NNCPAP has also dipped its toes into opioid treatment and chronic pain in adults.

Navigating persisting behavioral, mental healthcare access challenges

But for all of the programs’ successes, Straus is realistic about limitations. For one, NNCPAP and McPAP flourished under pandemic-era telehealth flexibilities.

“We were doing a little bit of that before the pandemic, but the institutions were balking, and they were saying, ‘Well, legally, we have to at least see the person for the first visit, and then we can do the televisits,’” he recalled. “So that was a huge change, and hopefully it won't get reversed. It looks like it won't, but there are some inklings that some places that may be a struggle.”

“For example, the consultation program called PAL in Seattle, Washington, also does Wyoming and Alaska,” Straus offered. “They're talking to people 2,000 miles away, at the end of the Aleutians, and you're not exactly about to go in-person.”

Keeping up with pandemic-era telehealth flexibilities will be essential for individuals living in those regions, he confirmed.

Moreover, there is the issue of access to therapy.

“For therapy, the behavioral health clinician workforce is really struggling, and we're not solving that problem—we can't,” Straus explained.

In fact, programs like NNCPAP are increasing the demand for therapy, as did the insurgence of teletherapy that made mental healthcare access more convenient.

“With all the telemedicine, we're seeing even more people who are willing to do therapy because they don't have to travel or do it after hours,” Straus said. “They can take an hour where they close the door in their office, or if they're home, no one even knows that they're doing an hour of therapy during the day. It's made therapy much more accessible, which is great, but it's put pressure on the workforce.”

Filling in workforce gaps are serious problems that are hard to fix. Straus and other experts can’t create healthcare workers out of thin air, and trends of provider burnout and the high cost of medical education are making it harder to find more recruits.

But amidst those ongoing challenges, Straus says the referral network at NNCAP and McPAP are still doing considerable legwork and equipping healthcare organizations for the next phase of healthcare delivery that prioritizes team-based care and integration of behavioral health and primary care.

“These programs really become even more critical, and we're really doing things to support the integration of behavioral health into primary care,” he concluded. “And we're really supporting use of the collaborative care model because that's what will lead to better outcomes for the kids.”