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Pediatricians bring mental health counselors into the doctor’s office

You might think Dr. Maureen Montgomery’s pediatric practice is kept busy with fevers, coughs and earaches.

But Montgomery and her colleagues also see children and teenagers struggling with anxiety, attention deficit hyperactivity disorder and even disabling psychosis. One in five of the 10,000 patients at Amherst Pediatrics comes in with a behavioral problem.

So the practice brought in a licensed mental health counselor to work alongside the doctors, part of a growing movement in Buffalo and elsewhere to put mental health services into doctors’ offices.

“We aren’t experts in the field, yet we saw an increasing need to have the expertise here,” Montgomery said.

New efforts like the one at Amherst Pediatrics coincide with a trend in medicine to transform primary care doctors’ offices into “medical homes” that aim for more comprehensive and coordinated care provided by teams.

Mental health conditions have replaced physical illnesses as the top five disabilities of children in the United States.

“Twenty percent of our patients have a mental health disorder, twice the rate of asthma,” Montgomery said.

Typical cases include a boy who had been placed in a special education pre-kindergarten class because he was so aggressive with other children and adults. Teachers were concerned about him hurting others or running out of the building and into the street.

Janine Artis, the mental health counselor at Amherst Pediatrics, recalled that the parents didn’t know what was wrong. But it seemed right and comforting to turn to the pediatrician first for help.

“People trust their pediatrician. They’ve known the doctor since the birth of their child. It’s the obvious place to start. It takes away the stigma of a psychiatric diagnosis,” she said.

After treatment with medication and strategies to control behavior, the boy is back in a regular classroom.

Integrating mental health into primary care seems like a simple idea. But it has proven difficult to accomplish, and the ways health care providers get trained, paid and regulated impede progress.

Patients with mental disorders are more likely to suffer from chronic medical conditions, such as diabetes and heart disease. They’re more likely to die younger.

Yet two systems – one mental health and the other medical – operate separately in many cases to provide treatment.

Behavioral problems related to mental disorders or substance abuse often go untreated. Many patients referred to mental health specialists never show up, or they rely on costly emergency rooms when problems worsen.

Nearly 40 percent of adults with severe mental illness — such as schizophrenia or bipolar disorder — received no care in the previous year, according to the 2012 National Survey on Drug Use and Health.

Blue Cross Blue Shield of Western New York last year began a pilot project at four doctors’ offices – two pediatric and two adult – where a clinical licensed social worker and psychiatrist see patients. The insurer paid their salaries and helped with billing, said Dr. Thomas Schenk, chief medical officer at Blue Cross Blue Shield.

Excellus, the parent company of Univera Healthcare, started an approach aimed at six practices in Rochester to help doctors manage patients on site with depression.

Meanwhile, Amherst Pediatrics is one of eight primary care sites working with Independent Health in a two-year project to place licensed mental health counselors in the offices. The counselors assess patients, help devise treatment plans and intervene in crises. The practices pay for part of the cost with $736,000 in grants for the project from The Peter and Elizabeth C. Tower and John R. Oishei foundations.

Pediatricians see an urgent need to transform their practices.

It’s not just in pediatrics where mixing mental health with physical health is taking hold.

The state’s plan to reform Medicaid, which costs about $50 billion a year, makes a priority of integrating mental health. Among the reasons: The majority of preventable hospital admissions covered by Medicaid has been for people with behavioral health conditions. But the majority of state spending for these patients has been for chronic physical health conditions.

The Department of Veterans Affairs, a leader in the trend, committed itself a decade ago to researching and integrating mental health into its primary care facilities, including establishment of a Center for Integrated Healthcare based in Buffalo and Syracuse.

Last year, federal officials committed $54.6 million in Affordable Care Act funding to support 221 health centers in 47 states and Puerto Rico to establish or expand behavioral health services in community health centers.

“We’re seeing more initiatives in mainstream medicine because, despite the stigma, there is greater acceptance today that mental health problems are real problems,” said Dr. David Kaye, a University at Buffalo psychiatrist who directs Child and Adolescent Psychiatry for Primary Care.

The program provides toll-free phone consultations and training to general practitioners who treat children with mild to moderate mental health concerns, covering more than 90 percent of the state. The consults come from a team of specialists from five academic psychiatry departments, including UB.

The calls range from questions about medications, like the side effects from treatment for attention deficit hyperactivity disorder, to recommendations for the best evidence-based therapies for anxiety. In severe cases, the program helps physicians link with a specialist.

The state-funded program, which did 1,600 consults in 2014 and more than 100 educational conference calls, received a $2.4 million grant to operate from 2012 to 2014 and additional funding to keep it going at least through 2015.

“There are more than 20 statewide programs like ours. We’re popular with doctors, but we’re all struggling to demonstrate that the service is helpful and cost-effective,” Kaye said.

Many studies indicate that integrated care can improve results for patients with common medical and behavioral conditions, as well as their perceived quality of life. Yet health care remains fragmented for those with mental disorders.

Physician groups are pushing for change.

The American Academy of Family Physicians in 2014 joined five other national family medicine organizations to outline joint principles to make behavioral health a part of the medical home concept.

It’s not clear, however, where the money will come from to sustain the initiatives. Incorporating mental health counseling into doctors’ offices must prove financially viable for more doctors to embrace the idea beyond pilot projects.

“We need to demonstrate value if we’re going to expand,” said Dr. Judith A. Feld, medical director of behavioral health and health care delivery innovation at Independent Health.

That means patients with mental health concerns visit emergency rooms fewer times and their physical conditions improve. It also means primary care doctors become more comfortable prescribing psychotropic drugs.

“We’re hoping our program pays for itself through efficiency,” she said.