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Treatment and services research in the general medical sector has emphasized the importance of addressing organizational capacity to improve interventions for patients with chronic conditions. Efficacious interventions for child and adolescent mental disorders without substantial enhancements in mental health organizational capacity will not result in improvements for children. This paper (a) lists some organizational enhancements that have resulted in improved medical care, (b) briefly underscores recent market trends such as state healthcare reform efforts, increased use of electronic records and contracting initiatives that push consolidation of agencies, and (c) describes one example of the organizational development of child behavioral services that will enhance treatment delivery.
Interventions with documented efficacy are more available than ever, but child and adolescent mental health services in communities are generally considered inaccessible, ineffective, inefficient and uncoordinated (Harris et al. 2007; Singh 2009; AAP 2009). These concerns have led to strong calls for reform. In response, the child and adolescent mental health services field focused for more than two decades on Systems of Care (SOC; Pumariega et al. 2003; Winters and Metz 2009). SOC provided a set of aspirations for child services that aimed to limit restrictiveness of setting, enhance family involvement and increase coordination to improve child functioning. However, SOC has been criticized because changes in outcomes for children were not achieved (Cook and Kilmer 2009; Bickman et al. 1999).
A major problem at this point seems to be that coordinating ineffectual systems is putting the cart before the horse. Three decades of health services research in medical settings for adults with chronic illness underscored that a focus on either improving individual clinician care, as the focus of evidence based treatments, or coordinating systems alone is inadequate to improve patient outcomes as is emphasized in the SOC. Instead, a comprehensive population health approach that includes change for patient, family, clinician, practice/organization and accountable healthcare system embedded in the community is necessary to achieve high quality services and improved long term outcomes (Coleman et al. 2009; Epping-Jordan et al. 2004). High-quality preventive and treatment interventions exist for children and adolescents with or at risk of mental disorders. The research-practice gap, which, in part, is due to lack of sufficient training, treatments and implementation science, may largely be inadequate organizational capacity of child mental health service agencies.
General medical settings have increasingly focused on organizational capacity and their panels of patients. Population health management strategies, based upon public health frameworks, have been applied extensively in many fields and require strong organizational frameworks (Lin and Moutsiakis 2009; US Preventive Services Task Force, 2008; Angstman et al. 2009). Yet mental health has been slow to respond. In part, this may be because of perceived differences between mental healthcare and other types of medical care. The latter is often seen as procedure-focused and emergent or acute care. However, an increasing amount of medical care is focused on chronic medical services like diabetes and hypertension that require motivated patients, ongoing decision making, recurrent assessment, case management and rehabilitative services, which are features common to effective mental health services. Recently, renewed attention to the possibilities of a broader population health framework applied to mental health has been described in several influential reports (e.g., National Academies Press, 2000, 2006, 2009: IOM’s series of reports including prevention, adolescent health, and Integrating MH and substance abuse) as well as by advocates for mental health reform (e.g., SAMHSA, MHA). This emerging consensus offers insight into the possibilities for dramatic restructuring that might enhance the well-being of children and adolescents with mental disorders. The purpose of this manuscript is to describe the organizational features necessary for child mental health services to adopt a broader population health approach.
The last decade of science in child mental health services has emphasized the development and implementation of specific treatments for children and adolescents with particular disorders. Improving the diffusion of new evidence-based prevention and treatment services one at a time, while a sign of maturity for the field of child mental health interventions research, will not be sufficient to improve the mental health status of most children and adolescents. The overall system is ineffective for consistently delivering any adequate treatment to needy children in a timely and consistent manner (La Greca et al. 2009; Kazdin 2003). These evidence-based interventions need to be consolidated in effective system models that employ decision support for patients and clinicians, information sharing and analysis and system financing that supports best practices as noted in the Institute of Medicine Quality reports (2006), the Chronic Care models (Etz et al. 2008; Simon 2009) and the medical home studies touted in current health care reform debates (Carney et al. 2009; Domino et al. 2009). Examples from other fields of health care, science, engineering and social policy may be helpful to consider in finding the path to change from a singular focus on individual providers operating in isolation with panels of patients to a comprehensive and accountable process. In fact, leaders in psychiatry and psychology have called for similar changes in their responses to these documents. (Keyser et al. 2008).
Effective expert systems or organizations that manage complex health or social problems have attributes that allow them to function across settings and time for individuals and groups that are served. Some of the key attributes are listed below:
Specific recommendations to implement the features listed above are beyond the scope of this document as each particular item will require financing, policy, technology and social change. However, one could imagine the likely ways that current market, technical and professional currents will push the organizational capacity of child and adolescent mental health systems.
In the mental health specialty sector, the increased costs of electronic health records, economies of scale, the growing complexity of treatments and quality/pay for performance reimbursement will gradually push consolidation that is already occurring in the general medical sector. In fact, the percent of physicians working in solo practice has declined for more than a decade, and the trend is accelerating (Robinson 1998). Thus, expanding mental health clinician agencies could adopt organizational designs, electronic tools, family engagement strategies and other population health strategies if their financing supported such action (Mechanic 1993).
However, the limited growth of resources in the mental health sector outside of psychotropic drug costs as compared to all health spending and the already strained workforce suggest that the mental health specialty sector will not likely play a leadership role on a large scale in these transformations.
On the other hand, the rapid growth of accountable care organizations and aligned medical systems with deeper pockets in the general medical sector (Shortell and Casalino 2008) will increasingly draft regional mental health systems to meet the comprehensive needs of their larger populations. Such organizations will have the resources to provide aligned financial incentives, electronic health records, decision support, outcomes monitoring, and centralized tracking with regional outreach. They will push behavioral components to employ evidence based technology and patient specific tracking and communication. Some examples of such organizations exist today and include large behavioral healthcare components. Nationwide Children’s Hospital has more than 800,000 visits to its clinics annually in Ohio and almost 77,000 of them are behavioral health visits to their extended network of 14 outpatient mental health sites. All of these behavioral health sites are implementing an electronic medical record linked to the general medical record in an enterprise data warehouse. Safety data and outcomes are also entered into the warehouse. Satisfaction measurement, access and outcome results are being tabulated for each clinic and clinician. Some of the clinics have partnered with their co-located general pediatric clinics to use waiting room computerized assessments by families and others use electronic registration and reminder systems for behavioral patients, all of which are supported by systems run through the main pediatric hospital system. Electronic prescriptions for all patients allow for monitoring of inappropriate combinations of medications and information for psychotherapists who might not otherwise know about medications. The system also allows for training of psychiatric nurses, therapists and psychiatrists in the use of such tools for their future practice.
The laudable focus on improving the efficacy of preventive and treatment services for children and adolescents has resulted in an ever expanding repertoire of interventions for children and adolescents with or at risk of mental disorders. Unfortunately, the delivery system has not kept pace. Early recognition of system inadequacies led to a focus on coordination of public services and family involvement through the System of Care approach with mixed results.
Now, state healthcare reform initiatives, the mandated advent of electronic health records and decision support tools and market forces which favor consolidation, all of which have fundamentally altered general healthcare services, are beginning to change mental health systems in profound ways. Hopefully, these changes will provide the opportunity to focus on a population health orientation that carefully considers both individual family and contextual factors in a system that is organizationally capable of responding because of strong design characteristics, information technology and accountability systems.
Although it is possible that some mental health systems will evolve these capacities independently, the need for coordination with medical systems and the greater resources available in the pediatric healthcare system make it more likely that child and adolescent mental health services can best develop these capacities in partnership with general medical systems with strong infrastructure and ambitions to become more comprehensive accountable care organizations.