Integrating behavioral health at Hopple Street is big win for families, staff
The young mother was visibly frustrated. She had been bringing her 2-year-old son to Cincinnati Children’s Hopple Street Neighborhood Health Center for biweekly visits to monitor his weight. His diagnosis was failure-to-thrive, with some developmental delays. Although she attempted to follow the doctor’s instructions, she had difficulty being fully compliant, and her son failed to gain weight.
Rachel Herbst, PhD, a pediatric psychologist and integrated behavioral health specialist at Hopple Street, sat down with the mother during clinic to see how she could help.
Says Herbst, “The mother felt like she was under so much pressure, with everyone watching and waiting for a positive result that didn’t come. So I asked her what goals she would like to work on with her son. Interestingly enough, none of them were weight-related. They had more to do with behavioral issues.”
Herbst coached the mother on age-appropriate expectations for her child and suggested alternative ways of dealing with his behavior. As those issues improved, the quality of their relationship was transformed. The mother felt empowered and engaged. She was able to become her child’s advocate, setting up a round of appointments with Speech Pathology and Occupational Therapy, which he recently completed. There was one additional benefit – he gained weight, and he’s thriving.
This story is one example of the benefits of integrating behavioral health with primary care. It’s been a trend in healthcare for a while, but Cincinnati Children’s has developed its own unique approach to the issue.
“We’ve modeled our approach on an evidence-based national program called Healthy Steps,” says Mona Mansour, MD, director, Primary Care and School Health. “Healthy Steps screens kids, ages 0-3, and provides behavioral health services to those who are at the highest risk. Our program, however, screens kids, ages 0-5, and provides services universally to all children during their well-child visits.”
The program was implemented in January 2016 at Hopple Street, which has 6,800 patients and 13,000 visits per year. It’s an underserved population, with a high rate of poverty. Says Mary Carol Burkhardt, MD, medical director, “About 90 percent are publicly insured, and 10 percent need an interpreter. We have a lot of single parents. Many of the children are dealing with toxic stress, community violence and domestic violence. Our goal is to intervene early and stop problems from developing, rather than wait until kids are older and symptomatic to get help.”
How it works
Before the program began, Hopple Street had a psychiatric nurse practitioner who was co-located at the clinic. If a family needed behavioral health services, they were referred. Having a co-located partner was convenient and allowed for care in a familiar setting, which patients greatly appreciated. The model was designed for children with mental health pathology and was not part of the daily primary care practice, so efforts focused on piloting a fully integrated, universal, and preventative model. Now, patients are screened during well-child checks, using the Ages and Stages-Social and Emotional Development Screen or the Strengths and Difficulties questionnaire. Approximately, 20 percent of the scores are elevated.
Says Mansour, “We want to identify opportunities for positive parenting as early as possible to support normal child development.”
Herbst, whose schedule is woven into the patient flow, spends the first part of her morning reviewing charts. She sees about 14 patients each day – those who are here for well-child checks, as well as those whom the primary care provider has flagged as needing help.
The most common issues are:
- Behavioral concerns, e.g., biting, tantrums, etc.
- Sleep
- Eating, e.g., slow weight gain, picky eating, obesity, etc.
- Family adjustment, e.g., first-time parents, child mobility, trauma, etc.
Herbst goes in to see the families after the primary care provider is finished. It’s typically a time when the child is waiting to get a vaccine or other clinic follow-up. “We do a warm handoff, so they aren’t surprised when I walk into the room,” she says. “No one has declined our services. The families are very responsive. They get more value out of their visit.”
Teamwork is an important component of the program.
“The medical assistants know the families’ back stories, so they can give me context for the concerns families raise,” says Herbst. “It makes a difference in how well we meet the goals of the program.”
Typically, Herbst spends about 15 minutes with the family. Occasionally, if they need more help, she’ll schedule a longer visit. If the problem persists, the child will ultimately be referred to another provider, but she acts as a bridge to smooth the transition.
“I would love to have even stronger connections with community partners and resources, where they know about our program and we know about theirs,” she says. “Our families don’t always know how the systems work. We want to establish true partnerships with agencies we know have a big impact.”
Changing attitudes
Integrating behavioral health into the primary care setting takes the stigma out of getting help for these issues because services are offered to everyone in a familiar environment.
“A lot of families are open to creating a relationship with me,” says Herbst. “It’s a natural place to start, since they already have a relationship with their primary care provider, and we build on that. The vast majority are very engaged and look forward to it.”
Herbst employs motivational interviewing to help families develop and achieve their goals, meeting them where they are and bringing them along at their own pace. She also coaches staff on ways to approach families, including advising them about what words may or may not be helpful during clinic visits.
“It’s a role shift toward relationship-based care,” she explains. “For example, when the medical assistant prepares to give a child a vaccine, it’s a teachable moment. Just taking the time to say, ‘Okay, she’s going to cry, then you can pick her up’ let’s the family know what to expect and what they can do about it. The shift is about considering the family’s experience as the child receives the vaccine and not just about safely delivering it.”
Herbst also spends a good portion of her time training residents about behavioral health problems and development – soothing fussy babies, potty training, weight management, etc.
Says Burkhardt, “It’s hard to train residents about behavioral health because the problems kids have happen over time and the residents have limited opportunities to see that progression over years. With physical conditions, there’s usually a standard protocol to treat them, and the problem is solved. You don’t get immediate results with behavioral health issues.”
But Herbst is impressed by the residents’ eagerness and commitment to learn. One of the goals for this year is to fine-tune their educational curriculum in this area.
What’s next
Mansour, Burkhardt, Herbst and the rest of the team will be looking at ways to sustain the program, spread it to other areas, and improve processes, including investigating new screening tools that start at a younger age. In support of these goals, they are collecting longitudinal data in hopes of defending the business case for integrated behavioral healthcare.
Says Mansour, “We want to demonstrate that the screenings are reducing the risk for our patients – that by intervening during well-child checks before problems develop, we can prevent the need for more intensive services, an ED visit or admission later on.”
The program has broad applications across the board, according to Herbst. “Regardless of ethnicity, neighborhood, or socioeconomic status, everybody has questions and concerns about their kids,” she says. “We are here to support families in providing the best environment for their children to learn and grow.”