Scaling widespread anxiety screening through primary care integration

Recently the U.S. Preventive Services Task Force (USPSTF) announced it recommends anxiety and depression screenings as part of routine check-ups for all children ages 8 to 18. It’s an important step forward. We know that very often behavioral health concerns are the most significant health crises children will face. Even before the pandemic brought widespread school and social disruption to children’s lives, the U.S. Centers for Disease Control and Prevention estimated 5.8 million children were grappling with anxiety and 2.7 million with depression. The COVID-19 pandemic intensified this crisis and brought long-overdue urgency to prioritizing behavioral health care.

Virna Little, PSyD, LCSW-r
_{Concert Health}

Like many other health conditions, early intervention helps change the trajectory of a child managing behavioral health concerns. A child diagnosed early and connected with a trained behavioral health professional collects a lifetime of coping skills, whereas lack of intervention can lead to progressive difficulties and downward effects for years to come. The USPSTF-recommended screenings are essential for identifying concerns early, but without putting systems in place to streamline follow-up-on access to evidence-based behavioral health treatment, screenings threaten only to intensify existing obstacles. Too often, calls for increased screenings place additional pressure on thinly-stretched pediatric and primary care providers who, despite their best efforts to help patients in need, lack the resources to overcome a health system fraught with systemic barriers around access.

Accessing behavioral health treatment in the U.S. is a challenge, full stop. Confusing insurance plans, uneven coverage, and overwhelming provider networks leave parents at a loss on where to start. This is true even for families with great health care coverage who receive care in well-resourced health systems. It becomes even more true for families whose access to quality health care is restricted, such as those on government health care plans, those living in rural communities or those navigating a myriad of other disparities. With the spotlight now firmly on the mental health crisis we are all living through, we have an opportunity to jump-start solutions, accessing children where they already are and where they often first present, their pediatric provider’s office.

One model that’s demonstrated success is integrating behavioral health services directly into primary care. Called Collaborative Care, the model aims to ensure a behavioral health specialist or access to behavioral health services is directly embedded into primary care. The goal is to ensure pediatricians have the tools they need to screen for behavioral health conditions such as depression, anxiety, and ADHD, as well as the ability to directly connect patients to behavioral health specialists, eliminating the need for patients to hunt around for an in-network practitioner or wait weeks for an appointment. In addition, Collaborative Care gives pediatricians visibility into follow-up and treatment so they can remain involved and incorporate behavioral health support into holistic care plans.

The approach has been the subject of more than 90 clinical research trials, which have shown that it is effective not only in reducing barriers to care but also in helping address the issue of over-prescribing. For example, children treated under a Collaborative Care model received anxiety treatment that often did not require medication, because they were connected with a behavioral health provider to develop coping skills. Its success has spurred government payers to embrace it. Adopted by the U.S. Centers for Medicare & Medicaid Services in 2017, Collaborative Care is now recognized by commercial plans and is rapidly being adopted by state Medicaid fee schedules, in recognition that the approach enables better care for patients and is cost-effective for the system as a whole.

Our company, Concert Health, is an example of how to leverage Collaborative Care to improve access to behavioral health care. We have a team of over 250 behavioral health clinicians that have cared for more than 44,000 patients nationwide, in partnership with major health organizations such as CommonSpirit and AdventHealth. Our technology-enabled approach integrates remote behavioral health services with primary care, women’s health, and pediatrics–making it easy for primary care providers to deliver comprehensive care and improve clinical outcomes. Patients are assigned a Collaborative Care Clinician (CCC) who is a trained, masters-level clinical provider that works closely with the pediatric provider to help patients see results right away. The Collaborative Care Clinician schedules frequent check-ins with patients to help set goals, develop and nurture coping strategies, and provide support around behavioral health medications (if prescribed). They meet with patients (via phone or video) to help track treatment progress and collaborate with other members of the care team to make adjustments to care plans as needed.

The USPSTF recommendations will assuredly lead to more children getting the care they need for anxiety, depression, and, likely, other behavioral health concerns that might have otherwise gone unmanaged. That is the first piece of good news. The even better news is that the USPSTF move comes at a time when we have an evidence-based model for effectively scaling behavioral health services. We should view the USPSTF recommendation as a launching pad for the next decade, an era rife with opportunities to rapidly advance parity in behavioral health care and positively impact millions of children’s lives.

Virna Little, PSyD, LCSW-r is an internationally recognized executive and advisor for her work integrating primary care and behavioral health, developing sustainable integrated delivery systems and suicide prevention. She is the chief clinical officer and cofounder of Concert Health, a national organization providing behavioral health services to primary care providers. Her extensive clinical experience and leadership roles have distinguished Concert as a leading medical group. Outside of Concert, Dr. Little is a member of the national and international Zero Suicide initiatives and the National Council for Mental Wellbeing, and she has spoken on national suicide prevention strategies at the White House.