NU678 Unit 5 Practice Issue, Child Psychiatry Access Example

No Child Psychiatrist in the County: A Practice Issue Paper Arguing for a Telephone Consultation Program With a PMHNP Consultant Behind Rural Pediatric Offices

[Student Name]

Purdue University Global

NU678: PMHNP Diagnosis and Management Across the Lifespan Clinical III

Unit 5 Practice Issue Paper

[Instructor Name]

[Date]

The county, clinics and figures are composite; local numbers are bracketed placeholders for current data.

The Problem

[Harlan County] is a composite rural county of about [31,000] residents, [7,200] of them under 18. It has two family medicine practices and one pediatric practice, together employing [nine] primary care clinicians. No child and adolescent psychiatrist or PMHNP with a pediatric focus practices in the county. The nearest child psychiatry clinic is [ninety] miles away, and when I called in [month and year], its first available new-patient appointment was [five] months out.

The result is that the county's primary care clinicians already manage most children's mental health problems, from ADHD and anxiety to depression with suicidal thoughts, often without anyone to ask. In an informal survey I conducted by phone with [six] of the [nine] clinicians, [five] said they had started or adjusted a psychiatric medication for a child in the past month while uncertain about the choice, and [four] said they had referred a child to the distant clinic knowing the family was unlikely to go. These figures come from a small, informal survey and describe local experience, not a measured rate.

The Scope

The county's situation is typical rather than exceptional. Using national workforce data, McBain and colleagues found that the number of child psychiatrists per 100,000 children in the United States rose from about 8 to about 10 between 2007 and 2016, but that 70% of counties had no child psychiatrist in either year, and that child psychiatrists were concentrated in higher-income and metropolitan counties (McBain et al., 2019). Growth in the national supply has therefore done little for counties like this one, and there is no reason to expect a child psychiatrist to settle here soon.

Causes

Four causes contribute, ranked by how much each explains.

1. Workforce supply and distribution. The biggest single factor. There are too few child psychiatrists nationally, and they settle where incomes, education levels and population density are higher (McBain et al., 2019). PMHNPs with pediatric experience are also concentrated in cities.

2. Geography. A [ninety]-mile trip means a missed school day for the child and a missed work day for a parent, and many families cannot make it repeatedly.

3. Reimbursement. The county's [largest] payer for children is Medicaid, and the distant clinic limits the number of new Medicaid patients it accepts each month.

4. Primary care confidence. Clinicians are willing to help but often feel unprepared to diagnose and prescribe for children's mental health problems without backup.

I have not included stigma as a ranked cause, because I have no local evidence that it is greater here than elsewhere, and assuming so would be unfair to the county's families.

Options

Three options were compared on reach (how many children could be helped in a year), cost to the county's clinics and evidence of effect.

1. A visiting specialty clinic. A child psychiatrist or PMHNP from the regional center would hold a clinic in the county [two] days a month. Reach: limited to about [twenty] new children a month at best. Cost to clinics: space and scheduling support. Evidence: direct care is effective, but reach is the problem.

2. Direct telepsychiatry visits. Children would be seen by video from home or from a primary care office. Reach: better than a visiting clinic, but still limited by the number of specialists available and by the same wait list. Cost to clinics: modest. Evidence: direct care by video is generally acceptable to families, but it adds no new specialist time.

3. A telephone consultation program. A regional team of a child psychiatrist or PMHNP, a therapist and a care coordinator answers calls from primary care clinicians the same day, advises on diagnosis and medication, sees a small number of complex children directly, and helps families find local services. Reach: potentially every child seen in primary care. Cost to clinics: little, if the program is publicly funded. Evidence: described below.

The county's problem is not that its children see no clinician; they see primary care clinicians every week. The problem is that those clinicians have no one to ask.

Evidence for the Consultation Model

The Massachusetts Child Psychiatry Access Project was established to give pediatric primary care clinicians rapid access to child psychiatry consultation through six regional teams. Over three and a half years it enrolled 1,341 primary care clinicians in practices covering 95% of the state's young people, and served more than 10,000 children. The most common reasons for calls were diagnostic questions, finding community resources and medication advice. The share of enrolled clinicians who said they could usually meet their patients' psychiatric needs rose from 8% to 63%, and 91% found consultations helpful (Sarvet et al., 2010). A later account described each regional hub as staffed by one full-time child psychiatrist, a licensed therapist and a care coordinator, noted that the program served more than 10,000 children in a single year, and reported that similar programs had spread across the United States (Straus & Sarvet, 2014).

The evidence has limits. Much of it comes from clinician surveys rather than measured outcomes for children, and a program that works in a compact, well-resourced state may be harder to run across a large rural region. But the model directly addresses the county's main cause, the distribution of specialists, by spreading one specialist's time across many primary care offices.

Recommendation

I recommend that the county's three practices join, or help the state create, a regional telephone consultation program, with a PMHNP as one of its psychiatric consultants. In that role the PMHNP would:

1. Answer calls from primary care clinicians within [thirty minutes] on weekdays, advising on diagnosis, medication choice and dosing, and safety planning.

2. See a small number of children directly by video when a question cannot be answered by phone, and return them to primary care with a written plan.

3. Offer brief case-based teaching to the county's clinicians, for example on ADHD medication titration or on screening adolescents for depression.

4. Work with the care coordinator to connect families with local therapists and school-based services.

If the state already has such a program, the first step is simply to enroll the county's clinicians and make sure they know the number to call. If it does not, the three practices, the county health department and the regional hospital could jointly propose a pilot to the state Medicaid agency.

What the Recommendation Cannot Fix

A consultation program cannot provide inpatient beds, and the nearest child and adolescent inpatient unit remains [140] miles away. It cannot replace ongoing psychotherapy, which still depends on local therapists, of whom the county has [three]. And it will not work if primary care clinicians do not use it, which is why enrollment and teaching are part of the recommendation.

Conclusion

The county will not gain a child psychiatrist soon. Its children already see primary care clinicians, and supporting those clinicians with a specialist on the phone is the fastest way to bring psychiatric expertise into the county. A PMHNP serving as consultant can extend that expertise to many more children than a visiting clinic could reach.

References

McBain, R. K., Kofner, A., Stein, B. D., Cantor, J. H., Vogt, W. B., & Yu, H. (2019). Growth and distribution of child psychiatrists in the United States: 2007-2016. Pediatrics, 144(6), Article e20191576. https://doi.org/10.1542/peds.2019-1576

Sarvet, B., Gold, J., Bostic, J. Q., Masek, B. J., Prince, J. B., Jeffers-Terry, M., Moore, C. F., Molbert, B., & Straus, J. H. (2010). Improving access to mental health care for children: The Massachusetts Child Psychiatry Access Project. Pediatrics, 126(6), 1191-1200. https://doi.org/10.1542/peds.2009-1340

Straus, J. H., & Sarvet, B. (2014). Behavioral health care for children: The Massachusetts Child Psychiatry Access Project. Health Affairs, 33(12), 2153-2161. https://doi.org/10.1377/hlthaff.2014.0896