Dr. Bob Underwood (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Bob Underwood. And with us today is licensed clinical social worker Rebekah O'Donnell, who is an integrated behavioral health provider from Children's Mercy Kansas City. And today, we will talk about integrated behavioral health and how this model can transform care for children and families in the primary care setting. So, Rebekah is going to help us understand that a little bit better. Rebekah, welcome to Pediatrics in Practice.

Rebekah O'Donnell: Thank you for having me.

Host: Absolutely. So just to start us out, to level set for all of our listeners, how do you define integrated behavioral health in a primary care pediatrician's setting? And what does a good integration look like in a day-to-day practice?

Rebekah O'Donnell: Yeah. So, integrated behavioral healthcare is integration, bringing in mental healthcare into what would traditionally be medically focused. I am in our primary care clinic working with psychologists and our medical providers to meet the everyday needs of our families.

There are different types and levels of integration. So, the highest form of integration is our behavioral health clinicians being able to go in to the medical appointments, participate in warm handoffs, and meet directly with the families while they're here for their medical appointments. There are also different levels of integration like co-located services, where mental health providers are located potentially in the same building. And then, there are also lower levels of integration where it's more community relations, being able to refer families to community-based care.

I think we have a bit of a mix of all of that here at Children's Mercy, where we have our integrated providers, we have our specialists or the therapists and other clinics. And then, we also still coordinate with community providers as well.

Host: Sure. So, there's an array of these.

Rebekah O'Donnell: Kind of like thinking about like a taco even is an example we'll use. Like, you have your taco completely put together, all your toppings, everything in there, versus a taco bar where you have the choice to pick and choose what to put together, but it's accessible, versus going to get takeout, I suppose.

Host: Yeah, I love it. It's a great analogy. And the idea is to kind of make this a little bit more seamless in terms of getting behavioral health services, integrating them in with the pediatrician's practice.

Rebekah O'Donnell: Exactly, yeah.

Host: So, some pediatricians might feel a little overwhelmed by the volume of behavioral health needs that they actually see. So, how does an integrated model change what happens in a typical, say, 15 or 20-minute visit?

Rebekah O'Donnell: I think it just adds to. I don't think it changes much for the medical provider. That they are there, they're doing their job, they're ruling out medical concerns. And this is just a bonus add-on. We get a little more depth. We get to figure out kind of seeing a more holistic picture of what's influencing a potential behavior or medical condition.

So when we talk about mental health care, talk about behavioral mental health needs, but also health behaviors as well, how do we improve sleep, nutrition? I used to work in a clinic that was lifespan of integrated care. So, that's a few more topics we would cover there. But in pediatrics, I think, it just adds a little more depth. And then, it kind of takes that weight off of some of that diagnostics. How do we get a clear diagnosis? What kind of treatment is more specified to what that family needs? And how do we kind of take that load off the medical provider for us to be able to take care of that connection

Host: And that's amazing and got to be, you know, a benefit to the pediatrician, but also to the patient and the families to be able to integrate like that. So, what types of concerns are best suited for integrated behavioral health within the medical home versus referral out to a specialty behavioral health service? So, kind of a combination question of what are really good integrated behavioral health.

Rebekah O'Donnell: I think that's the beauty of integrated care is it can be a bit of everything. I think it really depends on the clinic and what their needs are. So, being able to do at their own needs assessment, getting to know your different providers. Some may feel very confident in addressing ADHD, but some not so much, and so that's why they need a behavioral provider.

So, I think it depends on the program. I'd say particularly here at Children's Mercy and our psychology team, Dr. Belzer and all of them have done a fantastic job really addressing neurodevelopmental concerns such as autism screenings and things like that. So, I think it depends on your medical providers, what they need support in, what our community is coming in and expressing, and where there might be barriers for access in community care and how can we create accessibility within a space they're already coming to. In social work, we say meeting people where they're at and in their environments.

So, I think typically a lot of integration really started with a focus on like depression, anxiety, things like that. But we also have families coming in with universal human experiences like grief or figuring out parenting at different developmental stages. So, I think it really just depends on the program. But that's the beauty of it, is being able to tailor it to your providers and your community needs.

Host: I absolutely agree with that. And, you know, often, I think, many people may try to view behavioral health and medical care as separate, but they are so intertwined. And this gives us the opportunity to make sure that we're addressing both simultaneously.

Rebekah O'Donnell: Yeah. So actually, when I introduce myself, I always am like, "I'm Rebekah. I'm a behavioral health consultant, which is just a big fancy way of saying I talk to kiddos about their mind and their body and how those are connected." So, we all have a mind, we all have a body, they influence one another. And there's all the research to show how we take care of our mental health impacts how our health outcomes go in long term.

Host: Yeah, absolutely. So, from your experience, what are some barriers practices might face when they are trying to implement integrated behavioral health, and how have successful teams worked through those challenges?

Rebekah O'Donnell: Yeah, I think first barrier is getting integration up and running. I think people fear, "Oh, we're going to have to pay another salary. It's going to be expensive." But research actually shows us that it's cost-effective and the benefits. And on a macro level, we're seeing payer sources change to more value-based payer sources, things like that. That's a whole different conversation. But I think that financial barrier really scares a lot of programs, or I think there's sometimes some outdated "mental health is separate," but we know it's not. Barriers can look different depending on what community. Are we in a rural community where we have less access to community-based resources? And how can we get flexible with that of programs doing a lot more virtual services to the rural communities or connections to psychiatry or things like that? I think the overwhelm we mentioned earlier can be a big barrier in itself.

Providers are like, "I don't have time. I already have so many other things I need to address." So I think there's a couple different barriers there of financial kind of attitudes and just that overwhelm for sure.

Host: Speaking of which, this may be part of the answer to the next question, which is how does integrated behavioral health support pediatricians themselves, particularly around burnout, decision-making, managing complex family dynamics, those types of things? Where does integrated behavioral health fall into that mix?

Rebekah O'Donnell: Oh, I think that's one of my favorite things about it. That sigh of relief when you walk in a room or, "Thank God you're here." I wish I would start tallying how many times I hear that in a day. I think the beautiful relationship we have is such a privilege with our medical providers. I have one who jokingly calls me her Swiss Army knife. Another calls me Miss Congeniality. We're really here for them as much as we are our patients, because that is what's going to give our communities better care, allowing them to focus on the medical. Let's make this decision together. Let's talk about options.

And so, I think it helps reduce burnout because it reduces that overwhelm. I think when we allow our providers to be human and they don't have to know everything, and we can take away some of that decision fatigue. I think it just takes so much off their plate. And they can then trust that we're providing quality care as well, because that can be a barrier too of, "Can I trust you with my patients?" Because these are my patients, first and foremost, and especially with complex family dynamics, being able to have kind of multiple eyes on the situation, being able to spend a little more time with the family to tease apart some of the particular factors influencing maybe why are we not adhering to medication management, or is there some social determinant of health barriers that we need to address?

So, allowing providers to know they don't have to do it all and that we're here for them just as much as those patients, I think is one of the most beautiful parts of integrated care for sure. And particularly being in a teaching hospital, our residents don't always get the most robust behavioral healthcare. So, how can we educate them as we go along? And I think it teaches them to not be afraid of behavioral health. Just because a kid's got autism, we don't have to be scared to go in that room. So yeah, I think it just humanizes them, takes some of those barriers and those burdens away and, just long-term, provides better care for everyone.

Host: Okay. For pediatricians listening who don't currently have access to integrated behavioral health, what are one or two concrete steps that they could take now to move their practice closer to this model?

Rebekah O'Donnell: First always, this might be my social work background, a needs assessment. What are we seeing? What's going on? Where are there maybe some gaps in our care, in our education? So, first, identifying what could we do, and then advocacy with leadership about the benefits and also connecting with what resources are already out there. I think all the time I hear that with referers, they're like, "I just didn't know or I would've been telling everybody about this." I'm like, "Well, that's my job to know."

So, first, identifying what the needs are, and I think that goes to like barriers. We can't do everything. So, what could we target to do and do well if that means creating particular clinical pathways and then trialing that in the clinic? What does it look like to have a psychiatrist we can refer to? What does that look like to create a referral liaison between a community mental health provider and ourselves? How do we educate ourselves about the best therapy models and medication management? Because things are constantly changing. So first identifying needs, advocating for these programs, understanding the benefit of them, and then on that personal note of how do I provide quality care with what I have access to?

Host: And that's awesome. To be able to provide that and to guide clinicians, again, patients, family members all along through those things that they may not have even heard of or been integrated with before. So, as we conclude, is there anything else you'd like to add?

Rebekah O'Donnell: I think it's such a privilege to get to do this work and to meet with our families. We're seeing on a macro level that primary care is the touchstone. Like, we are that linchpin for families of where do they go to first. And so, being able to be here to receive their needs and for them to leave with a little more support and a little bit of relief that we have a plan, I think that's worth it, worth any of the financial cost, which research does say balances out in the long run. So, I would just encourage everyone to advocate to have some level of integration.

Host: All right. Rebekah, thank you for being on today.

Rebekah O'Donnell: Thank you for having me. I appreciate it

Host: Absolutely. And as a reminder to our audience, claim your CME credits after listening to this informative episode today. You can do so by visiting cmkc.link/cmepodcast. And then, click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Bob Underwood. And this has been Pediatrics in Practice, a CME podcast.