Program helps pediatricians find child psychiatrists for patients

Program helps pediatricians find child psychiatrists for patients

By David Hench dhench@mainetoday.com

Staff Writer

In her practice as a primary-care pediatrician, Andrea Loeffler gets at least a couple of calls every day from families who need help with mental-health issues.

Between the ear infections, immunizations and broken bones, Loeffler said, she has to shift gears and try to assess whether a teenager's irritability and defiance is normal or something requiring specialized treatment.

"The bulk of adolescent mental health lands on our doorstep first," she said. The right response can mean the difference between ensuring mental health services that the patient needs and a suicide attempt.

A growing number of pediatricians are signing on with the Child Psychiatry Access Project, an innovative program that gives primary-care doctors in southern Maine quick access to child psychiatrists.

The psychiatrists provide regular training sessions for pediatricians on such topics as warning signs that a child might need psychiatric care and the effects of various medications and treatment.

The project also helps the pediatricians link patients with counselors -- or psychiatrists, if necessary.

The program seeks to address a chronic shortage of child psychiatrists in Maine, a problem that has been identified nationally by the American Academy of Child & Adolescent Psychiatry, said Dr. Sandra Fritsch, a child psychiatrist who is the program's director.

"The state with the most child psychiatrists per child is Massachusetts ... and that is the state that initiated the first consultative, collaborative care model," she said, referring to that state's program. "Children couldn't get their mental health needs met in the state with the greatest number of providers."

Loeffler, medical director at Martin's Point Medical Group in Brunswick, said pediatricians are seeing more mental health crises and are increasingly called on to diagnose and recommend treatment for mental health issues.

"We have children being raised with a lot of stressors, a lot of stressors that are different than we grew up with," she said. As an example, she said reliance on social media can stunt social skills and maturity.

Doctors involved with the program say it has worked well in southern Maine and the 22 other states that have embraced it, and they would like to see it expanded to the rest of Maine.

Some Maine counties don't have a single practicing child psychiatrist, so families in northern and eastern Maine may have to spend hours traveling to appointments.

Others miss out on treatment altogether.

"There simply aren't enough people to help take care of this community," Loeffler said at a recent lunch-and-learn session that Fritsch held in Brunswick. "Without access to this program, we would be floundering. There are parts of the state that are floundering."

A shortage of psychiatrists led the Maine Association of Psychiatric Physicians to start a program in 2004 in which doctors were linked with psychiatrists they could consult by telephone or email. The program's part-time coordinator is paid with a $7,000 grant from the Department Health and Human Services.

Dr. David Moltz, who developed the program, said it was intended as a stopgap measure until a more comprehensive solution could be found. He said the shortage of child psychiatry in the rural parts of Maine is even more acute than the shortage of adult specialists.

The program gives primary care physicians "curbside consultations" but doesn't have a formal structure that includes training on child and adolescent mental health or direct consulting and services.

Southern Maine's Child Psychiatry Access Project serves an area that includes about 38,000 of the state's 300,000 children.

Fritsch said about 40 percent of the calls the program receives are from physicians trying to determine what resources are available for patients. A similar proportion is for telephone or email consultation. Currently, 34 pediatricians in nine practices are enrolled.

The remaining roughly 20 percent are direct referrals to the program's outpatient services.

Starting in 2009, the program's first three years were paid with a $300,000 grant from Maine Health Access Foundation. For now the program is funded by the Glickman Family Center for Child and Adolescent Psychiatry at Spring HarborHospital.

Expanding the program to include the rest of the state's 300,000 children would cost upward of $800,000, Fritsch said.

Some states, such as Massachusetts, that offer a similar program fund those programs, while others are funded jointly by the state and large research hospitals. Fritsch said another model for funding would charge practitioners enrolled in the program a fee that would work out to about $2.64 per child per year statewide.

The program is free for participating health care practices.

Fritsch believes it's a worthwhile investment in getting better care to children earlier, before problems become more serious.

Pediatricians do relatively little training in mental health issues, compared to psychiatrists who spend years on the topic.

"None of us here trained in that back in the day, but it has been a huge component of our work life," said Dr. Jan Wnek, a pediatrician in Brunswick who has been practicing for 45 years.

In the past, if the mental health issues exceeded a pediatrician's expertise, he or she could either refer the family to a specialist who had a long waiting list or send them to the Emergency Room with huge costs for the family and the health care system.

"As you wait, problems build and build and build. ... Everything you do includes that part of your body."

Providing more rapid care, either through a telephone consultation or by a direct referral to the program, has huge benefits.

"It's more that there are symptoms you can gain control of faster with the right directions," Loeffler said. "The trickle-down effect is enormous. They need less intense care and help because they get at it right away."

"I view this kind of collaborative effort as part of primary care and preventive care," she said. "It is much less costly to us as a society to be able to proactively address concerns and problems than to wait until they're much bigger."