Nimble Youth | Episode 8: Collaborative Care - the Future of Mental Health Management

If you’ve ever felt like you’re the one doing all the care coordination for your child—between doctors, therapists, teachers, and insurance companies—you’re not alone. The mental health system hasn’t always made it easy. But there’s a new model that’s starting to change that: it’s called the Psychiatric Collaborative Care Model, or Collaborative Care for short.

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Hello, everyone. Welcome back to the Nimble Youth podcast, where we explore practical tools and fresh perspectives to support kids' mental health. I'm your host, Matt Butterman. Today, we're tackling a big shift in how pediatric mental health care is delivered and why that's great news for families. If you've ever felt like you're the one doing all the care coordination for your child between doctors, therapists, teachers, and insurance companies, you're not alone.

The mental health system hasn't always made it easy. In fact, it probably has never made it easy, but there's a new model that's starting to change that. It's called the psychiatric collaborative care model or collaborative care for short. To help us break it down, I'm joined by doctor Gretchen Hoyle, a pediatrician with a special interest in youth mental health. And doctor Hoyle is part of a team at her practice that uses this model every day.

Before we get into it, remind you that the content of this podcast is intended for informational purposes only and should not be construed as medical advice. While we aim to provide valuable insights on pediatric mental health, it is important to consult with a qualified health care professional for any concerns or questions regarding your child's mental well-being. Welcome back to Nimble Youth, doctor Hoyle. Thanks for having me. So, let's talk about collaborative care starting with the definition of what it is.

I think I started down that definition, but can you give us a broader definition of it? Sure. So there are lots of new emerging care models that are happening in medicine across the spectrum. And and I think what's happening is that folks, and by folks, I mean, often payers, so, like, insurance companies and Medicaid and Medicare, are realizing that to adequately care for chronic conditions, that a lot of times that sort of, discreet visit with your doctor one on one is not adequate to manage the chronic condition because there needs to be something that's happening and happening in between doctor visits. Right?

So there are lots of different, like, models that are sort of popping up for that. And, ultimately, what is driving that is because insurance companies and, you know, other payers are recognizing that managing chronic illness is an important thing to do. It's important for patients' well-being for sure, but of course, for the most part, it's driven by the financial part of it, right? So, they are realizing that having untreated chronic illness actually costs them money in the long run. And so being proactive about chronic illness is, you know, as financially a benefit to them.

And so psychiatric conditions, especially mental health conditions and especially when you look at PD the pediatric group, that those conditions are chronic, and caring for them is different from it's a sort of qualitative experience. It's different from when you come in for, like, a sick visit for a non chronic condition. Right? So, if you come in for an ear infection or strep throat, then typically that's a discreet visit that we can kind of wrap up in a bow and be like, okay, we've, you know, we have evaluated and treated that condition and, you know, now we're moving along from it. It.

These chronic conditions and so for pediatrics, that can be seen in things like, you know, asthma or abdominal pain or other physical things that we think about. But mental health is a really big group of chronic conditions, and the payers are recognizing that it's important to be able to have a more unified experience for the patient. That means that there's stuff that's happening between visits with the doctor that is making it so that the chronic condition is better managed. And so the way that that is happening in this particular situation, so what we're gonna talk about today is something called the psychiatric collaborative care model, and we're gonna talk about it specifically in the context of a pediatrics practice. So the psychiatric collaborative care model has been around for, you know, years.

And I think most folks who've had experience with it have been doing it, like, in a family practice setting or internal medicine or where they're taking care of adults primarily. It's moving its way into the pediatric space, which I think is really helpful and important. And as it turns out, we've had experience with this type of care for a long time because it was clear even a decade ago that, when parents are faced with a kiddo who has a chronic mental health condition, that they often need additional help between visits. Okay? And so, what winds up happening here is that we do this in a team approach, and that's sort of the idea of collaboration.

Right? And so when I talk about the team that we use in our setting, sort of the first person I think is, you know, that I'll talk about is the pediatrician. So my role, because, you know, I'm the familiar face to the family, I'm the familiar face to the child, and I'm usually the person that kicks this off. You're you're you're the first baseman. Right?

Correct. Exactly. Yeah. And so I'm the person where, like, I will see a child or adolescent and make a diagnosis of a mental health condition. And so that's a chronic, you know, problem.

And, depending on the circumstances for that child, I will sometimes think to myself, oh, they would really benefit from this collaborative care model. And then I will be the next person kind of in line for that is someone called the behavioral health care manager. And I think that's what we're gonna be talking about the bulk of that today, as what that behavioral health care manager does and who that person is and how that helps families. But just to sort of round out the team, the other person on that team is someone called a psychiatric consultant. And this person, will is not somebody who's typically going to be face to face with the patient.

Right? So the patient's gonna see me in the office. They're going to potentially talk to the behavioral health care manager typically on the phone. But the psychiatrist is giving me access to somebody with additional training to help make decisions about best management practices for that patient. A lot of times, it's medication related.

Sometimes, it's other things. But it often like, this model kind of developed out of the fact that we have a real shortage of, like, there's trauma with access to psychiatric, you know, to seeing a psychiatrist. Right? And so we'll have these, and this is it depends to some extent in what market you're in, whether you're in a big city or whether you're in a smaller area or if you have an academic institution nearby. I mean, there's lots of sorts of variables as to what the access to psychiatry is.

But even though where we are is a fairly, like, moderate sized area and there is an academic, you know, institution nearby, and it's still, like, four to six months at best to get in with a psychiatrist. Right. Right? Yeah. Psychiatry.

Okay. So that being said, like, having this psychiatric consultant available to me as the pediatrician that I can then sort of curbside. So the curbside consult is kind of, is a known entity in medicine where you're like, well, oh, you're, like, you're rounding in the hospital and you're going to a patient's room and you run into your hematologist friend and you're like, oh, let me ask you a few questions about this without sort of putting everyone through the formal process of having them consult on the patient or, like, actually seeing the patient. So instead of it being a formal consult, it's kind of a curbside consult. Right.

That's what this feels like most to me with the psychiatrist in that, like, I'm going to sort of briefly explain the problem and say, okay. This child may or may not be on, you know, the list to be seeing a psychiatrist, but in the in the interim, before I can get them there, if that's what they need, I'd love to ask you a few questions about what you think about either the use of this medicine in this situation or the overall appearance for, like, what's happening with this child. And having that access for a primary care physician when they're taking care of patients who have mental health conditions is extremely helpful because most of us didn't get a ton of training in that. So it depends on how long you've been out of residency. But for me, like, mental health training, of course, this was, you know, in the nineties when I was in training.

So it's been a long time. And, you know, I spent the vast majority of my time in residency training, you know, in the ICU or, you know, the peds ICU or the neonatal ICU or rotating on the hospital floor or in the emergency department. And most of that was, you know, we consider to be, like, classic, like, physical symptoms and physical ailments. And, of course, it's somewhat of a false distinction between, you know, physical conditions and psychiatric conditions. But at least at that time, there was a pretty significant like, there's a line there.

And so we had, you know, some training in mental health, but not a ton. And so me having access to somebody who I could potentially kinda curbside and say, okay. You know, what do you think about this is extremely helpful, especially if I'm waiting on them to get a full evaluation from the psychiatrist. Right. So the psychiatric consultant plays an important role, but perhaps the player with the biggest role on the team is the behavioral health care manager.

And this person often does what a social worker will do, sort of coordinating all the care. And in many cases, they are, they have, degrees in social work or they're working towards licensure, that sort of thing. But oftentimes, they're just people who are good at coordinating things. They can be, some of the best behavioral health care managers have been parents themselves. Correct.

So they've gone through this, before, and now they can use that experience to the aid of others. So what does a behavioral health care manager do, and how do they, you know, perform this very important role on the team? Right. So, what will typically happen is that what if I identify, when I identify, patients who I think would benefit from this collaborative care model is that I will make a referral within the office to the behavioral health care manager and sort of into the collaborative care team. Okay?

And so sort of the first thing that happens is that the behavioral health care manager will do what we call an intake, And this is really done over the phone. Okay. So it's not an in person like experience. And so we really are trying to provide these services in ways that are most, like, accessible for families. And so depending on the age of the child, that intake can be either with the parent only.

Sometimes it's with the parent, and they'll talk with the patient a little bit. Sometimes with our older patients or really, ultimately with our older patients, it's going to be the behavioral health care managers gonna be talking to the patient. And by that, I mean, like, these are older teens or even we go through college age. And so they do an intake and sort of get, and they can get lots of additional information even sometimes more than what I can get because I'm limited by time. It just says those constraints of modern, you know, medicine.

And they have more time to spend with the patient and get down into a lot of, you know, additional information. A lot of times these are sort of what we call social determinants of health. Like, what are the social pressures that are currently happening with this family, who lives in the home together? And are those people having troubles, and do we have, you know, access to a car, and are we able to get to our, you know, appointments, and are we having food insecurity? I mean, lots of different things that do sound sort of sound sort of social work y kind of things.

But all of that can be assessed in the intake with the behavioral health care manager. And then that person will start doing things on behalf of the patient that is guided by what they find out in the intake. And so typically those things can fall into several categories. Probably the most common thing that the behavioral health care managers are doing, or usually the first thing that they're doing is working on referrals to other mental health care providers. Okay.

And so we think to ourselves, oh, well, you know, like years ago, I would say, oh, well, your child has this diagnosis. They need to see a therapist. And then I would say, okay, well, you need to find out for your insurance who you can see. And that just did not work at all. I mean, like that just never happened.

It was because what will happen is that parents will, you know, potentially find out from their insurance carrier who is on their provider list. And assuming that they have time during the workday to try to make these connections and call these offices, a lot of times what they were met with was, you know, somebody is either not taking patients anymore at all or actually they've changed their insurance plan and they're no longer taking your insurance or they're in a location that is, you know, not accessible or their co pay is so high that it makes impossible to do that, or lots of different reasons why, you know, it's not a good match. And so they were going down this mid this list sort of, you know, hoping to hit on the right person that they can get an appointment with. And a lot of times, you know, if they were able to get through all of that, then they may not actually be seeing somebody who has experience in what the child is suffering with. Right?

Or with the specifics the nuance of what it is that's going on with that kid. And so a lot of what our behavioral healthcare managers are doing are, you know, assessing the situation and then taking their sort of knowledge of the landscape of the community as far as therapists. So which therapists do which type of, you know, are have special interest in what that person needs. Certainly, the insurance, you know, insurance gets a say. That's just true in everything.

And so, they'll know, you know, which insurances are, you know, available for that provider, and whether or not, you know, that provider takes that patient's specific plan. And they'll have a sense as to, you know, whether it's sort of a good fit or a good match based on, you know, sometimes that's a gender based, you know, provider. So, sometimes you want a gender match provider for what the problem is. And so, and they know all these really nuanced things about all the people who are available for therapy, and they also know how far out they're scheduling. So, you know, if it's the kind of thing where, you know, I really want this person to see them, the child is reasonably stable.

There's some things that we can do in the interim to get them to that person, or they need to see somebody right away. We need that, you know, it helps us decide who you know, how we're going to pursue a therapist for that person. Lots of different variables. Sure. So the behavioral health care manager plays this important role with the referral for therapists Mhmm.

And also connecting parents with community resources, things like after school programs, support groups for whatever conditions Sometimes it's like the food bank. I mean, I guess stuff like yeah. I mean, like Existential concerns that the family is facing. Social determinants of health. Right?

One of the critical roles that they play is they coordinate with schools. Yeah. Which is increasingly let's call it dicey True. Subject right now in an age of declining resources for schools to to deal with students who have special needs. Correct. Yep.

Yep. And so that's getting more complicated. And I will say, like, this is, like, just one of the great things about having a baby health care manager, who is able to connect with schools on behalf of the patient. And a lot of times they're doing, you know, one of two things. One is sort of gathering information.

And so sometimes it's something as simple as, oh, well, this child looks like they may meet criteria for a diagnosis of ADHD, but I need a pair of forms from the teacher. And so they're able to reach out to the teacher or, you know, to the school and either just something that sometimes is easy as just faxing that over and getting it back. Because the actual, like, interaction that sometimes the parent has to have with the teacher to be able to get that form and get it back to them and then get it to me can be really challenging, especially if that kid is having a lot of trouble in the classroom setting. When the parent looks at the information that the teacher is providing to me to be able to make a diagnosis, if they're looking at that in between before they get that to me, then a lot of times it's revealing things that the parent may or might not have known, and that can cause some level of consternation or even conflict with the with the teacher. And so being able to have an intermediary to work with the teachers, and then sometimes they're working, you know, with the school counselors too.

So some kids who've already had have been identified or have qualified for exceptional children's services. So this would be something like having an IEP, which is an individualized education plan. Having my behavioral health care manager connect with the guidance counselor and finding out what's actually, you know, on that IEP. Sometimes the parents know a lot about what's happening, and sometimes they don't. Sometimes it's a different caregiver from when we originally got that document.

And so getting that information from the school is extremely helpful. And I do find that, sometimes things will go better with the conversation between school personnel and the behavioral health care manager because it's kind of like two mental health professionals talking to each other as opposed to trying to have the parent gather that information when they may or may not have the language to ask for what they need. Right? So the behavioral healthcare manager is familiar with the lingo that is used in these sorts of interactions with schools about special services or accommodations. And, and they're able to sort of articulate that to the school because of their experience in doing this.

And it also sort of turns down the volume on any sort of, like, negative, sort of emotionally charged interactions that the parent is having with the school, which are typically not helpful. Right? So, like, if there's a conflict there, then having an intermediary to try to gather that information. And then sometimes be able to advocate for the child too because the behavioral health care managers talked to schools a lot and they've talked to the parents and found out what's been going on. And sometimes they can ask for things that the parents wouldn't necessarily know to ask for because of their experience.

And so advocacy, educational advocacy is a big thing that the behavioral health care managers, you know, are doing. And all of those things are just extremely helpful. It just really changes, like, you know, years and years ago before we were doing any of this and I was sort of putting this burden on parents, it just did not go well. Sure. Okay.

And so, you know, a lot of times, I mean, parents are a lot of times they are obviously very busy during the workday. And so being able to connect with schools is challenging. Oftentimes, they are already sort of stretched by whatever's happening with their child, that's, you know, causing challenges. And then they have other children and other responsibilities, and sometimes they're taking care of their parents. I mean, it's all sorts of things that are happening in that parent's life and having a professional get to the bottom of the information that we need and then also doing the advocacy.

Sometimes that will take, you know, a ten minute phone call as opposed to weeks or months of back and forth between the parent and the school. Yeah. It's a really great resource, thinking back on my experiences as a parent. I wish I had a behavioral health care manager, there to deal with all the complexities that raising a child involves. So a couple other things that the behavioral health care manager does, for younger kids, they do parent coaching Mhmm.

Helping with things like bedtime routines, you know, star charts for doing chores and and, managing tantrums and and things like homework challenges. That's a big, big hurdle for a lot of parents. But let's talk a little bit about what they do for teens. They do something that's similar, but what you call brief therapeutic interventions. So Right.

Go through what those are and how they help. Yeah. So sort of the way to think about, like, brief therapeutic interventions and parent coaching. So both of these things are not a replacement for seeing a therapist. So sometimes these kids will still wind up seeing therapists.

A lot of times that's the case, but, of course, there is often a delay in that. And then also being able to have sort of reinforcement of, you know, these ideas in between visits with the therapist or the pediatrician is super helpful. So to sort of roll back a second to, like, the parent coaching stuff, I talked with my behavioral health care manager, and I said, okay. Well, what are the top five things that you are saying to parents that you find that you think are helpful? And so, for example, it's things like these are really sort of very, like, real world concrete recommendations.

So, for example, with kids with, like, probably the one of the biggest things that they'll say for kids with ADHD when they're talking to parents and they're coaching parents of children with ADHD, they'll say things like, we need to make sure that your child has a clean, clutter free workspace to do their homework. That is just a, you know, a super helpful tip. It seems somewhat obvious, but it is also the kind of thing where, you know, I will say it sometimes in passing during the visit, but I usually have so many things that I need to cover that I'm not able to sort of reinforce it. And so being able to have them enforce it, keeping in mind that the behavioral health care manager, after they do their intake, is typically going to have check-ins with the parent on a weekly basis. So it allows for this sort of reinforcement, you know, multiple times.

And so that's one of the things that they said. The second thing that they talked about was these are concrete examples of, you know, for kids with ADHD and you're trying to get them to complete a task like cleaning their room, they'll sort of try to make it into a game and you set the timer for two minutes on your phone and say, okay. In the next two minutes, we're gonna see how many, you know, articles of clothing you can pick up from your floor. And so when and so then that tends to sort of I think it was really doing is helping the child's actual dopamine get elevated in their brain because they become excited and interested in it because there's that sort of little, like, game competition kind of thing going on in their heads. And those are ways to help kids, like, learn how to do the task that we need them to do.

So those are a couple of really helpful, you know, recommendations. These are the kinds of things that people do with parent coaching. Another thing for kids with anxiety, or even with parents with anxiety or both is to encourage, like, we're gonna potentially say we're gonna set the goal that each night or maybe it's starting with one night a week or maybe and then we move it to two nights a week. It's like incremental goals of we're gonna take a walk together with that child without the phone for either one of you. Right?

For in the evening, we're gonna do that and we're gonna do it. Let's say it's two nights a week and it's gonna be at least fifteen minutes long. But setting that goal and then having that conversation the next week and saying, okay, Did that happen? When did it happen? What did you think about it?

Is extremely helpful as far as parent coaching. Right? And then also the behavioral health care managers can help parents learn how to do breathing exercises that help calm the nervous system, and they can help their kids with those things. And then this one is, I think, my favorite one because they use this technique calling three things you're proud of. And so they'll say to their parents, okay.

At the end of the day, you can sit with your child and say, okay. Tell me three things that you're proud of and write them down. And so that can be an incredibly helpful insight into what the child has experienced and what they consider to be positive. You can also flip it around where the parent's like, well, I'm gonna tell you three things I'm proud of you for this tip for today. Right.

Those are all really helpful parent coaching things. And, of course, we're not gonna just rattle off a list and be like, I want you to do these, you know, 10 things in the next week. We're going to be like, okay, well, let's, based on the main problem that you're having, we're going to recommend this intervention and we're going to try to do it maybe once or twice a week, and then we're going to build on that. Right? So that's sort of what it looks like with parent coaching.

With folks where the behavioral healthcare manager is actually directly interacting with the patient, then, you know, those are also sort of called brief therapeutic interventions. And, so in this setting, it's usually older, like high school age folks or people who are in college. And usually the problem is anxiety and depression or just difficulty with motivation. And so they'll start with these strategies of, like, breaking down problems into, you know, smaller achievable goals. So a lot of times, it's kind of the same idea.

Like, okay. Your dorm room is a mess. Your side of the dorm room is a mess. How are we going to deal with this? We're gonna break it down into today, we're gonna do these things in order to, you know, get back on track and break it down into small things and then recheck out of the next week.

Right. So those are sort of ways for parents to track progress Mhmm. In a way. They aren't full length therapy sessions, but they're sort of practical steps that parents can take to help their child. Mhmm.

And, I don't wanna spend too much time on it because we've covered it before, but, as the practice to, kind of evaluate the team's efficacy, their effectiveness in treating the condition. You use the surveys that we've touched on in previous episodes, the g 87 Yep. And, the PHQ nine. Right. And, obviously, since more health care providers or or or conglomerates companies are moving to the collaborative care model, there have been metrics that prove how effective the collaborative care approach is.

So for parents who want to get involved in a practice with the collaborative care model, what is your advice for them to find a practice that deals with collaborative care? Right. And so yeah. So this is an expanding program. It's an expanding model and other, you know, like, practices are starting to, you know, try to do this.

I think it's, I think it's helpful if parents are interested in this model to find out, first of all, if it's available at the practice that where they are. And if that's not the case, then, you know, indicating to the provider that that, you know, would be something that they would be interested in. Because a lot of times, what's happening is that we're in this sort of early adopter phase right now where some practices are doing it, and some practices are in what we call contemplation stage. So they're, like, thinking about it and how to activate it. A beta.

Yeah. Right. Exactly. Yeah. So they are really, you know, starting to try to figure that out.

And so hearing from patients that they're interested in this type of service would probably be helpful in moving people forward. And so that's one of the things that parents can do. I mean, I would also say I think it's so interesting to, like, these behavioral health care manager folks are so interesting. At some point, like, I'd love to have them come and talk with you a little bit. But we'll get them on in another episode Right.

Well, and one of the things, like, that they're saying to you that I think is so interesting is, like, you know, a lot of the times the folks that are struggling I mean, we talk a lot about, like, neurotypical kids and neurodiverse kids. And, one of the things that they use a lot for kids who when they're doing individual, like, like brief therapeutic interventions with patients who are older is, is journaling and art, which I think is so interesting because, like, as it turns out, a lot of times kids who are who are struggling, a lot of what their struggles is about, that their brain just different works differently from other people. But then they have these, like, skills and abilities that are sometimes maybe not as appreciated by our society.

And so when you can get them into doing something that they really enjoy, and a lot of times it's an art based, you know, thing, experience. And so writing and creating art is a technique that's been used by therapists. Sure. It's cathartic in therapy. It is.

Yeah. And it's also something that, you know, is something that the behavioral health care managers will encourage folks to do, in order to as another one of these sort of coping mechanisms that they recommend in order to get to, you know, improvement in their overall function. And I think it's important to recognize too that, like, what the behavioral health care managers are doing is we call skills based interventions. And so this is a little bit different from what, like, you know, a lot of times these kids are gonna be seeing therapists once we are able to get them in. But, and a lot of times in therapy, what you're working on is sort of trying to get to do a deep dive to get to the root of what the problem is and try to, you know, evaluate that and maybe demystify it and try to reorganize it and try to make it so that the brain is not as, you know, is not as sort of ruminating on it, that kind of thing.

Okay. So, what they're doing with the brief therapeutic interventions is really more of a skills based thing. It's to try to improve your function. Right? And so it's not necessarily trying to do that deep dive into what a lot of us think of as, you know, psychotherapy or whatever.

We're really just trying to say, okay. What are some things that we can do to get you back to functioning? And being able to, you know, break down problems into smaller achievable goals and finding access to things that make you happy like journaling and art and help you process your feelings can be helpful functionally, practicing mindfulness. So a lot of times we'll do guided meditations, breathing exercises, giving tips for how to reground yourself during an episode of acute anxiety, like a panic attack. These are all skills that the behavioral health care manager can help the patients with, whether that's the parent or the patient or the patient through the parent.

I mean, there are lots of different ways to get these sorts of skills out there. But you know, what we're really focusing on there is getting them back to functionality. Because a lot of times, once we can get folks back to functional, then we can continue to explore whatever their underlying issue is. But in the interim, they are back in school, back socializing with their friends, you know, back doing the things that they need to do to have a good life. Sure.

Yeah. So I think in summary, the collaborative care model is a positive step in health care management, in an age when so much of the time we're focusing on the breakdown of the system. Right? Right. This is a very positive development.

And so here at the Nimble Youth Podcast, we're very glad to see that. Thank you, doctor Hoyle, for your time today. That's it for today's episode, but please remember to visit our website at www.nimbleyouthpodcast.com. There you can sign up for our mailing list and newsletters and find recording links, full transcripts, and show notes for past episodes. And if you found this helpful, please share it with another parent and leave us a review.

It really helps us reach more families. And do remember, you're not alone and better support is possible. Take care, and we'll see you next time.