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A Comprehensive Behavioral Health System
164 13 A Comprehensive Behavioral Health System for Identifying and Treating…
To be successful, the system would need mechanisms for (1) screening/assess- ment of risk and current problems; (2) triage to different interventions based on the overall level of assessed risk (low, moderate, or high) and on the type of risk (sociodemographic; problems with child, caregiver, or family functioning; disease- specific concerns); and (3) reassessment on a periodic basis. Moreover, these dif- ferent components would need to be integrated into a cohesive whole. Figure 13.1 shows the process flow, from entry into the system to yearly re-evaluation. Each component of this process is described below.
Universal Psychosocial Screening at Diagnosis The first part of the process—
and the entry point into the system—is through an initial psychosocial screening (Chap. 12). Ideally this would occur at disease diagnosis, although it might occur at the first new patient visit; when the system is first rolled out, established patients would also need an initial screening. Screening could be completed by interview or via a standardized questionnaire. We recommend using a screening tool that could be used to categorize level of risk (or need for established patients). Measures designed to do this include the RI-PGC for children and youth with type 1 diabetes (Schwartz et al. 2014) and the PAT for children/youth with cancer (Kazak et al.
2011).
Assessed Risk Triage is based on assessed risk level. Following Kazak’s PPPHM (Kazak 2006), the model defines three risk levels or categories of need, as shown in Table 13.1. Assessed risk level then determines the type and intensity of interven- tion. Important risk factors include:
• Low SES
• Single-parent family
• Caregiver unemployment
1) Risk Screening 2) Assessed Risk Level
Disease Diagnosis / Initial Patient Contact with service
Universal Psychosocial
Screening
• Individualized treatment
Yearly Psychosocial Reassessment Moderate
(20-25%)
• Targeted eHealth/mHealth Intervention
(65-70% of patients)Low
4) Reassessment
• Universal preventive education materials and tools
Yearly Follow-Up (5-10%)High
At-risk concerns, lack of support Clinically-significant
concerns
Good coping/
support
3) Interventions
Fig. 13.1 The comprehensive model of pediatric adherence promotion, showing patient flow from risk assessment through triage and intervention, to yearly reassessment
• Child behavioral or psychological concerns
• Parent mental health problems
• Family conflict (including marital conflict)
• A current history of nonadherence (established patients)
As a rough rule of thumb, having two risk factors (or one risk factor plus poor ill- ness control) would place a patient in the moderate risk category, and three or more risk factors would place a child in the high risk category (Schwartz et al. 2014).
However, problem severity and parent distress/desire for intervention should also be taken into account when making this determination. For example, a child with significant behavior problems but no other concerns would likely still warrant clini- cal intervention.
Interventions Interventions should be offered based on assessed level of risk/need to ensure efficient allocation of resources and to cover the range of needs, from universal education to clinical intervention. Below we give an overview of the type of intervention indicated at each level, according to current evidence-based practice in behavioral health. The actual interventions are described in greater detail in the sections that follow.
Importantly, patients at higher levels of assessed need should also have access to interventions at lower levels. Thus, moderate risk patients would have access to the educational materials and management tools as well as to targeted interven- tions, and high risk patients would have access to all of the different intervention components.
• High risk. Patients assessed to have clinically-significant concerns should be seen by or referred to a pediatric psychologist or other specialist in behavioral or mental health, for individually tailored intervention. High acuity patients (e.g., with suicidal ideation) would probably need to be seen outside of the system be- ing presented here.
• Moderate risk. Moderate risk patients are characterized either by a single child or family-related risk factor (e.g., family conflict), or by one or more resource limitations. The primary goals for these patients should be to minimize risk,
Table 13.1 The risk categorization model and indications for intervention
Risk level Characterization Indication for intervention High risk (Clinical) Clinically significant concerns
with child or family functioning Individualized treatment Moderate risk Risk factors for problematic
adjustment or adherence Limited resources
Preventive low-level interventions designed to minimize risk and keep the child and family connected to the healthcare system
Low risk Good coping, good support,
adequate resources Universal educational resources and illness management tools
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prevent complications, and help keep the family tied in to the system. Thus, ap- propriate supports at this level would be targeted interventions focused on the specific area of risk identified (e.g., child behavior problem), help obtaining re- sources (e.g., from a social worker), and/or support for navigating the healthcare system (via a patient navigator or Care Ambassador (see below), depending on specific needs.
• Low risk patients have adequate coping and supports. The indicated intervention at this level would be universal educational materials, and access to illness man- agement tools that could make living with and managing their disease easier.
Yearly Psychosocial Reassessment For many patients, problems with adherence do not emerge until they have lived with the illness for a while. Some children and youth may experience management burnout (Polonsky 1996). Others may pass through the developmental transition into adolescence, a time during which illness management and control is known to be especially challenging, or may encounter other stressors that complicate management. As a result, continued monitoring of patients’ adherence and psychosocial functioning is critical.