Launches Pediatric Mental Health Access Initiative
Among the many factors contributing to the mental health crisis faced by America’s youth, access to quality care remains a problem. Children and families encounter numerous barriers to care, such as transportation, time away from school and work, too few providers, and the ongoing stigma of seeking mental health care. These obstacles often prevent
children from receiving the care they need in a timely manner—or at all.
To help alleviate some of these barriers, the Departments of Psychiatry and of Pediatrics at Dartmouth Health Children’s launched the Pediatric Mental Health Access Initiative, a multifaceted
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Our country and our region face a crisis in addressing the mental health needs of children and adolescents. This crisis has been building up for decades. In 2016— pre-pandemic—one in six youth in the U.S. had a mental health condition, according to retrospective research conducted by a team led by JoAnna Leyenaar, MD, PhD, MPH, professor of pediatrics and of The Dartmouth Institute for Health Policy & Clinical Practice. But more than one-third of U.S. counties, including half of rural counties, didn’t have appropriate treatment facilities for children. These researchers also found that a diagnosis of attempted suicide or selfinjury has increased dramatically and constituted 64% of mental health hospitalizations in 2019.
At Dartmouth Health, we have been turning toward this challenge in a range of ways, from screening for difficulties to embedding on-site mental health expertise in all of our pediatric primary care medical homes. Several years ago, a bequest from the estate of Jonathan Guloyan greatly accelerated and deepened our ability to increase timely access to high-quality care for children and adolescents. With the gift, we created the Dartmouth Health Children’s Pediatric Mental Health Access Initiative, allowing teams to rapidly implement science-supported practices across our region to transform lives.
In addition, Dartmouth Health partners closely with the state of New Hampshire to provide clinical care and medical directorship to the state’s citizens served by Health and Human Services programs. This work
includes leading statewide programs for children and youth with developmental disabilities and also those in the juvenile justice system. After a competitive bidding process this year, we now supply medical direction and clinical services at Hampstead Hospital, the only inpatient pediatric psychiatric facility in New Hampshire. As of July 2024, our child psychiatrists and psychiatric nurse practitioners are deeply engaged in providing and improving care at this hub of child and adolescent psychiatric care for the state.
These types of collaborations allow us to reach children and adolescents with mental health conditions who are in need of care and illustrate how the Departments of Psychiatry and Pediatrics—together under the Dartmouth Health Children’s banner— leverage the power of our academic health system to help all children live their healthiest, happiest lives.
As we are both, like you, alumni of these institutions, we are particularly pleased to share this newsletter with you.
Keith J. Loud, MD, MSc, RES ’00
Chair, Department of Pediatrics, Geisel School of Medicine and Dartmouth Health Dartmouth Health Children’s Physician-in-Chief
William C. Torrey, MD, RES ’89, D ’80
Chair and Raymond Sobel Professor, Department of Psychiatry, Geisel School of Medicine and Dartmouth Health
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Pediatric Mental Health Access Initiative
portfolio of programs that address various aspects of the youth mental health crisis with a specific focus on improving the impact and accessibility of quality care.
“There are people who are suffering every day, so we are trying to address these mental health problems earlier and expand quality services,” says Francine Morgan, MBA, the program director for the Pediatric Mental Health Access Initiative. “If you aren’t feeling like yourself, going to a therapist should be the same as going to your primary care doctor for strep throat. You can find information on Google, but that’s not quality care.”
Morgan says the initiative relies on three primary areas for success: connecting departments across the Dartmouth Health Children’s system, collaborating with external community partners, and innovating solutions to address persistent problems. The initiative currently spans the departments of pediatrics, psychiatry, community and family medicine, and population health, initially funded with a $1.5 million gift from the family and friends of Jonathan Guloyan, who dealt with mental health issues for many years before his death by suicide.
“We are trying new ways to reach providers and patients where they are,” Morgan says. She notes that the programs within the Pediatric Mental Health Access Initiative are “multiple doorways that lead to the same goal.”
Pediatric Collaborative Care: Creating the Model
Successful collaborative care models for mental health conditions have been well studied in adults, but there’s little research into how such models would work for pediatric populations. So, as part of the Pediatric Mental Health Access Initiative, the Dartmouth departments of pediatrics and psychiatry have joined together to greatly extend their implementation of a pediatric collaborative care model (dubbed PediCoCM, for short) in pediatric primary care settings throughout the health system. Clinicians are providing timely access to mental health care for children and gathering evidence to hone the model.
“Kids are more likely to engage with a mental health intervention when they’re in a familiar environment,” says Katherine Shea, MD, MPH, FEL ’17, MPH ’15, RES ’13, MED ’09, a child psychiatrist at Dartmouth Hitchcock Medical Center and assistant professor of psychiatry and of pediatrics at the
If
you aren’t feeling like yourself, going to a therapist should be the same as going to your primary care doctor for strep throat.
Francine Morgan, MBA Program Director
Pediatric Mental Health Access Initiative
Geisel School of Medicine at Dartmouth. “When a need is identified at a primary care visit, a behavioral health clinician (BHC) can come in at that moment and foster engagement early. The idea is to capture kids early to prevent exacerbation of psychiatric symptoms.”
PediCoCM is designed to help children with mild to moderate depression, anxiety, substance misuse disorders, and disruptive behavior through an integrated model that has been shown to improve access to care, improve patient outcomes, and reduce costs. BHCs are licensed, master’s-prepared clinicians embedded in primary care
The idea is to capture kids early to prevent exacerbation of psychiatric symptoms.
Katherine Shea, MD, MPH, FEL ’17, MPH ’15, RES ’13, MED ’09 Child Psychiatrist, Dartmouth Health Medical Center; Assistant Professor, Psychiatry, Pediatrics, Geisel School of Medicine
clinics to meet face-to-face with patients, follow up with children and families about progress, and support primary care physicians in providing mental health interventions. BHCs meet weekly with Shea, who provides medical expertise as a child psychiatrist, making recommendations for changes to treatment if a patient’s symptoms are not improving.
“It’s different from adult mental health care because kids come with families, so a lot of the work we do is with parent-child interactions, not just medication,” Shea says, noting that the model is still in development; for example, clinicians are still figuring out the best ways to follow up with teens. (“They don’t like to talk on the phone,” for example, Shea explains.)
In addition to embedded clinicians in a primary care setting, the collaborative care model also involves patient screening and a patient registry to track progress and follow
up. A PCP “champion”—either an MD, DO, or APRN who is especially interested in improving mental health care access— will also be working at each primary care site to facilitate the PediCoCM program development, implementation, and evaluation.
“The collaborative care model provides short-term, evidencebased care within a week, rather than a child waiting months for an appointment,” Shea says. “Children really do improve when they get care quickly.”
Teleconsult Access Line for Providers
Pediatricians are often on the front lines of mental health care for children and adolescents, yet they may lack the specialized training and support required to meet the mental health needs of some of the most complex cases.
Child psychiatrists at Dartmouth Health Children’s are now able to bridge the gap between pediatricians and mental health specialists through the Child Psychiatry Teleconsult Access Line, which is part of the New Hampshire Mental Health Care Access in Pediatrics (NH MCAP) initiative that promotes access to children’s behavioral health care within the state. Pediatric
DHMC child psychiatrist Katherine Shea (right), and behavioral health clinician manager Chase Trybulski, LCMHC, discuss the pediatric collaborative care model for implementing mental health care in pediatric primary care settings.
healthcare providers anywhere in New Hampshire can call the access line and schedule a free telephone consultation with a child psychiatrist at Dartmouth Health Children’s, enabling pediatricians to address their patients’ behavioral and mental health issues more effectively within their practice.
The teleconsultation line, which is a collaboration between Dartmouth Health Children’s and the University of New Hampshire’s Institute for Health Policy and Practice, will alleviate multiple barriers to timely mental health care for children. After talking with a child psychiatrist, pediatricians will be able to offer mental health care immediately in a setting that’s familiar to the child and family, preventing the need for the patient to wait weeks or months to see a specialist.
“We will disseminate our knowledge to pediatricians anywhere in New Hampshire to help them care for their patients, so these conditions can be treated earlier to prevent worsening symptoms,” says Jennifer McLaren, MD, DFAACAP, FEL ’10, RES ’08, section chief of child and adolescent psychiatry and the medical director of New Hampshire Bureau of Developmental Services. “If the child psychiatrist recognizes a complex problem during a teleconsultation, they can recommend a referral to a specialist if the child needs a higher level of care.”
This specialized line is an outgrowth of the broader eConsults program at Dartmouth Health, through which primary care providers can request specialty consultations on individual patient cases through the electronic medical record system.
Bridging the Gaps With Tool for Parents
Families will soon have direct access to a new tool to supplement traditional behavioral healthcare: Behavior Bridge, a self-guided digital health intervention for parents of children and adolescents with behavior issues. The program is expected to be available for pediatricians to distribute to parents by early 2025.
“Getting quality care can make a long-term difference in a child’s life,” says JT Craig, PhD, a child psychologist at Dartmouth Health Children’s, and assistant professor of psychiatry at Geisel. “We can make sure every child has a path forward in the very moment they are diagnosed with ADHD. They can access quality care right away, and they won’t have to wait for months for an appointment with a specialist.”
The Behavior Bridge content is delivered through video modules that provide evidence-based information and practice activities so parents can apply the skills with their child—giving the family a path forward when a therapist isn’t immediately available.
“We have packaged the most effective intervention skills into mini videos, and parents will be able to access these videos freely on their own time,” says Christina Moore, PhD, FEL ’22, a lead supervisor of child psycholotherapy training at Dartmouth Health Children’s and an assistant professor of psychiatry at Geisel who is working with Craig on the project. “We’ve delivered this information through tele-health with trained therapists who walk parents through the same content. So why not make it even easier for parents to access?”
Behavior Bridge is currently being tested and vetted in focus groups with child healthcare providers as well as with parents who are dealing with challenging behaviors.
“Pediatricians might not know how to help a 4-year-old with ADHD,” Craig says. “But not intervening can leave that child with significant problems throughout their life. So, this is an opportunity for pediatricians to be able to offer the parents our program and get the child the help they need.”
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Expanding Access to Care
Dartmouth Health Children’s tackles shortage of inpatient psychiatric care for young patients with partnership to provide care at Hampstead Hospital
Across the nation, youth experiencing a mental health crisis often have to wait in emergency departments until a pediatric psychiatric inpatient bed becomes available. Far beyond the recommended maximum of four hours, those wait times can sometimes stretch into days or even weeks.
This summer, Dartmouth Health took a big step toward reducing those delays for children, adolescents, and young adults in New Hampshire. Continuing a longstanding partnership with the state, the Department of Psychiatry was chosen to take over medical direction at Hampstead Hospital, which provides comprehensive psychiatric and medical care to young people ages 6-26. As the facility is the state’s only specialty inpatient and level 5 residential psychiatric treatment
hospital dedicated to treating young people, this significantly expands Dartmouth Health’s ability to provide high-quality pediatric psychiatric inpatient care across the health system and the region.
“We sought this contract out of a desire to build care that any of us would want for beloved family members, friends, and neighbors should they develop intensive need for care that cannot be met in a community setting,” says William Torrey, MD, RES ’89, D ’80, professor and department chair of psychiatry at the Geisel School of Medicine at Dartmouth and Dartmouth Health. “Our selection to lead patient care at Hampstead Hospital allows us to deepen our commitment to excellence in public-sector care.”
“Hampstead Hospital will be an important part of our comprehensive system of care,” says Jennifer McLaren, MD, DFAACAP, FEL ’10, RES ’08 (middle), section chief of child and adolescent psychiatry at Dartmouth Health and the medical director of the New Hampshire Bureau of Developmental Services.
The state of New Hampshire purchased the privately owned Hampstead Hospital in 2022 in order to better serve the mental health needs of vulnerable youth. In May, after a competitive bidding process, New Hampshire’s Department of Health and Human Services (NH DHHS) selected Dartmouth Health to lead and run clinical care at the facility.
The contract expands a trusted 40-year partnership between the state and Dartmouth Health’s Department of Psychiatry. Coupled with an existing contract to provide clinical leadership and services to adults at the 180bed New Hampshire Hospital in Concord, N.H., this new collaboration at Hampstead significantly increases access to high-quality inpatient psychiatric expertise for people of all ages.
“Our goal is to provide high-quality, evidence-based child psychiatric care and increase our capacity to care for the inpatient mental health needs of youth,” says Jennifer McLaren, MD, DFAACAP, FEL ’10, RES ’08, section chief of child and adolescent psychiatry at Dartmouth Health and the medical director of the New Hampshire Bureau of Developmental Services. “The child psychiatry section at Dartmouth Health Children’s is a system of care across all of Dartmouth, not just at Dartmouth Hitchcock Medical Center. Hampstead Hospital will be an important part of our comprehensive system of care.”
As of July 2024, Dartmouth Health clinicians, including child psychiatrists, pediatricians, psychiatric nurse practitioners, and others, now provide psychiatric and medical services at Hampstead. This additional access, McLaren says, seeks to decrease children’s boarding time in emergency departments.
Acute care hospitals all over the country have seen a dramatic increase in the number of children coming in for mental health crises, and most of these hospitals don’t have the capacity to properly care for them. Consequently, these children end up boarding in the emergency department—meaning clinicians have determined the child needs hospital admission for mental health care but must wait in the ED for a pediatric psychiatric bed to become available.
“Nearly 99% of acute care hospitals [in the nation] are boarding adolescents until a pediatric psychiatric bed opens up, which is distressing for patients, their parents, and clinicians,” says JoAnna Leyenaar, MD, PhD, MPH, a pediatrician and the vice chair of research for pediatrics at Dartmouth Health Children’s and the Geisel School of Medicine, who published these findings in two recent papers. “Increasing the availability of pediatric psychiatric beds will decrease children’s wait time, so kids who need inpatient care can get it sooner.”
Read more about the new partnership with Hampstead Hospital at dartgo.org/hampstead
Nearly 99% of acute care hospitals are boarding adolescents [in the emergency department] until a pediatric psychiatric bed opens up.
JoAnna Leyenaar, MD, PhD, MPH Pediatrician Vice Chair of Research for Pediatrics
Putting mental health into primary care
Child
psychology fellowship improves care for vulnerable patients
Recognizing the rising rates of mental health challenges among youth, Dartmouth Health Children’s has been working to address the shortage of healthcare providers who can offer interventions to children and families.
In 2021, Dartmouth Health’s Department of Psychiatry created a permanent postdoctoral child psychology fellowship to embed specialized mental health support in the general pediatrics clinic at Dartmouth Hitchcock Medical Center (DHMC). The fellowship has been funded in part through the Pediatric Mental Health Access Initiative, the umbrella encompassing Dartmouth Health Children’s commitment to improving quality mental health care for children.
Now in its third year, the fellowship program has expanded to include two fellows who are training to address anxiety disorders, disruptive behavior disorders, mood disorders, and more.
“I wanted to be in clinical work because of the many hats psychologists wear—research, psychotherapy,
“Being part of an integrated medical care team will raise the overall knowledge of mental health challenges across the whole primary care clinic,” says Christina Moore, PhD, FEL ’22 (right), who was the first child psychology fellow.
Produced by:
cognitive assessments, and individual and family interventions,” says Christina Moore, PhD, FEL ’22, the first child psychologist to complete the fellowship. Moore was hired as a full-time faculty member at DHMC and an assistant professor of psychiatry and of pediatrics at Geisel School of Medicine. “That’s why an academic medical center is great: I can train others in evidence-based practices, be in the community to provide care, and be involved in research, learning how we can provide access to proven therapies—especially in underserved rural communities.”
Since being hired full time after her fellowship, Moore spends one day a week practicing in the primary care setting with a team of two post-doctoral psychology fellows and a pre-doctoral psychology trainee. Within one year, the team has seen approximately 350 children. Moore says primary care is a powerful place to reach children having mental health and behavioral problems, overcoming several potential barriers to care, such as stigma, transportation, and extra time away from work and school.
“We have increased children’s access to these evidencebased practices by catching them in a help-seeking moment with a caring pediatrician,” Moore says.
The child psychologist also works as a member of an integrated behavioral healthcare team, allowing a clinic to offer a continuum of mental health care services. For example, some clinics have behavioral health clinicians (BHCs) who offer short-term therapy for anxiety, disruptive behavior, substance use, and depression, while the psychologist may address needs that are outside those areas, are higher acuity, or require diagnostic clarity.
“Access issues are big problems to solve.” Moore says. “It’s exciting to work with colleagues at Dartmouth Health Children’s who care deeply about increasing access to evidence-based services.”
