The Primary Care Coalition and its partners initially had no mechanism to connect Care for Kids (CFK) participants with essential behavioral health services. But in 2017, PCC received a five-year grant from the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services to pilot behavioral health services for CFK participants through the Caring for the Whole Child (CWC) project.
CFK enrollment grew quickly during the five-year CWC pilot, from 4,800 to more than 7,000 children a year. When the program took in 794 new children in FY 21, 65.8% (523) were from the influx of unaccompanied minors, many of whom had experienced violence and trauma that no child should have to endure. CFK could not have addressed their behavioral health needs without the Caring for the Whole Child services.
The CWC project replicated a successful model for providing integrated behavioral health care among low-income, uninsured adults in Montgomery County. It was able to serve children with similar vulnerabilities by race/ethnicity, income, and immigration status. And it identified children and adolescents with unmet behavioral health needs; connected them to accessible, appropriate care; promoted collaboration among providers to improve the availability and delivery of services; and sought public and private support to maintain the program beyond the pilot.
With the CWC project, PCC partnered with four safety-net clinics that treat Care for Kids children: Catholic Charities Medical Clinic, CCI Health & Wellness Services, Holy Cross Health Center Germantown, and Mary’s Center for Maternal and Child Health. In the first year of program evaluation (April 2017-March 2018), these clinics served slightly more than a third (37%) of the Care for Kids participants. By March 2022, when the pilot ended, the clinics were serving three-quarters (75%) of the Care for Kids enrollees, and more than 400 children* had received over 1,400 behavioral health visits. Each clinic offered a medical home for well and sick care by pediatricians and other pediatric primary care providers. They also provided behavioral health services on-site staffed by licensed mental health professionals.
Now that the pilot program is over, PCC and our partners continue to serve children in need, independent of the HRSA funding. The CFK budget has included stable behavioral health services funding from Montgomery County since FY2019—covering counseling and psychotherapy for children and their families, as well as psychiatry visits and substance abuse treatment for patients who need the services. PCC has also generated interest among private foundations for additional support.
Despite the program’s success, it wasn’t without challenges. The routine screening and service connection processes were more complicated than expected. When PCC applied for HRSA funding, we anticipated overwhelming behavioral health needs waiting for a service opportunity. “If you build it, they will come,” in pop culture speak. There was minimal literature on the prevalence of behavioral health needs in pediatric populations. Still, it was clear that many Care for Kids participants had significant trauma exposure associated with behavioral health needs.
Yet CFK participants were slow to access behavioral health services, and it was clear we needed input from participating families for a more nuanced understanding of their behavioral health needs. Getting that input, however, was an ongoing challenge.
For insights, PCC began holding parent and teen advisory group sessions, complete with refreshments and stipends. Parent and teen sessions were held at the same place and time to minimize travel and time burdens. During the pandemic, PCC also experimented with virtual meetings that eliminated transportation. Whether held in person or virtually, participation in group meetings was inconsistent and often low. Care for Kids staff scheduled calls with individuals rather than groups for final participant input activities, and participation was relatively high: eight adolescents and seven adults. Although this model loses the ability for participants to build on each other’s comments, it may work better to include more participant voices.
Although process improvement and quality assurance are ongoing needs, they are hampered by data challenges. Providers generate a wealth of information in notes but comparatively few structured data points. Each clinic has its own electronic health records for the project with structured field capacity and documentation protocols. Simply mapping how information is entered and determining whether or not it represents extractable data took more than one grant year during the pilot project.
Despite the structural limitations, PCC’s partner behavioral health providers are passionate about this work. During the life of the grant, partner clinics received stipends for their participation in data collection and a quarterly learning collaborative. Participants opted to continue collaborating at the final meeting in March of 2022, even without funding support. They have committed to participating in ongoing quarterly meetings to share challenges and ideas for improvement and connections to other services.
That dedication is crucial because the pandemic uptick in behavioral health needs is real—at least in PCC’s patient population. The percentage of patients screening positive for depression doubled between 2021 and 2022, from 15% to 30%.
Ultimately, HRSA funding has spurred sustained investment in meeting children’s behavioral health needs, playing a foundational role in the availability of behavioral health services for children, many of whom have a history of trauma exposure. These services cannot erase the harm children have experienced, but they can help assure the brightest possible future for some of our newest neighbors.
*This figure is the sum of the unduplicated participants in each evaluation year. There may be some overcounting if participants received behavioral health services in more than one evaluation year.
This article has not been reviewed or approved by the Montgomery County Department of Health and Human Services.
This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $650,000 with 62 percent financed with non-governmental sources. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.