Promising Practices: Pediatric Primary Care at UMass Memorial Medical Center and UMass Chan Medical School

The Role of Screening, Family History and Ongoing Monitoring for Mental Health Disorders

As part of the larger hospital system, PPC is the nursery provider for most infants born in the hospital. After a baby is born, the practice begins services for families within the nursery and clinic. If PPC does not have capacity to enroll the family, they refer the family to other trusted providers within the community. Often families appreciate the connections and referrals available to them through the larger hospital system and the relationships PPC has with other medical providers with diverse specialties.

Mental health screening begins when the family comes for their first newborn visit and follows the Bright Futures schedule using the Edinburgh Postnatal Depression Scale (EPDS) screening tool for the first six months of an infant’s life. In Massachusetts, Medicaid includes developmental screening at every well child visit as part of Early and Periodic Screening, Diagnosis and Treatment. The State includes the EPDS as an accepted screener for child development during infancy. Inclusion of the EPDS as a screening tool in pediatric care acknowledges the important role of parental mental health on child development.

Additionally, conversations at visits on family histories complement screening results to identify mental health concerns. As part of visits, families complete a formal tool that assesses social determinants of health (SDOH). Results from the SDOH assessment are used alongside results from other screening tools and family health history forms to discuss any adult mental health concerns. When asking about social history, particularly with younger parents, PPC providers look for social networks and community resources that support the family. Particularly relevant for young families who may not speak English as their primary language, providers are attuned to assessing for isolation and lack of access to resources that may also contribute to mental health concerns. Additionally, parents who may be juggling multiple work and home obligations may have unaddressed mental health needs that the practice can identify and address.

PPC also assesses for mental health issues more broadly by asking questions within the context of conversations on social history. This informal approach allows the practice to gauge support systems, relationships within the home, issues of substance use, and anxiety while ensuring families feel safe enough to share their experiences. A critical component of these conversations and visits is identifying family strengths, noting what families are doing well and the resources they are accessing. PPC uses these moments to form strong relationship with families, building culturally appropriate responses to family needs and utilizing a video interpreter when families’ preferred spoken language is not English.

Responding to Identified Needs

When depression screening tools or family assessments identify a concern, PPC providers connect the family to the Massachusetts Child Psychiatry Access Program (McPAP), a program that offers consultation for psychiatric issues for children or the practice works with obstetricians within their system to connect caregivers to McPAP for Moms, a specialized program to support pregnant and parenting people. McPAP for Moms offers primary care providers consultative assistance or referrals to support the mental health of pregnant and postpartum people.

Additionally, when PPC providers identify mental health concerns in postpartum and parenting family members, they connect back with adult care providers within the UMass Memorial Medical Center organization. As concerns arise during screening and ongoing health monitoring checks, PPC providers message directly with the obstetrician or adult primary care provider to share the identified concerns and consult on next steps for treatment within the electronic medical record (EMR). This internal referral and information sharing system provides a family-centered approach where all members of the family gain access to mental health support they need, when they need them. Often, because the system is so tightly connected, families receive treatment promptly and have access to the resources they need.

Community-based referrals are also a critical part of PPC’s work and include Early Intervention, public school systems, child welfare system, lactation specialists, home visiting, and the Women, Infants, and Children (WIC) program. As part of the larger medical institution, PPC accesses these partnerships that are already in place.

Alongside these referrals, PPC providers offer anticipatory guidance as they identify concerns. During conversations within the context of health supervision visits, PPC providers use open ended questions to assess for adult mental health status, access to resources and follow up on previous guidance. These ongoing conversations help providers track referrals, impacts of mental health on child development and services rendered to ensure adult mental health needs are met. Additionally, having integrated behavioral health services within the practice makes a significant difference in delivering supports to families. The social worker offers short term therapeutic care and provides referral within the system when more intensive intervention is needed. A warm hand-off is provided by the social worker to ensure follow-up occurs in a timely fashion. When concerns are escalated, PPC providers may see families more often depending on their needs. The EMR tracks both visits and referrals offering ongoing data about needs and services.

The Culture of Mental Health Services within PPC

Within PPC, providers understand that mental health issues are pervasive, common and part of most individual’s experience. PPC providers are comfortable assessing and referring for perinatal mental health and present information to families in a way that makes them feel comfortable as well. By acknowledging that mental health concerns are common, conversations become more about ways to respond to the concerns and less about the stigma associated with them. Families may have different responses and look to explain behaviors in clinical ways, yet PPC providers persist in sharing information that is helpful to educate families about the concerns and resources that are available to them. Because mental health conversations are part of the regular routine within the visit, the discussion is expected and promotes information sharing between families and providers in order to identify and respond to concerns. Additionally, the practice will find a way to see families, regardless of whether they are late or miss visits and understands the complexities of a family’s life that might create barriers to attending appointments.  

PPC is structured to offer ongoing support to all providers and staff to ensure a consistent approach to services. Pediatric residents are paired with experienced physicians to ensure ongoing learning, reflection and support. Additionally, the team meets on a regular basis to discuss patients and their needs, ensuring that all providers working with families understand their needs and respond in a holistic way. The close-knit relationships within the practice support this approach of focusing deeply on child and adult mental health and its impact on optimal child development. It also serves as a system to monitor service delivery, ensuring families receive consistent, comprehensive health care.

Lessons Learned

A critical component of PPC’s approach is the ongoing, routine conversation about mental health services that occurs within clinic visits. Because it is a regular part of their services, families expect to have conversations about mental health and know that PPC providers are prepared with the resources to respond. While many practices face PPC’s challenge of having enough mental health sites available to support families, conducting research to identify what is available, connecting to obstetricians and adult primary care providers and being prepared to have conversations is a critical step in identifying and responding to mental health needs.