Partnering to Improve Behavioral Health Care

Access to mental health services for children in Skagit County insured on Apple Health has historically been limited to three mental health agencies: Catholic Community Services (CCS), Compass, and SeaMar. Unfortunately, the referral/communication process with these agencies has presented challenges for our medical providers:
  • Inconsistency in whether the mental health provider sees the child’s records from the primary care provider (PCP).
  • Families have difficulty navigating the appointment process to begin mental health care for their child.
  • If they do begin care, often families have difficulty making it to appointments.
  • It is hard to close the loop – we need to know whether the child is seen, what the intake indicates and what the treatment plan is.
Skagit Pediatrics knew that kids needed a better system, so they began what turned out to be a fruitful effort to improve communication with CCS.
Both CCS and Skagit Pediatrics wanted to streamline the referral and feedback process, in order to provide better coordinated and integrated care for the child and family. They drafted a memorandum of understanding which outlines specific roles and workflows and plan to connect on a regular basis to identify successes and/or barriers to care. Several improvements have been made thus far.
Skagit Pediatrics started with an effort to create a better system of referral from their clinic to CCS. There is a federal mandate that any child on Medicaid insurance have an EPSDT Mental Health Referral Form signed by the referring provider. Despite this system being available for many years, it was not being used effectively. They created a referral form that incorporates the necessary components of the EPSDT and can be attached to the provider’s most recent clinic note. This allows CCS to recognize the patient as an “EPSDT client” and keep the included paperwork in anticipation of an intake visit with the client. The approach also triggers a protocol at CCS that includes 1) reaching out to the client to arrange an appointment within a few days of receiving the form and 2) notifying the PCP if no appointment is made or an appointment becomes a no show.


With the EPSDT referral form Skagit Pediatrics also includes consent for mutual exchange of information signed by the parent and/or youth so the mental health clinician can speak as needed with the PCP.  CCS often sends Skagit Pediatrics a similar consent for exchange of information form. To streamline this exchange, CCS and Skagit Pediatrics intend to develop a consent form that will be workable for both entities.


After the intake, CCS sends a standardized document back to the PCP that includes a brief summary of the concern, a provisional diagnosis and treatment plan, and the name of the assigned mental health clinician. This is often only one page and includes the data most important to the PCP.


Skagit Pediatrics is also working on a systematic means for feedback from CCS to communicate with the clinic when a patient is discharged from mental health services (either due to “graduating from care” or due to no-shows). They are creating a workflow to monitor this process, logging all CCS referrals and following up on those for whom they do not receive feedback within a reasonable time frame. They will collect data to illustrate the improvement in access and follow up, and to inform process improvement.

Note: Pediatric TCPI can help your clinic with Behavioral Health Integration. Learn more here.

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