Stewart Gabel, M.D. Medical Director, Division of Children and Family Services

1. ADDRESSING THE SHORTAGE OF CHILD AND ADOLESCENT PSYCHIATRISTS IN NYS:INNOVATIVE MODELS OF CARE PROVIDE INCREASED ACCESS Stewart Gabel, M.D. Medical Director, Division of Children and Family Services NYS Office of Mental Health

2. Child and adolescent psychiatrist (CAP) workforce issues and distribution • Approximately 7400 practicing CAPs in the U.S. • NYS has among the largest number of CAPs of any state---but there is a significant disparity in distribution. • Rural and underserved areas in NYS and elsewhere are particularly hard hit. • In NYS, 24 of 62 counties (approximately 40 %)have no CAP (Kaye et al, 2009).

3. Child and adolescent mental health disorders • Approximately 15-20 % of youth have mental health disorders. • Only about 25-30 % of these youth receive any mental health treatment. • Early intervention is effective in many cases (Olds et al, 2007)

4. HOW CAN THE NEED FOR CAPs BE ADDRESSED? • The AAP and AACAP (Pediatrics, 2009, a,b) emphasize that more youth with mental health disorders should be treated in the primary care setting. • Pediatricians are often reluctant to take on this additional burden, however (Stein REK et al, 2008). • Nonetheless, the task of assessing and treating youth with mental health disorders sometimes is forced onto PCPs when there are no CAPs in the area.

5. Prescribing psychotropic agents and treating youth in NYS: Who does it? • Survey of county officials in NYS about the shortage of CAPs and strategies to address this—Kaye et al (2006). J of Psychosocial Nursing and Mental Health Services • Forty eight percent of county officials used nurse practitioners (NPs) to prescribe for and treat youth. • Pediatricians, more than any other professional group, were used to prescribe and/ or monitor psychotropic medication in addition to or along with CAPs. • Nurse practitioners and general (adult) psychiatrists were second most common professionals to prescribe and/ or monitor psychotropic medication in addition to or along with CAPs.

6. OMH Efforts to Address the Shortage of CAPs in rural and upstate areas • Community telepsychiatry program. (Columbia University) Well received clinically; variable usage Emerging national consensus: Telepsychiatry is well received by patients and families, accessible and feasible. • State psychiatric hospitals in rural, upstate areas that serve children or adolescents Telepsychiatry program working with SUNY-U, NYU.

7. OMH EFFORTS TO ADDRESS THE NEEDS OF PCPs FOR INCREASED SUPPORT FROM CAPs • Project TEACH– A Community Consultation, Education and Liason Program for Primary Care Providers • Goal is to have more youth with mental health disorders treated in primary care settings (AAP, AACAP, 2009) • Consultation for PCPs: Face to face, telepsychiatry, telephone • Education and training around mental health disorders and approaches, psychopharmacology.

8. OMH EFFORTS TO ADDRESS THE NEEDS OF PCPs FOR INCREASED SUPPORT FROM CAPs • This is a start, but only a start. The numbers of PCPs and youth who can be served are small. • For a sustainable program, there will have to be viable financial models. PCPs will have to be reimbursed for time spent with patients/ families addressing mental health disorders and for consultation time with CAPs. • Adequate reimbursement for CAPs who provide consultations or treatment via videoconferencing technology will be needed.

9. TELEPSYCHIATRY IMPLEMENTATION ISSUES AT THE STATE AND LOCAL LEVEL • There has been no difficulty contracting with academic medical centers for CAP telepsychiatry services. • Not all community mental health clinics have videoconferencing capabilities. • PCP office based videoconferencing capabilities now operational.

10. For more information: NYCaT (New York Consultation and Telepsychiatry) http://omh.ny.gov/omhweb/nycat/