Children's Primary Care Medical Group, Inc.

Hilary M. Bowers

Integrated Health Champion

Hilary M. Bowers has championed the integration of behavioral and mental health services into pediatric primary care throughout her career. Her commitment began with the experience of caring for a child with ADHD, when the patient's mother questioned why she, as a pediatrician, could not provide behavioral health care instead of referring her child to a psychiatrist in a strip mall, where people smoked outside and the child was less familiar to the provider. Motivated by that experience, she educated herself by shadowing a Developmental-Behavioral Pediatrician colleague twice a week, attending the Friday Fellows Conference at Rady Children's Hospital San Diego (RCHSD) for Developmental-Behavioral Pediatrics fellows, consulting psychiatrists who responded to her calls and collaborating with colleagues across the United States and within CPCMG. In 2015, she presented her vision to CPCMG's President/CEO and Medical Director, advocating for documentation within EPIC, tracking billing codes, embedding therapists in primary care practices, providing handouts for families and connecting patients with community programs. The initiative began with patients in her own office and has since evolved into a resource relied upon across CPCMG's 30 sites for behavioral health referrals.

Addressing the Barriers to Pediatric Mental Health Care

Compensation and time. Whether it is a sick visit or a well check, pediatricians have many questions to answer. Well visits are 15 to 30 minutes and sick visits are 10 minutes. Families often prepare questions ahead of time. It is important for clinicians to establish an agenda with the family about what will be covered during that visit and schedule another visit to cover the rest. It can be frustrating when families cannot afford the co-pay and want to cover everything on the list. Families often feel overwhelmed and unheard during behavioral/mental health visits. Even though time spent before or after the day of service benefits patient care, we cannot bill for it. Following the appointment, we often need to communicate with therapists and psychiatrists to coordinate care, including reviewing records from therapists, psychiatrists, schools, other pediatricians, etc. Several phone calls or emails may be required and are unpaid. A busy pediatric practice cannot use care coordination billing codes because they are intended for adult clinicians. Billing insurance companies for these diagnoses should be more straightforward.

Education. Lack of training and cultural taboos prevent many clinicians from discussing these topics. Taking the time to train clinicians and staff about this is a priority. Increasing care impacts everyone. Also, these patients are already coming to our clinic, they just do not have a note stating anxiety. Often, they complain about behavior, stomach aches, headaches or missed school. In order to find out why these concerns arise, it takes time, sometimes several visits and trust.

Strengthening Collaboration Across Pediatric Behavioral Health

Because of the work I had begun at CPCMG, when Rady Children's Health – San Diego (at the time, Rady Children's Hospital San Diego) received a huge donation in 2019, we were ready to be the main primary care partner. The grant enabled our clinicians to attend Patient-Centered Mental Health in Pediatric Primary Care (PPP) training. All our clinicians have the same understanding of how to diagnose, treat and monitor ADHD, anxiety and depression in children and adolescents, regardless of where they attended medical school. The training was attended by all clinicians at CPCMG. In the past six months, CPCMG has funded this training for all new hires.

“The goal is to provide a continuum of excellent care to our patients and their families.”

The Transforming Mental Health Initiative includes therapists in primary care. Our first site opened in June 2020. It was less than two months after California shut down due to SARS-CoV-2/COVID-19. During this time, I was also on the CPCMG Board. As a result, my organizational goals focused on behavioral/mental health.

I break down barriers as a leader. I will talk to anyone to improve my clinical skills. Please feel free to contact me via any method that works for you. I'm willing to have repeated conversations to make sure we are on the same page.

A key lesson is that pediatricians, NPs and PAs in primary care view patient care differently than therapists and psychiatrists. Each visit in primary care is packed with a lot of information. Joint decision-making and care plan agreement are essential. Psychiatrists and therapists talk slower. Therapists will remind us to contact the family if they don't make an appointment for therapy. Getting the family ready can be frustrating for pediatricians. I respect my therapists and psychiatrists. Our complex patients benefit from their knowledge. All of us contribute something to our families.

Building a Stronger Future for Pediatric Mental Health

Find a champion within your organization to lead the way. Learn from those who are doing the work currently. Start small. Although my north star is to have a therapist in every office, we are not there yet. Partner with other community-based organizations. The goal is to provide a continuum of excellent care to our patients and their families.

I frequently use a football analogy. The pediatrician is the quarterback, helping to oversee and manage care. Over time, we will bring team members off the bench, including therapists, psychiatrists, school counselors and others. The goal is to have an excellent Team Child.