How Collaborative Care Models Deliver Quality ADHD Care – Seamlessly

Attention deficit hyperactivity disorder (ADHD) is highly treatable, yet systemic barriers — from cost and lack of pediatric services to fragmented care systems — often hinder identification of ADHD in children and/or prevent them from receiving optimal care. According to the American Academy of Pediatrics (AAP), primary care providers often view ADHD as distinct from other pediatric conditions and outside the scope of primary care.¹ What’s more, only one-third of school-aged children diagnosed with ADHD receive both medication and behavioral therapy to treat the condition, as recommended by the AAP.²

Fragmented, unreliable care is ineffective care for children with ADHD — and most providers and caregivers feel powerless to affect change.

Enter integrated care — a collaborative health-care model wherein primary care and behavioral health professionals work seamlessly together (and with families) to provide patient-centered, systematic, and cost-effective care.³ Collaborative care is a type of integrated care model meant to treat persistent, broadly impactful conditions that require systematic follow-up, like ADHD.⁴

Integrated care eliminates common barriers to health-care, and evidence also links collaborative care approaches to increased engagement and adherence to ADHD treatment plans.^{5 6 7 8} Here, we’ll demonstrate how this model could benefit a fictitious pediatric patient with ADHD (“Sarah”), plus her family, and health care team.

Collaborative Care for ADHD: Framework and Features

Integrated care aims to reduce the silos that notoriously appear in traditional health care settings and impede quality care by connecting the following vital roles and responsibilities, all within one physical setting and system:

• Primary Care Provider
• Behavioral Health Care Manager
• Psychiatric Consultant

[Get This Free Download: Choosing the Right Professional to Treat ADHD]

Primary Care Provider (PCP)

Primary care is the ideal setting for integrated care for the following reasons:

• Patient-provider trust is often already established.
• Pediatric patients already have regular and frequent contact with PCPs.
• PCPs are one of few medical professionals who look at patients holistically.
• PCPs commonly refer patients to specialized services and care when needed.

The PCP retains the same responsibilities under this model as they would in a traditional setting, which include but are not limited to the following:

• identifying conditions using clinical interviews, screeners, exams, history, etc.
• treating conditions; prescribing medications; developing and adjusting treatment plans
• monitoring patient health over time; adjusting diagnoses as necessary

Consider Sarah, an 8-year-old girl who presents for a checkup. Through routine, universal behavioral health screening, Sarah’s parents indicate that is not doing well in school and is struggling socially. Could Sarah be exhibiting symptoms of ADHD, and/or something else?

Outside an integrated care model, Sarah’s parents might have been limited to discussing these concerns in a follow-up appointment. The PCP would have likely provided Sarah’s parents with ADHD screening tools for themselves and Sarah’s teachers to complete before the next appointment. A referral — and a long wait — to see an ADHD specialist were likely next steps.

[Read: Your Complete ADHD Diagnosis and Testing Guide]

In this scenario, much of the burden falls on Sarah’s family to make connections and pursue next steps with the PCP, who is essentially working in isolation on the case.

But it’s a different story under collaborative care, wherein the PCP collaborates with a behavioral health care manager (BHCM) and a psychiatric consultant to build out a patient’s profile in a time-efficient manner.

Sarah’s PCP identifies her as a great candidate for this collaborative approach, explains the process to her family, and obtains consent to start before introducing them to the BHCM.

Behavioral Health Care Manager

The BHCM plays a pivotal role in collaborative care. BHCMs are counselors, social workers, psychologists, nurses, and other behavioral health professionals who act as a linchpin between patients, the primary care facility, and other systems like school.

The BHCM will do all of the following in Sarah’s case:

• Connect with Sarah’s family, listen to their needs, field concerns, and further explain the collaborative care model.
• Communicate with Sarah’s school and her other health care providers; build partnerships.
• Review medical and school records; help gather additional information on Sarah (academic and behavioral challenges, family circumstances, prior treatments and supports provided, barriers to care, etc.).
• Provide brief evidence-based psychotherapeutic interventions as needed.
• Monitor Sarah’s progress through a registry and advocate for her across multiple settings.

BHCMs work to paint and share an ongoing, accurate picture of a patient — a process that often takes considerably longer in traditional systems (and likely with gaps at that).

In doing this work, the BHCM learns that Sarah is possibly showing signs of anxiety — critical information that was not revealed during the initial PCP appointment. The BHCM updates Sarah’s shared file, and flags the team’s psychiatric consultant, who will evaluate Sarah for ADHD and anxiety — conditions that are often confused for one another but can also co-occur — with these factors in mind. Ahead of the evaluation, the BHCM provides Sarah and her family with an anxiety screener to complete, and ensures follow-through.

Psychiatric Consultant

The psychiatric consultant supports the BHCM and PCP in treating patients with behavioral health issues. They may suggest treatment modifications, perform evaluations, and otherwise lend their psychiatric expertise — a scarce resource — to a great number of patients.

Prior to meeting with and evaluating Sarah, the psychiatric consultant will access her shared file for key information gathered by the BHCM and PCP. Merging that information with new details gathered during evaluation, the psychiatric consultant learns the following and initiates additional steps:

• Sarah meets criteria for inattentive ADHD. ADHD screeners and other data collected by the BHCM show that Sarah has exhibited symptoms of inattention since kindergarten. The consultant recommends a stimulant trial, and reviews with Sarah’s family what that would entail.
• Sarah’s worries are mostly related to her school performance, especially activities around numbers, so suspicion for a separate anxiety disorder is lessened. Teachers told the BHCM that Sarah is at grade level in most areas, but she exhibits significant impairment in math concepts. Her difficulties in math merit follow-up psychoeducational testing to determine if she has a specific learning disorder like dyscalculia. (After all, up to 45% of children with ADHD also have a learning disability.⁹)
• Sarah’s problems around school have created tension between her and her mother. Sarah’s father also has ADHD, and there is evidence of multigenerational trauma and dysfunction. A referral for parent behavioral therapy could benefit the family.
• Sarah is having trouble falling and staying asleep. The consultant discusses the association between ADHD and sleep problems, and emphasizes lifestyle factors including sleep hygiene, proper nutrition and regular physical exercise.

Collaborative Care: Putting It All Together

Sarah’s family will eventually meet again with the PCP, who now has access to a wealth of additional information gathered by the BHCM and psychiatric consultant to aid in her role. If the family agrees to the stimulant trial, the PCP will write the prescription and collaborate with the team to observe Sarah over time and adjust her diagnosis and/or treatment plan as needed.

The BHCM continues to work with the family on the following:

• outlining goals and developing a treatment plan for Sarah, which may include connecting to a behavioral parent training provider
• connecting with Sarah’s school on psychoeducational testing and communicating results to the team
• advocating for Sarah in school, including attending Individualized Education Plan (IEP) meetings and informing parents of their legal rights
• connecting the family to additional community services as needed
• monitoring Sarah’s progress, which includes school (especially math) performance
• maintaining connections with the team (meeting monthly with the PCP) and outside partners

The psychiatric consultant will also provide case guidance on an ongoing basis, especially if Sarah is not improving on a treatment plan.

Sarah’s case helps illustrate the positive impact a collaborative care model can have on children with ADHD, their families, and other partners:

• Families have a medical home where they can receive collaborative support without fear of gaps or inefficient communication lapses.
• Families receive evidence-based care and information earlier in children’s lives, improving patient satisfaction.
• Job satisfaction improves as the PCP, BHCM, and psychiatric consultant learn from one another.

Collaborative Care: Making It the Norm

Many academic medical centers within larger cities offer integrated care models for a variety of conditions, but the approach is not yet standard.

Clinical practices can learn more about the collaborative care model through the University of Washington, which developed the approach. The university’s AIMS Center provides the following resources:

• Overview
• Implementation Guide
• Training (CEUs) and Support
• Billing and Financing

The American Psychiatric Association (APA) also offers information and resources on the collaborative care model, including examples of successful implementation across the U.S.

Even outside a collaborative care model, there is plenty that clinical practices can do to implement an integrated care approach:

• Develop concise, efficient workflows. Partnership reduces duplicated work and takes the burden off parents as intermediaries.
• Engage in outreach and affirm the desire to collaborate. Get to know external medical professionals and partners, including personnel at local schools and community programs. Encourage all medical staff to do the same.
• Commit to ongoing education about IEPs, 504 Plans, and other programs and services patients often use that are implicated in their care.
• Research and incorporate available integrated care services. The Partnership Access Line, for example, connects PCPs in Washington, Alaska, and Wyoming to on-call pediatric psychiatrists for telephone consultations.

Collaborative Care for ADHD: Next Steps

• Free Download: How Is ADHD Diagnosed?
• Read: What Does an Effective, Efficient Treatment Team Look Like?
• Read: It Takes a Village (and a Plan) to Stay the ADHD Treatment Course

The Clinicians’ Guide to Treating Complex ADHD from Medscape, MDedge, and ADDitude

• What should I consider when developing a comprehensive treatment plan for ADHD?
• What medications and other approaches should I turn to as first-line treatments for ADHD?
• How can I decide which ADHD medication to prescribe first?
• What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
• What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• How should I follow up with patients with ADHD, and what should we discuss during these checkups?
  • How should a clinician follow up with a patient being treated for ADHD?
  • How can collaborative care models improve care for patients with ADHD?
  • How can clinicians educate patients about the danger of drug diversion?
  • Why might a child resist ADHD treatment, and how can clinicians address medication aversion?
  • How does positive psychiatry benefit ADHD patients in the long run?
  • Free webinar: How to Get, Afford, and Refill Your Prescriptions With Minimum Hassle
  • Free webinar: CBT and DBT for ADHD: How Talk Therapies Reduce Symptoms and Boost Confidence

The content for this article was derived, in part, from the ADDitude ADHD Experts webinar titled, “Integrated Care for Children with ADHD: How to Form a Cross-Functional Care Team“ [Video Replay & Podcast #411],” with Sheryl Morelli, M.D., Leslie F. Graham, MSW, and Douglas Russell, M.D. which was broadcast on July 12, 2022.

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