Project CLIMB

Overview

Project CLIMB (Consultation Liaison in Mental Health and Behavior) is an integrated behavioral and physical health services program addressing mental/behavioral health and development in children and their families. This model, based out of Children’s Hospital Colorado, was implemented in 2005 and continues to expand. Through integration of mental and behavioral health providers in the context of the medical home approach, Project CLIMB improves access to mental and behavioral health services for children and families and addresses the full continuum of behavioral health care – prevention and health promotion to early identification, intervention, and treatment.

Recommendations

Recommendations for entities interested in implementing a similar model to improve the systems of care through the medical home lens:

• Identify needs and start small.
  • Integrating mental and behavioral health into primary care takes time. First identify behavioral health gaps. Then slowly implement services and expand as capacity builds.
    • Example: Begin with implementing 1 screener 1 day a week with clinicians in the practice who are early adopters. Choose a screener for which there are existing resources to address families’ needs (e.g., early intervention services for developmental screening; an onsite behavioral health clinician who is available to meet with families with positive screens).
    • Engage in continuous quality improvement efforts with clinical staff and families receiving care to adjust implementation and enhance integration outcomes.
• Support wellbeing of program staff.
  • Inclusion of behavioral health providers (psychologists, psychiatrists, behavioral health clinicians, interns) on the medical home team is a great support and resource for families to address the mental and behavioral health needs of their children. Addressing family behavioral health needs, social complexity, and psychosocial stressors can also impact providers, leading to secondary trauma and burnout. The behavioral health team members also provide support for clinical staff to reduce burnout and secondary trauma.
• Ensure language access for families/caregivers.
  • Families receiving services in a language that is not their first language does not support health equity, inclusion, or appropriate primary care/medical home services. Families deserve full access to care, which includes communicating in their primary language.
    • Example: Project CLIMB recruits bilingual and, when possible, bicultural providers and trainees. The clinic is staffed by two full-time Spanish speaking interpreters, available to interpret visits for families of whom Spanish is their primary language. Interpreters are also available virtually for families who speak languages other than English. Providers who speak Spanish and on-site interpreters are trusted by families and facilitate building strong relationships between clinical staff and their families receiving care in the clinic.

Data/Outcomes

• In 2022, the Project CLIMB team completed 4,172 integrated behavioral health visits for 2,282 unique patients across all insurance types; 3,431 visits were for patients with public insurance.
  • The team completed 4,976 maternal depression screeners, 3,876 adolescent depression screeners, 16,358 psychosocial screeners, and 10,336 developmental screeners.
  • Screening processes allowed the Project CLIMB team to identify and provide support to children, adolescents, and their families as concerns emerge.
• The level of patient complexity, resource needs, and risk have increased exponentially due to the COVID-19 pandemic for families receiving care at Children’s Hospital Colorado.
  • Project CLIMB completes numerous risk assessments weekly for children as young as 8 years-old and for adult caregivers who endorse risk.
  • These risk assessments typically require several hours of direct patient care and additional time to coordinate care and resources.
  • 76% of the risk assessments completed in 2022 were for the Medicaid population.
  • The risk assessments necessitate close monitoring and frequent follow-up in the primary care setting.
• Given the pediatric mental health emergency declared by Children’s Hospital Colorado, the American Academy of Pediatrics, and across the United States, the integrated behavioral health services provided by Project CLIMB are even more critical to ensuring that children and families receive the care they need.

Project Background

• Project CLIMB is an innovative program that addresses the need for collaborative services between behavioral health and primary care professionals, implemented in the Child Health Clinic Medical Home (at Children’s Hospital Colorado) since 2005. The program provides:
  • onsite program development, direct service, training efforts, and program evaluation,
  • technical assistance and support to practices across Colorado and the country to expand capacity to integrate behavioral health services into primary care settings serving pediatric populations.
• The Project CLIMB team is comprised of part-time faculty including psychologists, psychiatrists, behavioral health clinicians, and a developmental and behavioral pediatrician.
  • A full-time behavioral health navigator also works on the team.
  • Behavioral health trainees are also part of the team and include psychology fellows, child psychiatry fellows, psychology interns, and psychology externs.
• The CLIMB Team has been instrumental in developing, training, launching, and implementing behavioral health services in Children’s Hospital Colorado including:
  • screening initiatives that align with the Centers for Medicare and Medicaid alternative payment model methodology (i.e., developmental, maternal mood, adolescent depression, and psychosocial screening);
  • mental health consultation services, psychopharmacologic and psychiatry services, early childhood behavioral health services that include universal prevention and health promotion efforts (HealthySteps, Baby & Me/Mi Bebe Y Yo groups);
  • crisis evaluations, brief intervention, short term behavioral health visits, and triage and referral services.
  • Specialized clinic within a clinic for children in out of home placement
• As part of Children’s Hospital Colorado, many children and youth with special health care needs receive primary and integrated care through Project CLIMB.
  • Children with medical complexities who are more likely to receive care through a separate clinic are also eligible for integrated services; three of the Project CLIMB faculty work in the medical complexities clinic and can connect families to behavioral and mental health services offered through Project CLIMB.
• Not including screening efforts, Project CLIMB provides services to approximately 20% of the Children’s Hospital Colorado population, conducting 4,000 visits a year for approximately 2,000 patients/families.
  • About 90% of patients receiving care through Project CLIMB are Medicaid beneficiaries.

Funding Mechanism

• The program is funded through revenue coming through the clinic via billing by clinical staff, grants for implementation of specific programs and for behavioral health training, and contracts.
• The program has expanded as more revenue became available to support its growth, through screenings and other services offered that became eligible for payment.
• The program has been able to sustain and then expand its capacity for services by cyclically investing revenue coming in back into the program, and not requiring any outside funding streams to continue current efforts.

Related American Academy of Pediatrics (AAP) Policy

• The work of this promising practice aligns with recommendations and evidence outlined in the AAP policies, “Mental Health Competencies for Pediatric Practice”, and “Achieving the Pediatric Mental Health Competencies.”