Vermont Medicine Magazine

While public awareness about the current mental health crisis among U.S. youth has increased during the pandemic, many people still lack an understanding of the challenges of accessing and delivering appropriate psychiatric care for young people. Chief among the hurdles faced by patients and their families is access to trained child and adolescent psychiatry clinicians, due to a longstanding workforce shortage in the field.

According to a January 2021 article in Pediatrics, a 2019 study found that “thirty-six states have fewer than 10 child psychiatrists per 100,000 children, with only 3.3 child psychiatrists per 100,000 in the most extreme case.”

“People were dealing with problems like poverty, food insecurity, domestic violence, poorly resourced schools before the pandemic,” says psychiatrist Greta Spottswood, M.D., M.P.H., a Class of 2011 alum of the University of Vermont Larner College of Medicine. “[These issues] ballooned during the pandemic, and at the same time, the workforce shrank,” she notes.

Spottswood, who joined Vermont’s Community Health Centers (CHC) in 2017, started her career in Boston, where she completed a general psychiatry residency and fellowship in child and adolescent psychiatry at the Cambridge Health Alliance—a health system widely recognized for its innovative approaches and dedication to providing equity and excellence. Equity and population health has long been a priority for Spottswood. As a medical student, she both worked in the UVM Children’s Hospital’s New American Clinic and co-led a New Hampshire/Vermont Schweitzer Fellows project focused on developing curriculum to enhance patient-centered care for LGBTQ patients of all ages.

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Establishing a system to get mental health care to the children who need it

While in Boston, Spottswood recognized that there would never be enough child/adolescent psychiatrists to meet patients’ needs working within standard systems. This led her to seek ways for child psychiatrists to extend their expertise to help more children, which included supporting primary care providers and models for delivering integrated care at the clinic level. For the first couple of years after coming to CHC, Spottswood provided psychiatric care alongside primary care providers in the clinic, which she says she loved and where she learned a lot. She admits, however, “The current system underserves the patient. My wait list was six months for a follow-up appointment, and that’s not safe care.” She set out to identify where gaps existed both at her clinic and across the state and looked at how other states were addressing the issue, with a goal of finding a program that provided equitable access to primary care providers across the state. “I knew there was a big need for primary care providers working rurally,” she says.

The January 2021 Pediatrics article strongly supported the implementation of Child Psychiatry Access Programs (CPAPs) as an innovative model to help primary care pediatricians provide more robust mental health care, and concluded, “The existing data and anecdotal evidence indicate that CPAPs are an effective strategy for leveraging the existing workforce of child psychiatrists [to] help more children.”

Vermont was one of only a handful of states without a CPAP, so Spottswood helped launch an effort to get one established. She received private funding from Four Pines Fund, a donor advised fund at The Vermont Community Foundation dedicated to improving the treatment and care provided to people struggling with suicide. Then she connected with the Vermont Department of Mental Health (DMH), the Division of Maternal and Child Health in Vermont’s Department of Health (DoH), UVM’s Vermont Child Health Improvement Program (VCHIP), UVM Medical Center, and designated agencies like Howard Center and Northeast Kingdom Human Services to gather recommendations for Vermont’s CPAP. She also checked in with patients and families, reviewed the existing literature, and learned from what other states are providing to confirm that such a program would be helpful.

She worked with Vermont DMH, DoH, and VCHIP to help Vermont obtain a Health Resources and Services Administration (HRSA) Pediatric Mental Health Access Care grant, which was offered to states trying to start or expand child psychiatry services to improve accessibility.

Vermont received the HRSA grant—some to fund the CPAP and some for other initiatives—and DMH announced the launch of VTCPAP in June 2022. The program, for which any Vermont primary care provider (PCP) serving children and adolescents 21 and under is eligible to register free of charge, provides telephone consultation service to assist PCPs with diagnosis, medication management, psychotherapy recommendations, and community-based referrals.

The timing of the program has been critical, given the rise in child and adolescent mental health issues since the onset of the COVID-19 pandemic.

“The uphill battle around social determinants of health for families during the pandemic became even more challenging,” Spottswood says, citing the example of the increase in domestic violence. “Kids couldn’t go to school and had to stay home. Things continue to be hard at school, and there is still illness and increased absences. We’ve learned from schools that many kids came back [to school] with signs and symptoms of trauma.”

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Vermont’s Child Psychiatry Access Program

CHC, which hosts Spottswood and the VTCPAP system, “really plays a key role,” says Spottswood. “As a federally qualified health center, they immediately recognized the need and went above and beyond to host a statewide program.” More than 200 telephone consultations have been provided through VTCPAP since mid-June 2022. The phone line, which is staffed every weekday from 9 a.m. to 3 p.m., features liaison coordinators who are licensed clinical social workers. They take the initial calls from PCPs, provide resource information, and answer some clinical questions to ensure kids receive targeted care that day or week, instead of just waiting for a specialist. When needed, liaison coordinators immediately refer questions to child psychiatrists.

UVM Medical Center funds staff to provide consultation services on Mondays, and is supporting clinic-level coordinated care. The UVM Medical Center VTCPAP team now proactively reaches out to PCPs with patients on their waiting list, to help with treatment planning. In addition, a number of subcontracts help round out the child psychiatrist team, one of whom is George “Bud” Vana, M.D., a Class of 2014 Larner College of Medicine alum who provides remote consultative services two days per week from his home in Arizona. Vana is a triple-board physician, with credentials in adult psychiatry, child psychiatry, and pediatrics. He also provides remote services to the Bellingham, Washington-based Lummi Nation.

A Vermont native, Vana connected with Spottswood after learning about her efforts to launch VTCPAP. “Vermont is the context I know for kids and youth and a community and group of people I desperately want to help,” he says. “Both Greta and I are passionate about access,” says Vana, who also serves as a volunteer faculty member of the University of Washington Department of Psychiatry & Behavioral Sciences.

Vana says he “works the ‘phone lines’” on Thursdays and Fridays for VTCPAP and is always ready for a telehealth call to come through to his home office, which features several computer monitors. He works with a social worker who triages the call with the PCP and determines how urgent the case is, gathers information from the PCP, and then advises Vana when the provider would like a callback.

When Vana speaks with the PCP, he first confirms the patient information, and then provides guidance on the diagnosis, as well as treatment, medications, and what to tell the family. The interactions last about 5 to 15 minutes, he explains, and sometimes include discussion about additional children on the PCP’s patient panel with mental health needs. After the call, the social worker sends an email to the PCP and directs them to targeted tools for future use.
“As a system, it’s trying to develop a playbook that gives people some answers,” says Vana. “We want to support them, give them the best guidance possible.” The PCPs consistently express gratitude for having immediate access to a psychiatrist’s expertise and available resources for treatment planning from the liaison coordinators, he adds.

Lewis First, M.D., professor and chair of pediatrics and chief of UVM Children’s Hospital, says, “The creation of the Vermont Child Psychiatry Access Program has made a real difference in improving the access pediatric clinicians have to a child psychiatrist. Being able to pick up the phone and contact the CPAP child psychiatrist at the end of the line for consultative advice can make all the difference in enabling that clinician to better handle a mental health issue with a patient and family rather than have that situation escalate because of a lack of access.”

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Advocating for better mental health care for Vermont’s kids in the future

Spottswood describes her role as “helping a PCP sort out, diagnostically, what is going on, and then making a plan.” She notes that, “As kids grow, more becomes clear about their symptoms and environment.” The PCP partners are already providing recommendations for things like summer camps and food security in order to support parents, she explains. Together, the psychiatrist and PCP can discuss situations in which the parent could benefit from therapy and provide a safer caregiving environment. One key component of Vermont’s CPAP, she emphasizes, is the role of the clinical social worker liaison coordinators.

“Greta and I have a lot of the same priorities—we’re advocating for these kids in Vermont who are struggling,” says Vana. “I’m grateful to her for the work she did to make this program possible.”

In the future, Spottswood says, she and many state partners hope all primary care clinics will have some aspects of integrated care, such as behavioral health care coordinators, who can follow up with patients and review the list of needs with PCPs. She also has a goal to help more remote clinics across the state have equitable access to child psychiatry and mental health care for higher acuity patients.

“I love this field because improvements happen via coordination across hospitals and agencies,” says Spottswood. “Vermonters all win when we have cohesive mental health care for kids and families.”