SPM 3 - The number of pediatric and/or behavioral health providers receiving training and support services on pediatric mental health care in underserved communities/counties statewide.
Introduction: Children’s Mental Health Access
Data: The state measure for this project-focused priority is a process indicator that reports the number of providers receiving training in behavioral health care topics and, eventually, data on the teleconsultation model (once established). Training was provided to 98 pediatric or behavioral healthcare providers through the Project ECHO series of webinars, exceeding the year's objective. There were 191 attendees participating in the ECHO training series; however, 93 were not specifically healthcare providers.
Evidence: HRSA promotes the Pediatric Mental Health Care Access Program as a strategy to address the shortage of behavioral health providers by providing pediatric primary care providers with behavioral health training and a telephonic/telehealth consultative warmline. The warmline, staffed by a psychiatrist, psychologist, care coordinator, and social worker, provides teleconsultation, training, technical assistance, and care coordination so that pediatric primary care providers can more effectively diagnose, treat, and/or promptly refer children and youth with behavioral health conditions. The program's overarching goal is to use telehealth modalities to provide timely detection, assessment, treatment, and referral of children and adolescents with behavioral health conditions, using evidence-based practices, such as web-based education and training sessions. The MCH Evidence Center provided ample evidence indicating that telehealth services improve access to healthcare for underserved MCH populations.
Title V lead/funding: The PMHCA grant is administered by FHSD and funds two staff positions to manage and build the program. Although no Title V funds are used to support the program directly, Title V-funded staff assist with data, contractual, and media support. As the grant requires, FHSD’s Community Health Center Special Fund is being used as the state’s 20% match. Through this funding, FHSD will support and coordinate community mental health needs for children and youth.
Key Partners: This project is a unique collaboration between the Department of Health, John A. Burns School of Medicine (JABSOM), DHS Med-QUEST Division, Project ECHO Hawaii, Hawaii Primary Care Association, American Academy of Pediatrics-Hawaii Chapter, and University of Hawaii Pacific Basin Telehealth Resource Center. This multi-agency collaboration will strengthen pediatric providers’ access to needed mental health consultation services in underserved communities statewide.
Objective: By July 2025, provide training and support services on pediatric mental health care to 80 pediatric and/or mental health care providers in underserved communities statewide.
Strategies: The strategies to implement the project focus on three key areas:
- Refine, develop, and implement a pediatric mental health care access model.
- Promote workforce development and training on pediatric mental health care.
- Support services and linkages in underserved communities.
Strategy 1: Refine, develop, and implement pediatric mental health care access model
PMHCA grant: FHSD was awarded the PHMCA grant in September 2021 to establish a state system of behavioral health teleconsultation and care coordination for children, especially those in underserved areas and rural communities. These areas suffer from chronic severe shortages of behavioral health providers and have other barriers to care. Overall, the grant aims to promote integration of primary care and behavioral health to improve and increase services to children, youth, and their families in their communities.
Activities for FFY 2022 largely focused on hiring the PMHCA Coordinator and Assistant Coordinator, developing contracts for the training and model, and continuing to support efforts for the three key strategies.
The first strategy focused on the infrastructure to support a model that provides pediatric providers' mental health consultation before client needs escalate into a crisis and/or need for prolonged treatment. The activities were based on guidance from HRSA and included:
- Hiring a Project Coordinator and Assistant to coordinate the project activities within FHSD.
- Convening an Advisory Group to meet quarterly and help advise on project implementation.
- Executing contracts for services to be rendered around provider and family engagement and reviewing existing PMHCA models to develop a state model for implementation.
Strategy 2: Promote Workforce development and training on pediatric mental health care
This strategy focused on identifying providers and providing training on pediatric mental health care to address shortages of both pediatric and behavioral health providers and enhance knowledge and skills of existing providers. The activities for this strategy included:
- Partnering with Hawaii's Project ECHO to conduct training for healthcare providers on nine pediatric behavioral health topics: Integrated Behavioral Health in the Primary Care Office, Overview of Child and Adolescent Mental Health Division, Depression, Disruptive Behavioral and Parent Management, Attention Deficit Hyperactivity Disorder, Post Traumatic Stress Disorder, Pediatric Anxiety, Setting up and Maintaining Integrated Behavioral Health in the Primary Care Office, and Mental Health Needs of Sexual and Gender Minority Children and Adolescents. Trainings began in April 2022 through September 2022 by a host of local Hawaii pediatric and behavioral health experts.
- Evaluating training feedback and revising curriculum for future pediatric behavioral health ECHO series to community providers on mental health topics.
Strategy 3: Support services and linkages in the community
FHSD identified service capacity issues and linkages needed to support children’s mental health. Hawaii continues to look at a coordinated intake and referral system to help promote the coordination of services to ensure no gaps between intakes and referrals and services. There is the recognition, however, that not all communities have mental health services and treatment options available.
This strategy focused on assuring mental health service availability and access for families throughout the state. Activities for this strategy included:
- Partnering with the Hawaii chapter of the Federation of Families, Hawaii Families As Allies (HFAA) to serve on the advisory and represent families with lived experiences of mental health disorders
- Partnering with a local philanthropy organization, Hawaii Community Foundation, which was implementing its Promising Minds initiative to improve early childhood behavioral health in Hawaii.
Current Year Highlights for FY 2023 (10/1/2022 – 6/30/2023)
This section highlights the Year 2 work for the PMHCA grant with the hiring of two key staff to oversee and coordinate the activities to support children and youth mental health through the warmline and training.
Strategy 1: Refine, develop, and implement pediatric mental health care access model
The first strategy focuses on the systemic infrastructure to support the PMHCA grant. The PMHCA grant deliverable is developing a pediatric mental health care access model that pediatric providers will access to work with behavioral health providers. Activities included:
- The PMHCA Coordinator and Assistant Coordinator were hired in the Fall of 2022, continued hosting Advisory Committee meetings, and met with stakeholders to promote and develop the model.
- Staff worked with the HRSA Project Officer who provided technical assistance (TA) to connect Hawaii to national consultants who lent their expertise to help develop the Hawaii warmline model.
- The grant Coordinator left the grant for another FHSD position; however, the Assistant Coordinator easily transitioned into the lead and continued the grant work.
-
Finalized the logo for the Pediatric Mental Health Care Access model approved by the Advisory Council. The logo is based on the traditional weaving arts, symbolizing the many cultures of Hawaii working together. It represents unity and community within the Pediatric Mental Health Care Access network and the support this network brings to both pediatric providers and their patients. The logo is shaped into a heart to show PMH's support for pediatric providers while highlighting how professionals from differing practices come together to care for patients.
- The Hawaii project merged with efforts in the Pacific jurisdictions. The HRSA Project Officer convened the Pacific Jurisdictions - Palau, Federated States of Micronesia (FSM), and Commonwealth of the Northern Mariana Islands (CNMI) - and encouraged Hawaii to develop a warmline that could be used throughout the Pacific given the severe shortage of behavioral health providers in this region. HRSA hosts quarterly calls among the Pacific Jurisdictions to support this critical partnership.
Strategy 2: Promote Workforce development and training on pediatric mental health care
Like most of the nation, Hawaii has a workforce shortage of behavioral health and primary care providers. There are 216.1 FTE pediatricians and 342.2 FTE family medicine and general practice providers statewide (as of November 2020), with an estimated workforce shortage of 412 FTEs across all islands (AHEC).
Because of the workforce shortages and increases in youth mental health needs, FHSD focused on offering providers access to timely mental health training. This strategy focuses on workforce training efforts. Highlights of activities include:
- Working with Hawaii’s Project ECHO to develop a second round of mental health topics and to provide training to providers starting in the summer of 2023.
- The PMHCA Staff met with The REACH Institute (Resource for Advancing Children’s Mental Health) to provide training on evidence-based therapies to better diagnose, treat, and manage child and adults with mental health issues. A contract is being executed to pilot this training in Hawaii.
- The AAP-Hawaii Chapter selected a Pediatric Mental Health Champion to assess provider needs around mental health needs and promote the PMHCA model. With the PMHCA coordinator, focus groups began with pediatricians across the counties. This work is supported through the PMHCA Program Utilization Chapter Funding Opportunity grant submitted collaboratively by HRSA.
- The PMHCA staff is sponsoring a behavioral health track at the next annual Hawaii Health Workforce Summit in September 2023 for approximately 600 participants, including physicians, physician assistants, ARNs, Community Health Workers, Medical Directors, Office Managers, Allied health Professionals, and more.
Strategy 3: Support services and linkages in the community
The PMHCA Coordinator continues to connect with community providers, help learn and support community-based efforts, and identify partnership areas.
- FHSD’s Title V Planner and the PMHCA Coordinator worked with the University of Hawaii Office of Public Health Studies to complete a Child and Family Mental Health Data Tracker that includes data on the maternal and child health population. This data tracker compiles local and national data to learn and track mental health issues in Hawaii and was launched in May 2023. Hawaii Health Matters :: Indicators :: Child & Family Mental Health
- The PMHCA Coordinator contracted with the University of Hawaii Center on Disability Studies to conduct a literature review of evidence-based programs that support children and youth mental health.
- The PMHCA Coordinator will be working with a family organization to assist with convening focus groups to develop and promote infographics on mental health messages that will be family friendly.
- The PMHCA Coordinator is partnering with the DOH Child and Adolescent Mental Health Division (CAMHD) and Suicide Prevention Coalition to conduct an environmental scan of existing mental health services statewide, including behavioral health services, inpatient treatment programs, treatment programs, inpatient hospitalization or emergency departments, clinical providers, nonprofits addressing mental health and practicing mental health clinician as part of the CAMHD Needs Assessment.
Challenges Encountered
Some of the major challenges for this priority measure include:
- Although HRSA provided extra funds to support PMHCA efforts in Hawaii, systemic procurement challenges and contracting delays make it difficult to encumber and expend funds promptly.
- Like many other states, Hawaii saw an increase in children and youth mental health needs exacerbated by COVID, which continues to be a problem. Mental health issues existed prior to COVID; however, there is an increase in mental health needs for children and youth due to anxiety and depression caused by social distancing and lack of socialization of youth; increased social media and cyberbullying; and family stress due to economic concerns.
- Limited mental health services and treatment options are currently available, which often means that children and youth in rural communities and neighbor islands must fly in or drive to Honolulu for services. This is true for both intensive treatment options and preventive services.
- Lack of comprehensive/directory of system services. New federal and state funding for mental health services resulted in new service options.
- Based on the experience of other states, even those with a larger population size than Hawaii, building a well-staffed/costly warmline service for a relatively low call volume is challenging.
- The stigma of mental health impedes assessment and provision of needed care.
- Cultural understanding and responses to mental health need more research and evidence for best practices as an effective option to traditional Western therapy and mental health treatment.
Overall Impact
Child mental health is a relatively new area for FHSD, although FHSD promoted maternal depression screening and completed some work around infant mental health. The PMHCA grant allows FHSD to expand efforts to address critical mental health needs of children, which COVID and its lasting effects have intensified.
Networking meetings and interviews resulted in substantial data/information collection. Across many sectors of services for children/youth, mental health is an urgent concern. Key findings from these meetings led to refocusing some grant activities into systems building. Even with the onboarding of PMHCA staff, there are still challenges with building the warmline and ensuring that pediatric providers will use the curbside consult model.
Introduction: Telehealth Access
For the Cross-Cutting domain, Hawaii added this new state priority to expand telehealth services to underserved communities in response to health and digital equity issues that emerged because of the COVID pandemic.
The pandemic highlighted the health and digital inequity experienced by many underserved communities and families. Some people do not have the digital literacy to access online information and services or do not have devices and/or adequate internet or cellular service, even if they know how to use the internet. Before COVID-19, FHSD set up telehealth access at all of the neighbor island District Health Offices to provide some access for families. But these sites were closed to all outside visitors during the statewide COVID emergency. The DOH sites continue to be closed for telehealth use.
The Library Telehealth Access Project (LTAP) allows individuals and families to access telehealth with telehealth navigators in state public libraries in underserved areas.
Evidence: A review of the MCH Evidence Center shows evidence is fairly strong for use of telehealth to increase access to underserved populations for women’s preventative health services; pregnancy and postpartum health messaging; adolescent health; parenting support for infant and toddler health; raising awareness about child mental health and health insurance access; reaching underserved children via teledentistry; and supporting child/adolescent mental health via teleconsultation.
Title V lead/funding: Within FHSD, the Genetics Program continues to serve as the telehealth lead for the Title V agency. After successfully integrating telehealth technology throughout the Hawaii Title V agency, this project focuses on addressing telehealth access issues to reach underserved communities in the state. Funding for this project is from a Centers for Disease Control and Prevention grant: National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities awarded June 2021.
Key Partners: This new project is a unique collaboration of the Hawaii State Department of Health (DOH), Hawaii State Public Library System, University of Hawaii (UH) Pacific Basin Telehealth Resource Center, and UH John A. Burns School of Medicine.
Objective: By June 2024, establish 15 new telehealth access points with health and digital navigators in public libraries located in underserved communities statewide
Strategies: The strategies to implement the project focus on three key areas:
- Library Telehealth Access Project infrastructure development
- Workforce development
- Service Provision
The report for FY 2022 reflects the grant plans and continuing startup activities.
Strategy 1: Telehealth Library Access Project infrastructure development
Activities for FFY 2022 continued formulating/adjusting the project plans, securing key partnerships, and developing/adjusting plans for the three key strategies.
The funding for the new project was awarded to DOH on June 1, 2021. Grant activities for FY 2021-22 included:
- Hired Librarian Project Coordinator in May 2022 who is working on the position descriptions for the staffing of LTAP, scheduling implementation at the libraries, developing the training curriculum for the telehealth navigators, and testing initial pilot library site in Naalehu (Big Island).
- The contract with the Research Corporation of the University of Hawaii (RCUH) was executed to cover hiring of the island program coordinators and telehealth navigators.
- Protocols for the telehealth services were tested and revised as necessary.
- Set up procurement for the private room for telehealth for the two libraries on Hawaii Island and one library on Kauai that don’t have any.
- Continue executing contracts for services.
- Continue implementing pilot phases at each library until procedures are finalized before full implementation begins.
- Continue setting up collaboration with the Hawaii State Public Library System, UH, community-based organizations, and families in the communities near the libraries.
Strategy 2: Workforce development
This strategy focused on actions needed to develop training for project staff and in FY 2021-22 was still in the planning phase. Activities include:
- Health and digital navigators were changed to be called telehealth navigators.
- Identify and develop training for the telehealth navigators.
- Hire project coordinators on each island as each island enters the project.
- Hire individuals from each community as telehealth navigators for each library as each library implements the project.
- Provide training to staff.
- Develop and implement evaluation of activities.
Strategy 3: Service Provision
This strategy focuses on the activities for actual provision of telehealth services, and in FY 2021-22, were still in the planning phase. Activities include:
- Telehealth navigators will help individuals and families locate information about telehealth and make telehealth appointments.
- Telehealth navigators in the libraries will help individuals and families complete the scheduled telehealth appointment.
- Telehealth navigators will have individuals and families who receive services evaluate their experience.
Current Year Highlights for FY 2023 (10/1/2022 – 6/30/2023)
The project received a no-cost extension to May 31, 2024, from the CDC. The library renovations and upgrades to the broadband are complete, and the vacancies in the libraries have reduced significantly. Libraries that are ready to implement the project are identified. This allows the project locations to hire telehealth navigators to start the library services.
Challenges Encountered
Some of the major challenges for the grant include:
- The quantity of paperwork and approvals necessary to implement project activities.
- Competing funded activities (e.g., libraries received funding for major renovations, so the locations could not be used until the renovations were complete)
- Difficulty recruiting appropriate staff.
- Changing priorities for community-based organization partners as the pandemic issues decreased.
Overall Impact
During the pandemic, telehealth proved to be a valuable tool to provide access to healthcare services in Hawaii especially for the neighbor island families. However, the lack of digital literacy and access to devices and broadband/cellular connections was clear for the families that were not able to use telehealth during the pandemic. Many of these families did not have and continue to not have access to in-person healthcare services close to their communities. Providing a safe and publicly accessible space with telehealth navigators, equipment, and internet connection will allow individuals and families to access healthcare via telehealth without leaving their community. Since this project is based in libraries in underserved communities around our state, the greatest impact will be on those who can't access health services.
To Top