Through an Infant-Early Childhood Mental Health (IECMH) consultation program, Louisiana provides consultation to home visitors and treatment services to families participating in the state’s two home visiting programs. Louisiana’s home visiting program is provided by 19 teams that deliver services through either Nurse-Family Partnership (available statewide) or Parents as Teachers (available in particular regions). Families must be eligible for Medicaid, WIC, SNAP, TANF or SSI to be eligible for home-visiting. In state fiscal year 2018, 3,817 families were served and 39,017 visits were conducted.
The IECMH services delivered within the home visiting program are a mix of consultation to home visitors and direct services to families. Currently, consultants spend approximately 75 percent of their time consulting with home visitors and 25 percent on delivering services to families. Consultation consists of education, individualized support and guidance, joint visits with families, and assistance identifying resources for families and making referrals. Consultants offer monthly in-service trainings to home visitors, with topics primarily related to trauma- and diversity-informed care, parent-child relationships, and mental health issues, such as maternal depression. Home visitors also participate in monthly individual consultations and can receive more frequent consultations, as needed. Home visitors can request consultations for any concerns they have and consultation requests are automatically made when parents screen positive for depression or anxiety, or are known to have experienced trauma. Consultants can also conduct visits jointly with home visitors to assess mental health concerns, provide psychoeducation, and help address family mental health needs.
Currently, each team has an embedded consultant at half-time equivalency. From 2016-2018, 6,334 consultations that focused on 1,273 clients were conducted, along with 169 joint home visitor and consultant visits and consultant participation in 625 case conferences.
IECMH consultants provide direct services to families by delivering Child-Parent Psychotherapy (CPP), an evidence-based dyadic therapeutic model designed to address trauma (see research summary on dyadic treatment). Exposure to trauma is the predominant criterion used to determine whether to offer CPP services, but the decision to offer CPP to a family is made following consultation with the home visitor and a joint visit to the family. During the joint visit, if the consultant feels that CPP may be a good option for the family, she may approach the family to see if they are interested in being assessed for participation in CPP.
Consultants are licensed mental health professionals with additional training in infant mental health. In-person training for consultants is provided by Tulane University’s Institute for Infant and Early Childhood Mental Health and consists of 15 days over a five-month period. Consultants begin providing services to home visitors before their infant mental health training is complete. However, new consultants with limited prior infant mental health experience receive weekly individual supervision. All consultants have individual clinical and reflective supervision at least one to two times a month. There are also monthly half-day statewide IECMH Team meetings that includes a case presentation, as well as monthly consultation with an adult and child psychiatrist. Consultants can also access a statewide consultation program, the Louisiana Mental Health Perinatal Partnership which helps health and mental health care providers identify and address a range of conditions including maternal depression, anxiety, and substance abuse.
With the incorporation of CPP training into the consultation model, the current group of consultants is now receiving training, free of charge, through the National Child Traumatic Stress Network’s Learning Collaborative model. During the CPP training period (which is approximately 18 months), all consultants have twice-monthly supervision plus consultation calls with the CPP trainer two times a month.
In regions of the state that lack consultants, services are provided by a consultant who lives in another region. In these cases, the consultants travel to the site at least once monthly and provide consultation by telephone or video-conference when they are not on-site.
Currently, the Title V Maternal and Child Health Services Block Grant provides funding for the infant mental health consultants’ delivery of both consulting and direct services. Previously, a HRSA Targeted Innovation Award supported the IECMH consultation; the grant’s aim was to develop and retain a highly-skilled home visiting workforce, with special attention to mental health needs. In addition, the state provides funding through the Title V Maternal and Child Health Services Block Grant for consultants to participate in training in IECMH at Tulane University and for transportation to CPP training.
Monitoring and Evaluation
On-going monitoring of consultation services is incorporated into the model. Data are collected on the number, duration, content, and frequency of consultations, as well as on the amount of direct services provided by consultants. Data on home visitors’ knowledge from and satisfaction with services are also collected, as well as an annual measure of provider self-efficacy. Home visitors who work with consultants showed significant increases in ratings of professional self-efficacy, as well as in self-reported content knowledge and knowledge about community mental health services. They also report feeling supported by their consultants. However, data on client outcomes are not collected with respect to consultation.
Louisiana has developed IECMH consultation services for pediatric and family medicine providers and early intervention programs. The model focuses on expanding the capacity of the providers to identify children with mental health needs and risk factors and to implement interventions within the scope of their practice. The models promote the use of validated screening tools for child social-emotional problems and family risk factors (including maternal depression) and effective referrals and follow-up. These services are located in two parts of the state: New Orleans and the Lafayette area.
Consultation services in New Orleans are offered to pediatric primary care providers and are provided by the Tulane Early Childhood Collaborative (TECC), an initiative housed in an academic setting that employs part-time infant mental health clinical faculty in pediatrics and psychology to serve as the consultants. The TECC team also includes trainees in pediatrics, psychiatry, psychology, and public health. The consultants are available to provide onsite consultation at pediatric settings. TECC has developed online resources for providers, including validated screening tools and screening recommendations and guidelines. Consultations can be delivered via phone, e-mail, or secure video. Onsite consultation can include presentations, informal case discussions, and face-to-face consultations with children and their families to answer the pediatric primary care clinician’s consultation questions.
In the Lafayette area, the program consists of a single team serving pediatric primary care providers and early intervention programs. The team includes a child psychiatrist and two Master’s level IECMH specialists, with one focusing on pediatric primary care and the other on early intervention. The entire team participates in case conferences together. The pediatric primary care IECMH specialist is available full-time to provide on-site consultation in pediatric and family medicine practices. The pediatrician/child psychiatrist provides telehealth (with video-connection), in-person, phone, and email consultation. Telehealth and in-person consultations are provided by the child psychiatrist after discussion with the IECMH specialist. Early intervention programs have access to the IECMH specialist who provides in-person and in-home consultation with families, as well as additional consultation with the child psychiatrist (which can include phone and email consultation).
Consultation programs in both New Orleans and Lafayette offer treatment to a limited number of families involved in consultation. These families receive Parent Child Interaction Therapy, a dyadic treatment model designed to address externalizing behavior problems for children from two to seven years old (see research summary on dyadic treatment).
A number of strategies have been employed to reach out to and recruit pediatric providers to enroll in the consultation program. Initially, outreach was conducted through professional organizations such as the American Academy of Pediatrics and the American Academy of Family Physicians, as well as directly to larger practices. Ongoing efforts are focused on partnerships with federally qualified health centers and pediatric hospitals. Additional efforts include offering introductory webinars and grand rounds to pediatric providers.
Early intervention providers are recruited into the program through regular, quarterly in-service trainings and staff meetings where they receive information about the consultation services offered. New early intervention providers receive emails with information about the consultation program.
Original funding for consultation in the Lafayette region was from the Substance Abuse and Mental Health Administration’s Project LAUNCH. The salaries for clinical mental health consultants in primary care and early intervention as well as eight hours a week of psychiatric consultation services have been sustained by the Louisiana Office of Public Health, Bureau of Family Health through Maternal and Child Health Block Grant funding.
In New Orleans, funding comes from a mixture of state and philanthropic funds, with work being undertaken with the state to develop systemic approaches to funding. Initial funding came from a two-year grant from the Baptist Community Ministry, with matching funds from the Louisiana Office of Public Health, Bureau of Family Health. Since that time, funding has been from philanthropic funds. The budget for the project, which includes extensive training across medical disciplines, is about $100,000 annually. Efforts to create a system for billing billable services are underway.
Monitoring and Evaluation
In primary care, outcomes have included changes in providers’ self-reported ability to identify mental health needs, overall increase in use of recommended early childhood clinical skills, including promoting use of screens to identify and track disruptive behavior problems, anxiety, and for trauma and adversity exposure (including maternal depression), and a trend towards identifying mood and anxiety problems. A QI project that has been a component of the New Orleans program demonstrated an improvement in referral success using direct contact with and support to the families.
For early intervention, annual provider surveys show improvements in provider perceptions of their ability to identify and meet young children’s mental health needs, access intensive mental health services for young children, and access case management services. Other outcomes have included increased self-reported focus on parent-child and parent-professional relationships
Special thanks to Sarah Hinshaw-Fuselier, Assistant Professor of Psychiatry, Tulane University School of Medicine, and Mary Margaret Gleason, Professor of Psychiatry, Tulane University School of Medicine, for providing information for and reviewing this profile.