Overview and Results of Pediatric Pilot Program

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Pediatric Integrated Behavioral Health Pilot Program Funders






“This initiative recognizes and capitalizes on the fact that pediatric medical home is the logical place for providing effective integrated mental health promotion, prevention and treatment because the pediatrician is the most likely medical professional that children and adolescents come in contact with during their early and adolescent years and because for children, behavior and development are so much a part of their general health.”
- Pat Flanagan, MD, FAAP, PCMH-Kids Co-chair


From 2016 to 2019, CTC-RI led an Adult Integrated Behavioral Health (IBH) PCMH project with ten adult primary care practices.  Practices implemented universal screening for depression, anxiety, and substance use disorders and through on-site behavioral health clinicians, improved access to brief behavioral health intervention.  CTC’s adult IBH model has shown strong outcomes in promoting better care at reduced costs. Through this pediatric IBH initiative, CTC-RI and PCMH Kids will build on its success in implementing integrated behavioral health in adult primary care practices as well as leverage the behavioral health work done in pediatrics through our PCMH-Kids program over the past 3 years. 

Strategic Goals:

CTC/PCMH Kids: To develop, implement and evaluate a sustainable IBH model serving children, adolescent and postpartum moms within primary care settings.

Rhode Island Behavioral Health Fund: To address behavioral health (mental health and substance use) needs before people are in crisis.   

Pediatric Integrated Behavioral Health Objectives:

  1. To increase the identification, early intervention, and treatment of behavioral health challenges before children, adolescents and families reach crisis by implementing developmentally appropriate behavioral guidance, evidence-based screening guidelines, tools and treatment models for different populations of focus;
  2. To increase ready access to brief behavioral health intervention for patients with behavioral health conditions by hiring and integrating an on-site behavioral health clinician (based on size of the practice but no less than 0.5 FTE licensed behavioral health clinician);
  3. To provide care coordination for children, adolescents and families by developing a robust relationship with a community partner based on an identified population health behavioral health need;
  4. To improve performance by implementing two performance improvement studies, participating in quarterly learning network meetings and having practice team members participate in monthly planning meetings that are facilitated by the pediatric IBH practice facilitator.


3-year pilot program with 2 waves of practices

Qualitative Report

The full qualitative report can be found here and the executive report here.

Best Practice Sharing

January 2020 


Our Mission

The mission of CTC-RI is to support the continuing transformation of primary care in Rhode Island as the foundation of an ever-improving integrated, accessible, affordable, and equitable health care system.  CTC-RI brings together critical stakeholders to implement, evaluate and spread effective multi-payer models to deliver, pay for and sustain high-quality, comprehensive, accountable primary care.