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Connecting Care and Behavioral Health

It’s an alarming statistic: Evidence shows that while children with certain behavioral issues require 10 or more visits to various professionals, most drop out after only two or three such visits.

Dr. Joanne E. Cox of the Division of General Pediatrics decided to do something about it.

For more than three decades, Cox has tirelessly served children, adolescents, and their families — especially those who most need help and, paradoxically, often have the hardest time procuring it.

In recognition of the Primary Care Behavioral Health Integration Program she pioneered and leads, Cox is the 2018 recipient of the David S. Weiner Award, which annually recognizes an outstanding Boston Children’s Hospital faculty member, employee or provider for leadership and innovation in child health.

Sharon Weiner; David S. Weiner, former president and chief executive officer; Sandra L. Fenwick, president and chief executive officer; Joanne E. Cox, division of general pediatrics; Shari Nethersole, MD, executive director for community health; Judith S. Palfrey, MD, senior associate in pediatrics.

Each year, Boston Children’s Primary Care cares for over 22,000 children and adolescents. Most are from low-income neighborhoods, and they face many adversities — poverty, inadequate food or housing, a violent environment — that may lead to depression, post-traumatic stress disorder and poor functioning in school.

It’s a challenge to make sure these kids get the help they need from physicians, psychologists, psychiatrists and social workers. In the past, all too often they did not, for myriad reasons. “It was hard to track who was getting connected and who wasn’t,” Cox says. “Cases would circle around to us when, for example, the school would call.”

The idea behind the Behavioral Health Integration Program, which began four years ago with a grant from Harvard Medical School, was to integrate behavioral health within pediatric care. At the time, it was the only such program in a pediatric setting. Cox was grateful for the Harvard grant because it helped her team implement a structure. “We got organized,” she says, “in the various disciplines and meetings. We had to provide [Harvard] monthly check-ins, we had to show progress.”

The benefits of the integrated approach quickly became apparent. It dramatically increased the probability that patients would obtain help. “We began to see how much better it was to have a registry,” Cox says.

Today, the mature system features enhanced screening in primary care; same-day assessments when required; assignment to an appropriate level of care; better training of pediatricians on behavioral health issues; care coordination for children with severe symptoms; and the aforementioned registry, an invaluable tracking tool.

There are many children and adolescents who’ve benefited. Cox notes one example, a girl who had witnessed life-threatening domestic violence before turning nine. As the girl reached early adolescence, she complained frequently about abdominal and head pain. “So we talked about stress,” Cox says.

At age 13, the patient had severe depression and suicidal ideation. “She had a complicated treatment program set up,” Cox says. Before the Behavioral Health Integration Program came together, the girl was working with so many agencies that “things would fall apart.” But under the program, “we were aware that care was disrupted. We connected her to a therapist right in primary care. We started weekly meetings, we tracked her situation.”

The girl went back to school, graduated, got a job. Tragically, she suffered a personal loss — but then “she immediately reached out to us. We upped her services and were able to respond right in the moment.”

While Cox is pleased with the program’s progress, she’s not resting on her laurels. “We need to understand more,” she says. “What services do families really need? What barriers make it difficult for them to comply with their programs? Too much of the care is still crisis-driven.”

Praise for the program among Cox’s colleagues has been widespread and effusive. The Behavioral Health Integration Program is “the critically needed roadmap for implementing this care model in the urban setting,” notes Dr. David R. DeMaso, Psychiatrist-in-Chief at Boston Children’s. The hospital is “blessed to have her at the helm,” adds Dr. Judith S. Palfrey, Senior Associate in Pediatrics .

Cox’s response, typically, is to spread the credit. The award, she insists, “is not just about me, but the people I work with.” When fully staffed, that team will include 10 — another doctor, psychiatrists, psychologists, social workers, an administrator, and a research assistant.

Informed that she is beloved — the word comes up repeatedly — by those co-workers and by all those she has helped, Dr. Cox chuckles and deflects: “I guess if you stick around long enough, you become beloved.”

She certainly has.