Phone-based consultations with behavioral health specialists reduced prescriptions for antipsychotic medications by 49% among children enrolled in Medicaid in Washington state.

Dr. Rebecca BarclayDr. Rebecca Barclay’s study showed that Partnership Access Line (PAL) interventions helped reduce prescriptions for antipsychotic medication by nearly half.

The Partnership Access Line (PAL) helped reduce antipsychotic prescriptions by 49% for Washington state children enrolled in Medicaid from 2006 to 2013, according to an observational study published in the journal Health Services Research.

PAL is a free telephone-based psychiatric consultation program that connects Washington state and Wyoming primary care providers (PCPs) to child psychiatrists affiliated with Seattle Children’s and the University of Washington School of Medicine. The PAL team also delivers provider-to-provider consultations upon Medicaid division request for child psychiatric prescription reviews.

This study shows that the reduction in antipsychotic use was a result of PAL interventions,” said Dr. Rebecca Barclay, Seattle Children’s psychiatrist and lead author of the study.

Prescriptions dwindle as PAL grows

During the study, 1,458 providers received a consult through PAL, 759 providers attended at least one of PAL’s general psychopharmacology education conferences and 466 providers received a state-requested medication review consult.

The evidence-based support PAL provided to PCPs benefited patients and helped reverse a troubling statewide trend of steadily increasing rates of antipsychotic use for children.

Antipsychotic prescriptions decreased by 940 monthly users among children enrolled in Medicaid, even as total Medicaid enrollment increased by 186,855 during the study period. Increased use of PAL also correlated with decreases of more than 50% in high-dose antipsychotic use among teens and children 6 to 12 years old.

Significant reductions in antipsychotic prescriptions followed each stage of implementation of PAL’s sub-programs, beginning with elective telephone consults in 2008, which gave PCPs direct access to PAL psychiatrists on a dedicated phone line. Reductions continued following age- and dosage-based mandatory medication reviews in 2009 and mandatory reviews of combined antipsychotic and psychotropic treatment in 2012.

Novel approach addresses a healthcare need

Dr. Robert HiltDr. Robert Hilt designed PAL to help PCPs who may not have the training to adequately treat a child’s mental health problems.

Dr. Robert Hilt designed PAL to help PCPs who may not have the training to adequately treat a child’s mental health problems. Hilt tailored PAL to address recurring themes he and his colleagues encountered from referring PCPs.

“Access to next level of care, wait times and concerns about the appropriate level of care accompanied many of the mental health questions we received from PCPs around the state,” says Hilt, director of PAL and community programs at Seattle Children’s. “Mental health has grown significantly in importance for primary care over the years, as PCPs are often who a family is comfortable going to for their health concerns.”

Hilt modeled PAL after a pioneering consultation access program in Massachusetts and piloted the program, the first of its kind in Washington, in 2008.

Weighing risks and benefits

Antipsychotics provide important relief to children suffering from psychiatric difficulties, such as bipolar disorder, schizophrenia and autism, which can impact children’s ability to learn and develop.

The risk-to-benefit ratio of antipsychotics can make prescribing them a challenging clinical decision. Side effects of antipsychotics in children can include weight gain and high cholesterol, which can lead to future health problems. There is also national concern about using antipsychotic medications for conditions that can be treated more appropriately with either non-medication strategies or medications that pose far less risk of adverse side effects.

“Antipsychotics are helpful and necessary in many situations, but we want to make sure that we’re reserving their use to when absolutely appropriate,” Barclay says.

Over-prescription of antipsychotics in Washington is a potential byproduct of the high demand for mental and behavioral healthcare with only about 100 child psychiatrists in the state, according to the study. And, given that many families want their PCP to be the person they go to first with questions, it’s easy to understand why PCPs continue to see more and more mental and behavioral health cases.

“PAL serves as a vital resource in these situations and we have received thousands of calls from providers since PAL was implemented,” Hilt says.

Expanding PAL’s reach

PAL’s reach has grown within and beyond Washington’s borders. The program, implemented in Wyoming in 2011 and supported by the Washington Healthcare Authority and Wyoming’s Department of Health, provides approximately 2,400 consults and conducts four conferences each year in Washington and Wyoming.

The PAL care guides are widely downloaded, and Hilt has counseled other states looking to develop psychiatric access consultation programs.

In January 2017, Seattle Children’s announced the launch of PAL Plus, a pilot program in Washington’s Benton and Franklin counties that expands PAL services to include in-person counseling sessions with local behavioral health providers for children from economically challenged families.

“The next step for us overall is collaborative care and having local health systems do more integrative care within health practices,” Hilt says.

“Mental health has grown significantly in importance for primary care over the years, as PCPs are often who a family is comfortable going to for their health concerns.”

Dr. Robert Hilt