006 - Can You Focus On Behavioral Health In Pediatric DPC?

006 - Can You Focus On Behavioral Health In Pediatric DPC?

Join Dr. Phil Boucher and Dr. Marina Capella as they explore the critical topic of behavioral health in pediatric care within the Direct Primary Care (DPC) model. This episode dives deep into the evolving role of pediatricians from dealing primarily with acute medical conditions to addressing the growing needs around behavioral health. Dr. Marina shares her innovative approaches, including clinical hypnosis and integrative modalities, that are reshaping how pediatricians provide comprehensive care.

Link To Podcast: Can You Focus On Behavioral Health In Pediatric DPC?

 

00:01.16

Phil Boucher

Hey, everyone welcome back to another episode of dpc pediatricians Today we're going to talk about behavioral health this is something where I think a lot of pediatricians realize okay back in the day being a pediatrician meant spinal taps and um. Ah, midnight calls to the hospital for the third kid that has an emyema and needs their you know, ah chest tube reinserted because that was what pediatrics was like in the 1950 s and sixty s and before and now we're in this post vaccineine era where.

 

00:26.20

marinacapella

Her.

 

00:36.77

Phil Boucher

There's a lot of non emergency non life threatening stuff that pediatricians are called to deal with outside of like doing lumbar punctures and all of the the things that are our forefathers spent their nights worrying about like there's a lot of behavioral health concerns and I don't feel like. At least in my residency and from when I talk with other pediatricians that there was a ton of emphasis on that there was a couple there was the child in adolescent or child development month and the adolescent health time but by and large like a lot of the parenting strategies and a lot of the things that parents bring up on a regular basis. Here are the concerns that I'm having or how do I deal with this toddler issue or this um school aged issue. A lot of his really behavioral health related or mental health related and it's not necessarily. Which antibiotics should I use or what blood tests do I need to order for Wilson's disease for those sorts of things that are that are filling our days and so in dpc I think we get the opportunity and privilege to spend more time talking with families because we have longer visits because we have.

 

01:33.27

marinacapella

Yeah, um.

 

01:44.95

Phil Boucher

Less of a rush to get patients in and out and we can deep dive into those issues and explore those issues without just referring them or telling them not to read a book or a podcast. So a lot of Dpc Pediatricians in particular want to be able to provide some behavioral health resources and be a resource for their families and Marina you have. Ah, integrated this into your practice in several different Ways. Can you walk through kind of like what you've done or how you help families when they have the the typical behavioral health issues when they have more significant ah things that either need ongoing therapy you do hypnosis which is so cool. Um, or if they need Medications Talk. Can you just kind of lay the lay the groundwork for what you do in your practice when it comes to Behavioral Health issues.

 

02:21.82

marinacapella

Ah.

 

02:28.25

marinacapella

Ah, sure. Yeah I'll just start out kind of referring to my past life and what motivated me to do more behavioral health um in the fee for service practice where I worked is actually a community health center in California I was. Often frustrated by just these really rushed visits that of course everyone in pediatrics nowadays has and lots of you know seeing lots of teens with depression with anxiety sometimes with eating disorders or some other things. Um behavioral health challenges of all kinds right. And it was so frustrating to just feel helpless to really help them because I didn't have the time to do any sorts of therapeutic interventions myself not because I wasn't capable right? We're physicians were capable of so much. But um because I because of the time. And so my options were to refer them out to a therapist right or psychiatrist and those waiting lists are ridiculously long in most communities. So you're going to be lucky if they ever even call the number that you tell them to call right? because it's another barrier.

 

03:25.93

Phil Boucher

Right? right.

 

03:31.28

Phil Boucher

Um, you have right.

 

03:37.90

marinacapella

And then you're going to be lucky if they even get seen within a few months right I have even very well off families that um, that try to get into see ah a pediatric psychiatrist and.

 

03:41.80

Phil Boucher

Um, and.

 

03:50.36

marinacapella

It's four to six months out right? because there's a shortage with mental health providers especially for pediatrics but in general as well. So I always wanted to be able to do more and I knew that I could do more if I had the time so in pediatric dpc all of a sudden I have the time.

 

03:51.87

Phil Boucher

Um, anyway.

 

04:07.74

marinacapella

Now it's not always easy because as I get busier. You know it's not unlimited time either but still 30 to 60 minutes is is way better than 10 to 15 minutes that I had in my past life. So I started to.

 

04:16.32

Phil Boucher

Right.

 

04:22.90

marinacapella

Um, pursue trainings and education and things that would help me to enhance my ability to offer therapeutic supports like what can I do in my office so I am in 2021 actually know twenty early 2022 two years ago

 

04:30.57

Phil Boucher

M.

 

04:39.75

marinacapella

I started taking courses through the American society of clinical hypnosis. Um, and I just got hooked right away as like Wow this is really powerful. It's essentially people get scared by the term hypnosis because they associate it with mind control but it is not mind control. Yeah, ah.

 

04:52.38

Phil Boucher

Right? You think of like the clock that somebody is holding up and then the chicken like person running around like a chicken like that's just what cartoons have led us to believe what Hypnosis is.

 

04:59.16

marinacapella

Yes, exactly exactly that's stage hypnosis right? But really I think all Hypnosis is self Hypnosis. It's teaching people tools including things like visualizations guided imagery. Meditation and Mindfulness. There's a lot of overlap between hypnosis and those modalities teaching them how to practice those things to improve their state of well-being and so in kids it's a lot of utilizing their imagination. So Um I teach them this.

 

05:30.21

Phil Boucher

Um, right.

 

05:34.31

marinacapella

Visualization called the happy place visualization and another one called the bubblegum visualization and another one called the balloon release and the control panel and this is all hypnosis. But it's empowering these kids and it's helping them to realize that they have more control over. Their thoughts and their feelings than they've ever realized and it's so amazing. Just yesterday I saw a kid who um, who has underlying anxiety but was also in a car accident and had had sort of some behavior like.

 

05:55.22

Phil Boucher

Right.

 

06:08.28

marinacapella

Anxiety fallout from that accident and he's been practicing diligently every day before he goes to bed his happy place and his balloon releases and he told me that he also happens to have adhg so he was having some trouble sleeping not just because of the car accident but because with kids. And kids with Adhd. It's really hard to turn off that brain in order to go to sleep and so he told me that every night before he goes to bed. He does the balloon release and he lets go of all the fear and the sadness and the.

 

06:27.87

Phil Boucher

Sure right.

 

06:42.51

marinacapella

Stuff from the day and he's able to fall asleep right away and this is like a 7 year old boy it was just really heartwarming. Yeah, ah.

 

06:45.78

Phil Boucher

What an insight like oh my gosh. That's amazing. Yeah I will say as an aside I got to witness this when we're at the pediatric mastermind conference and it was just eye opening to me first and foremost what hypnosis was versus what it wasn't.

 

06:59.48

marinacapella

Ah.

 

07:05.40

Phil Boucher

But just sitting there I wasn't up on stage with you like being the the not the contestant. Um the subject. Thank you, They come up on stage. You're the next one on the price is right? um.

 

07:06.32

marinacapella

Um, yeah, the subject the volunteer. Yeah ah ah.

 

07:20.28

Phil Boucher

But it was I mean I could just see how helpful it would be because we would kind of close our eyes and visualize the things that you're talking about with the subject and you could just see how beneficial that would be for a child that's able much more than I am to involve their imagination and visualization. And to you know, really? ah, just be able to experience that and so I mean I think that's super cool and I actually signed up for the hypnosis training in October based like during that I was supposed to be focused I was so set my eyes closed thinking about balloons and control panel.

 

07:46.81

marinacapella

Excellent, Ah awesome.

 

07:56.11

Phil Boucher

And happy place but I was on the website like reser against bot for the conference as well.

 

07:57.32

marinacapella

Ah, ah, that's awesome. Yeah, so yeah, that conference is through the national pediatric hypnosis training institute. So I took a couple of courses through ash and then I found out about the pediatric hypnosis training institute. And I signed up for their conference which happens every october in Minnesota I encourage anyone who has any interest in this or in helping kids with behavioral health problems to look into it because it really is fantastic and you can do so much. It doesn't even take that much time. Um a lot of these kids that I see after car accidents I see them for like so. Six weeks then it's really just like a twenty twenty minute visit each time I'm also combining it with some other integrative modalities hands-on therapeutic technique called Milfasc Release Therapy which helps to kind of let go of the tension. The physical tension in the body but the kids are doing these visualizations and. Hypnosis techniques at the same time often depending on the age and depending on their unique situation and personality of course, but it's really cool to be able to do that I also sometimes just not everyone is willing to do hypnosis or willing to do visualization. So.

 

09:07.80

Phil Boucher

Um, right.

 

09:10.65

marinacapella

I Obviously do the stuff that a general Pediatrician does like Adhd medication management basic medication management for depression and anxiety. But I also try to incorporate these techniques as much as I can if the child or the teen is open to them and I do.

 

09:14.47

Phil Boucher

Sure.

 

09:29.82

marinacapella

Um, utilize a couple of cognitive Behavioral Therapy techniques as well. Um, and just talk therapy in general so because of the time and the flexibility of Dpc I've been able to do that with my patients that need it.

 

09:35.78

Phil Boucher

Yeah, yeah.

 

09:42.73

Phil Boucher

I Think that's the biggest thing is like like you said the waitlists are so long. The cost is so high for families and the time in a fee for service Practice. You just don't have time because you have to see 4 or 5 patients per hour. You just can't get into the weeds of working through those sorts of things or providing anything more than a referral or listen to this book or read this but read this book listen to this podcast. Ah you know, check this resource out I Just don't have the time because I got 3 other patients waiting to sit down and talk with you or do something.

 

10:10.77

marinacapella

Ah.

 

10:13.26

marinacapella

Yeah.

 

10:17.63

Phil Boucher

More involved like hypnosis or even like just kind of you know, strategizing together coming up with some ah scenarios and responses and those sorts of things.

 

10:27.13

marinacapella

Ah, yeah, um I will add you have to be careful with how you price these services because it's easy to just kind of calculate your numbers for general memberships and then.

 

10:38.16

Phil Boucher

Um.

 

10:39.15

marinacapella

If someone has more intense needs where they need a weekly visit. That's not going to be covered under your general membership plan. So I do um I kind of learned this the hard way in the beginning I was trying to do too much and then I had to create sort of ah a separate behavioral health membership for kids who really do need more intensive.

 

10:42.37

Phil Boucher

Right.

 

10:58.80

marinacapella

Therapy or work just in order to not lose money right? Yeah yeah.

 

11:00.87

Phil Boucher

And patients love it and they sign up for it because they see the value of it. Yeah, so it's more. It's valuing your time too and not just thinking well because I can do this I should do this for everybody. Well everybody doesn't need that all the time and they might have spells in their life where they need that.

 

11:16.56

marinacapella

Um, yeah.

 

11:18.23

Phil Boucher

And then they have spelled in their life where they don't need that so we can you know price things differently depending on their needs.

 

11:23.70

marinacapella

Yeah, um, yeah, tell me about your practice I know that you have a therapist that works within your practice I know that you have your own version of a behavioral health plan tell me a little bit about how that evolved and how it's working.

 

11:37.32

Phil Boucher

Um, so we do a couple of different things when it comes to behavioral health and mental health in our practice first and foremost I mean we provide the mental health. Ah you know medication management anxiety depression adhd autism ah you know medication management when when called for. For our members and we don't um, really carve them out if we're simply doing medication management. Um, we usually do every couple months visits for Adhd depression anxiety. Whatever it might be. You know at the appropriate intervals and then a lot of it is over text message or email like how are things going. Are we on the right dose of this medicine. What are we seeing in school and at home and things along those lines that general pediatrics wise we do have a specific mental health plan in our practice and this is specifically for families that want higher touch for their child's mental health needs. Whether it's and it's usually anxiety or Adhd or the 2 main ones. Ah, where we're helping where we're managing specifically their medications for their mental health issues but they're seeing their regular doctor for their sore throats and their physicals and their broken bones and those sorts of things.

 

12:29.59

marinacapella

Now.

 

12:46.20

Phil Boucher

And so we created that because there was such a like ah a need in the community for people that wanted a little more high touch when it comes to their child's Adhd or they want to try some things before they jump on medication and felt like their doctor just was like oh they have Adhd well here's their medicine. Ah see you later and they wanted more than than they were being offered.

 

12:46.73

marinacapella

Um, yeah.

 

13:00.20

marinacapella

Yeah.

 

13:05.92

Phil Boucher

But they didn't want to break up with their Pediatrician just yet because they like all the other aspects of it and they know that's something that we have the time and interest and passion for is well. What can we optimize before we start Medications and what can we do in conjunction with if we're doing medication to make sure we're actually making progress and not just.

 

13:11.62

marinacapella

Um, yeah.

 

13:23.33

marinacapella

Yeah.

 

13:23.68

Phil Boucher

Medicating them and and not addressing all of their executive functioning skills and and lack thereof and so we do that that is so a regular membership for a school aged child is $85 per month for our practice if they're doing mental health only it's $75 per month. So it's just a little bit.

 

13:28.80

marinacapella

Who.

 

13:35.34

marinacapella

M.

 

13:43.54

Phil Boucher

Um, more cost effective for families and actually it's really costof effective for us to do mental health versus making them join as a full member because we know the the the typical requirements of a child with Adhd in terms of visits and then we don't have to address get squeezing them in because they have a sore throat. Or a broken bone or anticipating their other needs so actually from ah ah, a cost and return on investment of our time. It makes sense to do a slightly reduced cost membership. That's just the mental health carve out and families. Love it too and it's been a really nice way for us to.

 

14:03.10

marinacapella

Yeah.

 

14:09.62

marinacapella

Yeah, yeah.

 

14:20.20

Phil Boucher

Help more families in the community that aren't ready to join fully or they have 1 child that really has this need but their other children are generally healthy and they don't see the value at this point of dpc they're able to to make use of that. We also do evaluations for those. So for. Um, adhd will do a 1 ne-time evaluation we can give them their information they can decide if they want to become members and and continue to access our resources or if they just wanted that evaluation done and then they're going to go see their regular doctor or someone else for the management of their their child's Adhd.

 

14:55.14

marinacapella

Yeah, speaking of adhg that reminds me I also do Autism evaluations and you do as well right? So um, yeah, and that's another behavioral health offering that you.

 

14:59.13

Phil Boucher

Um, yeah, yeah.

 

15:07.24

marinacapella

Have the option to do if you'd like in pediatric dpc not everybody wants to do that because it can be quite involved and requires extra training and supplies and things like that. But um, that was another need that I saw in my community in California as well as here in Utah and it was so frustrating seeing these poor families that are on waiting lists.

 

15:09.84

Phil Boucher

Right.

 

15:22.25

Phil Boucher

Orderly.

 

15:26.18

Phil Boucher

Oh yeah, for sure easily. But when you think about like okay my 2 year old needs an autism evaluation. They're not getting to get on to do as amount valueation until a three and a half that's like almost that's forty plus percent of their developmental time to date waiting to get that evaluation done and like you have.

 

15:26.19

marinacapella

For 1 to 2 years sometimes and it's crazy. Yeah, and so.

 

15:35.44

marinacapella

Yeah.

 

15:41.28

marinacapella

And.

 

15:46.30

Phil Boucher

Told me I mean you inspired me to get trained to do autism evaluations and it's one of my absolute favorite things to do getting to sit on the floor and do an ados with a two year old or a 4 year old like there aren't that many things that I enjoy I mean maybe doing stitches I enjoy as much but otherwise that's one of my favorite things to do is those.

 

15:50.86

marinacapella

Ah, yeah, ah yeah, ah yeah, ah yeah.

 

16:06.52

Phil Boucher

Autism evaluations.

 

16:08.57

marinacapella

I Would agree I love doing them. It was a little uncomfortable in the beginning because it wasn't something I had you know done before and the the way that you have to score the the Ados two is a little tricky in the beginning the first few times and you have to use the separate module for toddlers versus slightly older kids versus teenagers and so.

 

16:15.98

Phil Boucher

Yeah, so. Right.

 

16:26.83

marinacapella

It's a little bit of a learning curve. But I love doing it. Um I use it together with something called the Autism Diagnostic interview which I think is especially important for older kids with younger kids. You can often tell right away from the ados to like whether they meet Criteria or not. But.

 

16:34.26

Phil Boucher

Oh for sure.

 

16:43.51

marinacapella

Sometimes they evaluate older kids or teenagers who have very more subtle signs of autism and so it really takes kind of some digging into that history to really ascertain whether or not they meet diagnostic Criteria especially teenage. Yeah yeah.

 

16:47.66

Phil Boucher

Ah, for sure.

 

16:56.37

Phil Boucher

But again you have the time like you get to do this because you have the time because there's no way that you could do this in a fee for service practice where you have a you know sixty ninety minute ah ah Ados and then the scoring of that and then the Adi and all those different aspects that go into it.

 

17:11.22

marinacapella

Yeah, so.

 

17:14.38

Phil Boucher

In a regular fee for service practice. Your employer is going to say I think I'd rather have you just see 15 patients ah rather than do an autism evaluation. So we're not going to let you do that. Even though it's something that you're passionate about and that you could do and it would be a huge win for our community now. Why don't you just.

 

17:21.17

marinacapella

Um, yeah, ah exactly.

 

17:31.10

marinacapella

Um, yeah, exactly exactly? Yeah, so yeah and I don't do a time I do 2 to 3 a month you know and.

 

17:32.53

Phil Boucher

Create a bunch more our views instead. Yeah.

 

17:41.69

Phil Boucher

Um.

 

17:42.23

marinacapella

I get to charge I initially I was only charging 800 and I quickly realized that that's way too little for the amount of time that it takes so now I charge about 1500 for the evaluation and I've gotten more efficient and it's faster the more that I do but it's really nice and families are so appreciative.

 

17:47.42

Phil Boucher

Yes.

 

18:00.36

marinacapella

Um, some families can't afford to pay that 1500 upfront so I say look make a down payment of as much as you can and then just schedule monthly payments and I feel good about it I get the money eventually and like it's great to be able to do that. Yeah.

 

18:04.67

Phil Boucher

Right.

 

18:12.29

Phil Boucher

Totally that's exactly what we do to? We don't charge quite as much yet because it's still kind of a newer thing for us in the community. We do 900 but we'll do payment plans too because parents are just grateful and usually if they have to go ah and see a psychologist eighteen months in the future.

 

18:17.50

marinacapella

Um, yeah, yeah.

 

18:30.22

Phil Boucher

It's going to cost them a lot more anyways I mean it's usually 1500 to $5000 plus for an op evaluation when you're a private pay and so it makes financial sense for them too. Especially if you can offer them a payment plan like they're they're going to be happy to save all of that time.

 

18:32.44

marinacapella

Oh yeah, yeah, um, yeah.

 

18:41.51

marinacapella

Absolutely yeah, yeah, and I do for that specific service because it's a big chunk of money I offer super bills and so I say I don't guarantee that you will get any of your money back.

 

18:47.30

Phil Boucher

And save money too.

 

18:58.89

Phil Boucher

Yes.

 

18:59.71

marinacapella

Here's the super bill with the diagnostic codes and the cpt codes and whatever and and some families have been successful in at least getting partial reimbursement for that. Yeah.

 

19:07.20

Phil Boucher

Absolutely yep I think that's worth mentioning to because some families just want to make sure that they can at least submit it to insurance to get reimbursement for the other thing that I didn't really touch on. We have a therapist in our office too.

 

19:14.26

marinacapella

Yes. Um, yeah.

 

19:21.40

Phil Boucher

She's a play therapist and so she works with kids. This isn't something that I knew a lot about before getting into dpc like the different types of therapy play therapy is great for like ages 3 or 4 to 9 or 10 because it's more like you're sitting. You're playing games you're coloring. You're doing art.

 

19:29.65

marinacapella

Um.

 

19:38.84

Phil Boucher

And then you're talking through those things in a very child-directed way rather than sitting on a couch and spilling your guts to somebody that's kind of you know, keeps asking you questions. Um, and so she does play therapy for little kids and then she does regular cognitive behavioral therapy and some different modalities for for bigger kids too. She has her own llc.

 

19:45.26

marinacapella

Yeah, ah.

 

19:52.22

marinacapella

Yeah.

 

19:58.45

Phil Boucher

And she is in our space and so our members some of our members will see her and a lot of patients aren't members. Ah that see her and then they're just kind of in our space which helps with foot traffic honestly and they they kind of get to know the way that we practice as well and so that's been really successful.

 

20:01.27

marinacapella

Um.

 

20:09.83

marinacapella

Yeah, yeah, yeah.

 

20:17.41

Phil Boucher

Um, for getting patients access to a therapist in a much more streamlined efficient manner and so we love having her as a part of our team I mean we can. She's in her own lllc but we consider her part of our team. Um, and ah, it's nice to be able to bounce ideas off of her. It's nice to have that.

 

20:22.66

marinacapella

Um, yeah.

 

20:35.29

marinacapella

Yeah.

 

20:35.64

Phil Boucher

Co-located and then to have the families that see me and then they see her for their mental health needs and it's been a really cool way to serve the community especially with mental health issues and she's gone from 0 she was at 0 she didn't come with any patients and she's more than full now. And under 2 years Um, and so it's a very viable option for for practices as a way to bring in additional revenue increase their ability to serve patients bring in more foot traffic like it's been a win in every capacity for our practice.

 

21:06.80

marinacapella

Yeah, definitely definitely. Yeah, that's fantastic I would love to eventually have you know a bigger space where I can do that so that's my my goal in the next kind of 3 to 5 years to have more. People within myspace kind of create that medical home that you know other practices try to create but in a direct care sort of settinging with lactation support with behavioral health support with um maybe some pt o t you know support. So that's kind of my big dream but not everybody has to do that. But.

 

21:23.45

Phil Boucher

Strength.

 

21:29.10

Phil Boucher

You know.

 

21:38.57

Phil Boucher

Um I Love that is a great dream.

 

21:40.55

marinacapella

It's a possibility right? I will also add that we know some pediatricians who have decided to do direct care and they don't really like doing all the general pediatric stuff so they've opted to just focus on Behavioral Health and you can do that with indirect care because nobody's dictating what you.

 

21:53.30

Phil Boucher

Ah, great, totally.

 

22:00.26

marinacapella

Have to do you know in an insurance base system. So um I know someone here in Utah who does that and she thinks she only works like two days a week because she has a lot of kids and her family is a priority but she does pediatric hypnosis like I do and she does other sorts of therapy as well.

 

22:11.92

Phil Boucher

Um, me.

 

22:17.10

marinacapella

And she just focuses on behavioral health and she loves it. Um I think I know another pediatrician as well who was at the mastermind last year and talked about treating anxiety and she also focuses on behavioral health so that's a possibility as well. If your passion is. Treating kids with behavioral health and mental health conditions.

 

22:34.17

Phil Boucher

Totally yep I Think that's the thing that runs through all of these threads of all the episodes that we've done is you have the time you have the control and you can do a lot more than you've been told by the hospital clinic administrator and each practice.

 

22:39.90

marinacapella

Yeah.

 

22:48.65

marinacapella

Yeah.

 

22:52.58

Phil Boucher

You as the owner and as the operator get to pick what you like to do and focus it on that and it's so rewarding to be able to say I want to see more of this type of patient and not have it be this I mean I think a lot of people in the fee for service world.

 

23:01.70

marinacapella

Ah.

 

23:09.39

Phil Boucher

They get there and you know their child is in for their annual checkup and they look at the ph q nine and they're like oh shit. Um this is gonna this is going to throw a huge wrench in my day ah because I wasn't expecting this child to have this many issues and we only have 12 minutes to do their entire sports physical and talk through this.

 

23:23.11

marinacapella

Um, yeah.

 

23:28.60

Phil Boucher

Or they're full of anxiety like how are we gonna make this work whereas I'm like I would love to see more patients with anxiety because we have the time to really talk with them and come up with strategies to help them and to work through those things and then get them the extra support when they need it but feel really comfortable with here's where I think you should start here's what I think you should start with and then.

 

23:29.12

marinacapella

Yeah, um.

 

23:40.98

marinacapella

Um, yeah.

 

23:47.97

Phil Boucher

Let me text you in two weeks and see how we're doing and how things are going like that is just it's been such a dream to be able to offer that to families.

 

23:53.98

marinacapella

Absolutely yeah, so to all our listeners. What are you waiting for? come join us on the bright side all right? Well thanks for listening and until next time.

 

24:01.71

Phil Boucher

Um, amen.