HRSA Grants Improve Child Psychiatry Access in North Carolina 

Kenya Caldwell, M.D., Duke Second-Year Child and Adolescent Psychiatry Fellow

It is no secret that trying to get an appointment with a psychiatrist is a difficult task. There is an increasing demand for psychiatric services and a chronic shortage of psychiatrists. And this is even more of concern when trying to access child psychiatry.

In the United States, 77% of counties are underserved. And while there are approximately 8,300 child and adolescent psychiatrists, the estimated need is between 12,600 to 30,000 (Harris, 2018). In North Carolina, 84 of our 100 counties are considered mental health professional shortage areas (North Carolina Telepsychiatry Program, 2018), and 64 of our 100 counties do not have a child psychiatrist (Practicing Child and Adolescent Psychiatrist - North Carolina, n.d.).

To treat the 2.3 million children age 18 and under in North Carolina, only Durham and Orange counties have a “mostly sufficient supply” of child psychiatrists. Surprisingly, included in the “severe shortage” category is Wake County, which has the highest number of child psychiatrists but not enough to cover the nearly 250,000 children that reside within the county. Also, among the most populous states, North Carolina has the second largest rural population in the United States (Practicing Child and Adolescent Psychiatrist - North Carolina, n.d.).

Further, major depression in adolescents increased 52% from 2005-2017, and in the outcome of suicide, mental illness has become the leading medical cause of death amongst children and adolescents in North Carolina and the United States (Twenge, Cooper, Joiner, Duffy, & Binau, 2019).  The need for mental health treatment in kids has grown substantially.

What does this mismatch of supply and demand mean? Predictably, it translates to significant delays in treatment, decreased quality of treatment, and higher costs. For our patients, it means waiting months to see a psychiatrist, travelling many miles to see a psychiatrist, less evidence-based psychotropic prescribing, and poorer outcomes. For us, the specialty workforce, it means cramped schedules with protracted time with patients and review of their clinical information, less time to collaborate or liaise with the rest of the treatment team, and earlier burnout. 

So how do we address the mismatch? As many of us are aware, primary care providers are the first line for patients with behavioral health concerns. In pediatrics, 85% of all psychotropics prescribed to children are by pediatric primary care providers (Southammakosane & Schmitz, 2015). Further, 75% of children with psychiatric disorders are seen in a primary care setting and up to 50% of all those visits to pediatric providers involve behavioral, psychosocial, and/or educational concerns (Ford, Steinberg, Pidano, & Meyers, 2006).

However, in a survey by the American Academy of Pediatrics, 65% of pediatricians reported they do not have adequate training to recognize and treat mental health conditions.  Unfortunately, the clinicians that are most called upon to manage the mental health of children report they aren’t trained to do so. In 2003, Massachusetts recognized these challenges and implemented a novel intervention, a telephonic psychiatric consultation line serving as a pediatric access program.  This phone line, called the Massachusetts Child Psychiatry Access Program (McPAP) served as a type of integrated care model within pediatrics. It allows pediatric primary care providers an opportunity to consult with a care manager or child psychiatrist about patient mental health concerns in real time.  

At the heart of this program is an opportunity to provide education and training in managing mental health conditions in primary care.  Indeed, when McPAP started, 8% of providers in Massachusetts thought they could meet the mental health need of their patients, and after a few years enrolled in McPAP, 60% thought they could meet the need.  Now, McPAP is able to cover 1.5 million kids with just six teams (Straus & Sarvet, 2014).

Since that time, child psychiatry access programs have grown across the nation. According to a recent study conducted by the RAND Corporation, child psychiatric telephone access programs appear to increase the number of children who receive mental health services (Stein, Kofner, Vogt, & Yu, 2019), and these programs have led to more appropriate prescribing and decreased costs related to psychotropic medications. These access programs have improved outcomes by utilizing the available workforce and changing the model in which care is delivered.

In early 2018, Duke Integrated Pediatric Mental Health through a partnership with Cardinal Innovations, one of the state’s LME/MCOs, started the North Carolina Psychiatry Access Line (NC-PAL) based on the McPAP model. Initially, this program was designed to provide telephone consultation to pediatric primary care providers in six central and rural North Carolina counties – Franklin, Granville, Halifax, Person, Vance and Warren. In these six counties, NC-PAL provided consultation and referral resources to more than 40 practices covering 60,000 children aged 18 an under. The pediatric providers were able to connect to a care manager immediately and receive a  response within at least 30 minutes from the child psychiatrist.

In the first two years of NC-PAL, 100% of pediatric providers utilizing NC-PAL reported satisfaction with the program, 60%  felt there was a reduction in the need for immediate or a higher level of care, and 94%  felt their ability to care for their patients with mental health conditions improved.        

From the success of NC-PAL’s early work and substantial support from the state and North Carolina Psychiatric Association, North Carolina applied for and was awarded a grant from Health Resources and Services Administration (HRSA) in the fall of 2018 to expand NC-PAL state-wide over the next five years with a focus on the development of mental health consultative infrastructure and educational programs across North Carolina.

Additionally, the State of North Carolina received a second five-year HRSA grant to deploy a perinatal program that includes expansion of NC-PAL in partnership with experts at UNC Chapel Hill and Duke University. This program, called NC Maternal Mental Health MATTERS (Making Access to Treatment, Evaluation, Resources, and Screening Better), aims to support providers in identifying and managing pregnant and postpartum mental health concerns in 16 North Carolina counties.

As this program grows, funding beyond the HRSA grant will be necessary for the program to be sustainable. In September 2018, and with herculean efforts from NCPA and President Jennie Byrne, M.D., Ph.D., D.F.A.P.A., NC Medicaid approved primary care practices to use reimbursement codes to treat Medicaid patients using the collaborative care model. This is a step in the right direction to provide funding for integrated care models.  However, in order to fully meet the needs of North Carolinians, we must pursue further support from governmental and commercial payers to expand evidence-based mental health services in integrated care models that will ultimately lead to reduced costs to the health system and improved health among the citizens of North Carolina.

NCPA will continue to serve as an advocate for the expansion of integrated care models and to place psychiatry and psychiatrists front-and-center in solving the state’s health care challenges.


  1. Ford, J., Steinberg, K., Pidano, L. H., & Meyers, J. (2006). Behavioral Health Services in Pediatric Primary Care: Meeting the Needs in Connecticut. Farmington: Child Health and Development Institute of Connecticut.
  2. Harris, J. C. (2018). Meeting the Workforce Shortage: Toward 4-year Board Certification in child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 722-724.
  3. North Carolina Telepsychiatry Program. (2018, June 30). Retrieved from NC Department of Health and Human Services Office of Rural Health:
  4. Practicing Child and Adolescent Psychiatrist - North Carolina. (n.d.). Retrieved from AACAP:
  5. Southammakosane, C., & Schmitz, K. (2015). Pediatric Psychopharmacology for Treatment of ADHD, Depression, and Anxiety. Pediatrics, 136.
  6. Stein, B. D., Kofner, A., Vogt, W., & Yu, H. (2019). A National Examination of Child Psychiatric Telephone Consultation Programs’ Impact on Children’s Mental Health Care Utilization. Journal of American Academy of Child & Adolescent Psychiatry, 1016-1019.
  7. Straus, J. H., & Sarvet, B. (2014). Behavioral Health Care for Children: The Massachusetts Child Psychiatry Access Project. Health Affairs, 2153-2161.
  8. Twenge, J., Cooper, A. B., Joiner, T., Duffy, M., & Binau, S. G. (2019). Age, Period, and Cohort Trends in Mood Disordr Indicatiors and Suicide-Related Outcomes in a Nationally Representative Dataset, 2005-2017. Journal of Abnormal Psychology.