Children Guide

KEY ACTIVITY #22:

Adopt and Sustain Dyadic Care to Provide Integrated, Family-Centered Services

Overview

The Center for Advancing Dyadic Care in Pediatrics offers the following summary of dyadic care: “Infant and early childhood practitioners recognize the inextricable link between a young child and their caregiver and caregiving environment, making the relationship between the child and their caregiver and environment the focus of interventions. Dyadic care in pediatric primary care means expanding the focus of pediatric visits to include screening and support for caregivers, families and other environmental factors that will inevitably impact child health. Typically, dyadic care is provided by another member of the healthcare team, such as a licensed behavioral health provider or a community health worker who works alongside a pediatric healthcare provider.^[1]

As of 2023, California’s Medi-Cal (effective Jan. 1, 2023) covers dyadic services, a family-focused benefit treating children (under 21) and caregivers together for behavioral/social-emotional health during routine visits. This benefit, which does not require a prior diagnosis, covers assessments, screenings (maternal depression, ACEs), and counseling. See the Dyadic Services MediCal Provider Manual.

The dyadic care benefit establishes a mechanism that allows for same-day billing of behavioral health visits for patients and their family members up through age 21. This allows for warm handoffs to occur between medical and behavioral health staff, increasing the likelihood that families are more likely to engage in behavioral health services.

The dyadic benefit applies to both managed care and fee-for-service patients, even if the caregiver is not a Medi-Cal member. Dyadic care is reimbursed at the same PPS rate as a standard medical visit. Therefore, an increase in patient interactions enables clinics to optimize reimbursement for the care provided.

Why this matters

Dyadic care supports child development and mental health by treating children and caregivers together. Dyadic therapy models, such as HealthySteps and child parent psychotherapy (CPP) have a strong evidence base^[2][3] for focusing on the dyadic infant and caregiver relationship to mitigate effects of trauma and adversity experienced in early childhood.

Technology Considerations

Technology-enabled screening can be utilized to screen caregivers directly in the EHR, in applications used by care coordinators, and directly to patients via patient-facing outreach and engagement technologies.

Screening results may already exist for caregivers who are already enrolled patients. Health centers will need to determine a strategy to link results to the pediatric record and, where possible, to the caregiver’s record and manage any needed referrals. The linkage of information should be done in a manner that is sensitive to the privacy of the caregiver.  If information sharing is not possible through a shared record, health center staff should develop alternative processes for informing child/caregiver's providers.

In addition, optimizing the EMR is an important strategy to support proper documentation and billing and to reduce burden on staff/providers. This includes utilization of note templates and smart phrases, automatic loading of codes/modifiers to ensure optimal billing, and EMR preference lists to access codes easily.

Action Steps and Roles

1. Foster organizational leadership alignment and support for family-entered care

Suggested team member(s) responsible: dyadic care champion, behavioral health and clinic director.

• An important initial step is to identify key roles such as a dyadic care champion, dyadic care providers, and champion partners in QI, EMR, and claims processing. Health center teams should familiarize themselves with the qualifications of staff allowed to bill under California’s Dyadic Benefit; see the Dyadic Services MediCal Provider Manual.
• Consider organizational mission, strategy plan, goals, and metrics of success in crafting a value proposition for leadership. Implementing dyadic care promotes upstream intervention by supporting the family as a whole, considering both medical and psychosocial needs. Dyadic care also aligns with health centers' strategic priorities such as patient retention, increased visit frequency, and expanded opportunities for behavioral health integration. This may require making a case for dyadic care by aligning with organizational vision and strategic goals, demonstrating an opportunity to improve key clinical metrics, and presenting financial modeling for sustainability.
• Conduct a landscape assessment of clinical operations and identify the specific dyadic care model as this will inform the overall needs and plans for dyadic care implementation and workforce development

2. Provide clinic-wide training on dyadic care.

Suggested team member(s) responsible: dyadic care champion, behavioral health director, leaders of each clinical unit

Provide clinic-wide training on dyadic care to ensure every role understands what dyadic services are, when they apply, and how to execute the workflow reliably. Training should cover:

• The definition of dyadic care.
• Eligibility and documentation requirements.
• Same-day billing rules (including payer nuances).
• Screening-to-warm-handoff pathways.
• How dyadic care connects families to follow-up supports (BH, care management, parenting/perinatal resources).

The goal is consistent adoption across front desk, MAs/RNs, PCPs, BH clinicians, and billing teams—reducing denials, improving closed-loop referrals, and making dyadic care a repeatable engine for integrated behavioral health. Training should also include principles of trauma informed care, confidentiality protocols, and strategies for engaging both children and caregivers in care discussions.

3. Develop clear workflows that facilitate warm handoffs.

Develop clear, role-defined workflows that make warm handoffs the default when a behavioral health need is identified in primary care. Workflows should specify triggers (screening results, clinician concern, patient request), the exact steps and time targets for connection (same-day when possible), and “who does what” from the moment of identification through documentation, follow-up scheduling, and closed-loop referral tracking. The goal is to reduce drop-off between detection and treatment, increase timely engagement, and ensure patients experience a seamless transition to the right level of support/care.

Pilot test these workflows and revise regularly in order to incorporate staff/provider/patient feedback (ie. workflow to prioritize which patients are seen by behavioral health on the daily clinic visit list).  Workflows should view the family as a unit and support both crisis and non-crisis scenarios.

4. Establish methods to measure the impact of dyadic care.

Suggested team member(s) responsible: dyadic care champion, behavioral health director, clinic medical director , QI champion

Identify key care metrics, such as:

• Rate of completed developmental screenings and caregiver depression screenings
• Well child visit and vaccine metrics
• No show rates
• Patient and caregiver satisfaction
• Referrals to resources and services.

Establish a measurement approach to quantify the impact of dyadic care as both a sustainable billing strategy and a gateway to broader family-based, integrated behavioral health services. Using a small set of core monthly metrics (volume, payment/denials, timely follow-up, referrals and closed-loop completion, and pragmatic outcome signals), it’s possible to generate evidence to support staffing decisions and to strengthen the case for expanding integrated behavioral health in pediatrics/perinatal and family medicine.

Data measurement and tracking ideally is supported by a QI champion to support monthly reports, data tracking, and progress monitoring for optimal care and billing. Where helpful, sites could also run small pilots (e.g., on-call clinician billing tracking or QR code–based caregiver screenings) to test workflows and accelerate learning.

5. Consider opportunities for dyadic care across the life cycle.

Suggested team member(s) responsible: dyadic care champion, behavioral health director, clinic medical director, nurse/MA, and CHWs.

Given that the needs of children and caregivers change greatly over the years from 0-21, providers should consider opportunities to tailor dyadic care approaches to different age groups and patient subgroups. Examples of dyadic care topics could include:

• For toddlers: incorporate parental support, development guidance, and behavioral interventions related to the range of eating and sleeping patterns.
• For adolescents: coaching around shared decision-making and caregiver-child tensions around children’s transitions to greater independence.
• For pediatric patients with developmental disabilities: orientation and navigation/coordination of community support services.

As evidenced by the varied list above, dyadic care potentially spans a large variety of topics including behavioral health visits, access to community support services, psychoeducational services and family training/counseling for child development. Health center teams seeking to advance comprehensive dyadic care for all patients must develop skills in a variety of areas with techniques and approaches oriented to different age children. At the same time, integrated teams must also develop the skills necessary to identify opportunities to connect patients and families with dyadic care during routine and acute care encounters.

6. Consider financial sustainability

Suggested team member(s) responsible: dyadic care champion, billing department, and clinic medical director.

Dyadic care champion and other champion partners will need to have a good understanding of the CA dyadic benefit and how to optimize billing for the various components of dyadic care such as dyadic behavioral health visits and dyadic comprehensive community supports services; see the Dyadic Services MediCal Provider Manual. There are nuances for certain types of clinics like FQHCs.

Revenue quality monitoring efforts may utilize measures of appropriate use of codes, tracking of appropriate payments for visit types, or denial rates by health plans. Partner with health plans for process improvement efforts.

Use ongoing tracking and data to develop a sustainability plan and business proposal for dyadic care.