There are about 8,300 child and adolescent psychiatrists (CAPs) practicing in the US and over 15 million children and adolescents with diagnosable psychiatric disorders—that’s about 20% of the pediatric population (www.tinyurl.com/58wcu4bj). There is also a dearth of child psychiatric services in rural and low socioeconomic areas. Below are some tips to help you manage referrals to nonpsychiatrist prescribers. 

Which referrals will you accept?

Most CAPs receive more referrals than they can accept. How can you responsibly refer patients to other providers? Clarify your scope of practice: Decide what treatment modalities you use and what patient population you accept. Track how soon you can see new patients. For urgent referrals that you cannot accommodate, refer families to a list of local mental health crisis resources. 

Routine nonurgent referrals may not need a psychiatrist. You can refer these patients to a psychologist for diagnostic testing, a therapist for individual or family therapy, or a PCP for uncomplicated medication management. This allows you to focus on complicated patients who will benefit from assessment and treatment by a CAP. 

Redirecting referrals

Establish a system to respond to new patient inquiries within a reasonable turnaround time, ideally two to three business days. Put notices on your voicemail and email to seek crisis interventions—for example, inform people to dial 988 or 911 for mental health emergencies. 

Provide choices in direct referrals

If you have a list of colleagues or resources and you make direct referrals, provide patients with at least three names, preferably in writing. This gives families real choices and allows you to avoid the appearance of creating a professional relationship (when you give one referral, it can be presumed to be a medical recommendation). 

Keep a referral list

Some psychiatrists keep an up-to-date referral list with some variety based on payer type (private pay versus insurance), expertise (type of psychiatric concern), and discipline (MD and non-MD). This takes time to cultivate and keep up to date, but it will prevent frustration from patients or families if the names you provide are not open to referrals. 

Develop a template for referral redirection

Develop a template letter for redirecting referrals. Include an explanation for why you are not accepting the patient, at least three names of other verified providers, and what to do if those referrals don’t work out. For example, recommend patients contact their PCP, their insurance company, their state department of mental health, or the local chapter of their child psychiatry society for additional referrals (www.aacap.org/aacap/Member_Services/Find_A_Physician.aspx). 

Provide information even if unable to respond to new patient inquiries

If you are unable to respond to new patient inquiries directly, include a brief comment in your voicemail message that indicates you are not open to new patients and provides guidance on how patients can get other referrals (such as by contacting their insurance company). 

Build a list of referrals 

If you do not already have a network, here are some tips for building your own list of referrals:

• Learn the strengths of therapists who refer patients to you (eg, teens, cognitive behavioral therapy, autism, etc).
• Note the providers whom your patients, colleagues, and patients’ PCPs like.
• Check specialty organizations, like the National Eating Disorders Association ­(https://map.­nationaleatingdisorders.org).
• Check insurance lists of providers (although keep in mind that these lists are not always up to date).
• To find nurse practitioners, search “psychiatric mental health nurse practitioners in [your state].”
• Use therapist search engines, such as Psychology Today (www.­psychologytoday.com/us/­therapists) or Good ­Therapy (www.goodtherapy.org/­find-therapist.html).
• Look at local listings for members of organizations such as the American Psychological Association (https://locator.apa.org) or the American Association for Marriage and Family Therapy (www.­therapistlocator.net).

Stepping down stable patients

Develop a process for transferring stable patients who are taking psychotropic medications to other providers, such as pediatricians and other PCPs, developmental pediatricians, and psychiatric nurse practitioners (Shaligram D et al, Acad Psychiatry 2022;46(1):75–81). To preserve the joy of clinical practice and prevent burnout, balance taking new patients and maintaining continuity with existing patients. Here are some points to consider in this ­process.

Consider patient stability

Is the patient likely to remain stable for a period? See the treatment algorithms in Carlat’s newest fact book (Feder J et al. Child Medication Fact Book for Psychiatric Practice. 2nd ed. Newburyport, MA: Carlat Publishing; 2023).

Account for transitions of care at completion of other services

In settings where psychiatric services are part of a larger program and that program ends, you will often need to refer patients to other care. 

Ease up on appointment frequency

Push out follow-up appointments to see if patients can transition to less specialized care. 

Consider warm handoffs

For complex cases, have (and document) a conversation with the receiving prescriber to provide relevant information and promote a successful transition of care. 

Create a handoff template

Use a standard template to create individualized summary letters, addressed to the patient’s family, to share with future providers. The letter should include diagnosis, past treatment trial responses, and ongoing treatment ­recommendations. 

Talking with families

What do you tell the family to refer out a current patient? Some patients may want to step down care, perhaps to save cost or travel time or to have their PCP guide them. Others may have waited a long time to see you, have benefited from your care, and want to continue. For patients moving to less specialized care, consider the following options: 

• Recommend your own referrals. 
• Connect patients with local resources (eg, the San Diego County Access and Crisis Line in San Diego, CA, offers behavioral health ­resources). 
• Direct patients to their insurance company.
• For those who want to keep seeing you, consider reducing the frequency or length of visits and acknowledge your limitations (for example, you might say “I like working with you too; however, your care no longer requires my level of specialization, and I need to see others who are waiting for this level of care”).

Support for nonpsychiatrists 

Some pediatricians have professional interest in treating psychiatric disorders, sometimes getting additional training through organizations like The REACH Institute to become behavioral health champions. However, many PCPs are hesitant to manage psychiatric care. They worry about what to do if a child deteriorates, if a medication stops working, or if new psychiatric symptoms emerge (McMillan J et al, Pediatrics 2020;145(1):e20183796). Help the provider with these concerns. If you are able, offer to consult if the need arises. 

The American Academy of Pediatrics encourages PCPs to treat straightforward mental health cases of ADHD, anxiety, and depression (www.tinyurl.com/24ca7sp6) and offers additional guidance on these topics for pediatricians (eg, for depression, www.tinyurl.com/439cbbbj; www.tinyurl.com/5a3yjd6b). 

Advocate for systems-level guidance for collaborative mental health care, such as that provided in the American Academy of Child & Adolescent Psychiatry’s Clinical Update on the topic (www.tinyurl.com/mr2u934k). Your community may offer consultation to primary care providers managing mental health—check the National Network of Child Psychiatry Access Programs (www.nncpap.org). Two examples of consultative services are Vista Hill’s SmartCare Behavioral Health Consultative Services in San Diego, CA, and the Massachusetts Child Psychiatry Access Program. 

CARLAT VERDICT

You might not have the time to build and maintain referral lists, much less respond to every new request for your services. But you need mechanisms for declining new patients, referring to other providers, and helping existing patients transition out of your care. These processes will help you to respond to the demand as we try to build more capacity in our mental health systems.