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The relationship between an infant or young child and their caregiver(s) is one of the most critical factors influencing health and development for the rest of a person’s life. Dyadic care is a healthcare approach that recognizes the importance of the relationship, and thus provides simultaneous support for the child/caregiver as part of healthcare interventions. Dyadic care is the name of a Medi-Cal benefit that covers services provided to the caregiver and/or to the parent/child relationship in service of promoting child health during a child’s medical visit.
“Dyadic” approaches to health and wellness integrate the science of relationships into pediatric healthcare by centering significant relationships into screening, assessment, evaluation, intervention, integrated behavioral health services, and case management services such as referrals as part of the pediatric patient’s care plan.
The healthcare system has been historically structured to provide services in response to a problem of an individual, identified patient. Even early intervention services typically are accessed by families when children enter the school system at age five rather than earlier in life when brain development is occurring at the most rapid pace in a person’s lifetime.
Dyadic care recognizes that environmental influence, especially the caregiving context, on a child is a critical prevention and health promotion target to support healthy child development. For the first time, it allows a child to receive a mental health service even in the absence of a problem or risk factor. It allows caregivers to receive support via their child’s healthcare benefits if it is a service that is shown to benefit child health and development.
A presenting problem is a concern that leads a family to seek out professional care. Common presenting problems for young children, including typical childhood challenges, frequently occur within a relational dynamic. As such, the optimal approach to understanding and addressing childhood presenting concerns requires taking into account of the child, the caregiver(s), and their relationship dynamics. Common presenting problems that benefit from a dyadic approach include:
In addition to these presenting concerns, as family dynamics and caregiver mental health intimately affects the child’s well-being, families may also benefit from anticipatory guidance and intervening support to promote caregiver well-being and the family system.
Dyadic services involve simultaneous treatment for the child and parent/caregiver, with studies showing significant improvements in child behavioral concerns, and increases in positive parent/child attachment. Some examples of evidence-based dyadic models include Child-Parent Psychotherapy (ages 0-5 years), HealthySteps (ages 0-3 years), Dulce (ages 0-6 months), Triple P Positive Parenting Program (ages 0-16 years), and Parent-Child Interactive Therapy (ages 2-12 years). Dyadic services and evidence-based models are numerous and exist across a continuum of care from prevention and health promotion to treatment for acute and clinical concerns. Dyadic care also is provided across setting types, including pediatric primary care and outpatient mental health treatment settings. The dyadic care Medi-Cal benefit specifically covers dyadic services provided as part of the Non-Specialty Mental Health Services benefit. This benefit is often delivered as part of pediatric primary care; however, it can also be provided as part of other settings, including by independent community-based practitioners.
For more information on the different models:
Often behavioral health services in primary care function on a system of referrals where medical providers see a patient, determine a need and submit a referral for a behavioral health staff member to outreach at a different time and offer separate behavioral health services. This may happen while all the staff are housed within the same clinic. Integrated behavioral health approaches may involve a culture of team-based care and same day visits, but they also may not. Dyadic care typically leverages both same day and team-based visit approaches of integrated care, while also ensuring that the focus of the intervention is the family rather than exclusively on the individual or identified patient.
When we think about dyadic care within primary care using an integrated approach we are looking to shift that typical flow to become one where families and providers are working together as a team both in the direct moment of referral as well as for ongoing care. In these cases there is a culture of warm handoffs where behavioral health staff are available to join during a medical visit to introduce themselves and the service and sometimes begin the work. This model also includes an emphasis on joint visits whenever possible for our younger children so that the caregiver needs, which directly impact the growth and development of the child, can be attended to in the same moment as the child’s direct needs are being supported.
Both the caregiver(s) and children benefit from dyadic care. Some benefits include:
Intensive Technical Assistance Services
Targeted Technical Assistance Support
Learning Collaboratives and Training
Public Access Technical Assistance
Dyadic care is a team-based approach. A provider who uses a dyadic approach simply means they conceptualize their work to include another important figure in the child’s life wherein the assessment and intervention for the presenting concern needs to consider the relationship and psychosocial functioning of that other individual. Broadly, providers may include physicians, residents, nurses, psychologists, social workers, behavioral health clinicians, peer navigators, and community health workers.
While many provider types utilize a dyadic approach to their care, the Medi-Cal dyadic benefit is only reimbursable to providers who are eligible to be credentialed with the Non-Specialty Mental Health Services benefit.
Non-Specialty Mental Health Services (NSMHS) may be provided by Licensed Clinical Social Workers (LCSWs), Licensed Professional Clinical Counselors (LPCCs), Licensed Marriage and Family Therapists (LMFTs), licensed psychologists, Psychiatric Physician Assistants (PAs), Psychiatric Nurse Practitioners (NPs), and psychiatrists as consistent with the practitioner’s training and licensing requirements.
Associate marriage and family therapists, associate professional clinical counselors, associate clinical social workers, and psychology assistants may render NSMH services under a supervising clinician. Refer to the DHCS provider policy manual for additional guidance on provider types and requirements for each service.
The California Department of Health Care Services (DHCS) Provider Manual for Non-Specialty Mental Health Services (NSMHS) was updated to include reimbursement for a range of services and psychotherapy, including individual or family, or group therapy services to children without a DSM disorder. Instead of requiring a diagnosis, providers can use a few different Z-Codes to indicate that they are either providing preventative support or services for children who are at risk for future mental health concerns based on environmental adversities. Behavioral health clinicians can also now use health and behavior codes that assign qualifying physical health ICD-10 codes as their primary diagnosis for a behavioral health service.
Effective January 2023, Medi-Cal will cover integrated physical and behavioral health screenings and services for the whole family, not just the child who is the identified patient. This expansion is especially important for families in which the child is enrolled in Medi-Cal but the parent or caregiver is uninsured, and yet there is a need for dyadic treatment.
In order to bill for dyadic services, providers must be credentialed with a non-specialty mental health services payer, oftentimes via their county’s managed care plans, and claim the codes that are included as part of the NSMHS provider manual for psychological services.
Dyadic billing is held to the FQHC same-day exclusion, meaning that dyadic care providers cannot be reimbursed a second Medi-Cal PPS rate in addition to the initial PPS rate that would be paid for a same-day medical visit. Dyadic claims are eligible to be submitted for visits that occur on the same day as another service or as a stand-alone service; however, would not be eligible for a second PPS reimbursement when provided on the same day as another qualifying PPS visit. DHCS has proposed an enhanced fee for service payment that is pending with CMS.
The same day exclusion policy is a significant issue for the sustainability of dyadic services. Learn more in this issue brief from our partners at the California Children’s Trust.
We measure dyadic care by collecting and evaluating data related to the level of dyadic services provided and their related outcomes, including information on:
We use this information to guide our work and make practice improvements to ensure services are sustainable and meet patient needs in order to benefit childhood outcomes and increase the quality of care. Dyadic services evaluation and quality improvement efforts typically involve caregiver-level or relationship-based services, such as a measure of screening rates or referrals for caregiver mental health during pediatric visits.
Children and families with Medi-Cal insurance will be able to access dyadic care benefits under the Non-Specialty Mental Health services benefit. The dyadic benefit is designed for patients ages 0-20 and is only reimbursable to this age group.
Please reach out to your Primary Care Provider or managed care plan for additional information about accessing dyadic services or to find a provider.
There are many organizations both community-based and within academic settings that have a long history of providing training in dyadic models of care. ZERO TO THREE is a resource for learning and professional development for providers as they focus on young children and their caregivers. ZERO TO THREE outlines a set of competencies that have been created as a guide for providers practicing dyadic care and offers other professional development opportunities.
In addition, First 5 California, an organization whose mission is to create and implement a comprehensive, integrated, and coordinated system for California’s children prenatal through age 5 and their families, offers resources for training and professional development.
Evidence-based models of dyadic care, such as Parent-Child Interaction Therapy, Child Parent Psychotherapy, Trauma-Focused Cognitive Behavioral Therapy, DULCE, and HealthySteps have associated training that providers can access to become certified in the practice of the model. Because these are evidence-based approaches, it is common that in addition to provider training, clinics or providers may be required to engage in fidelity monitoring to ensure adherence to the evidence-based practice that is associated with the respective models’ outcomes.