By Marycon Young, Vitals Contributor
At Palo Alto Medical Foundation (PAMF) Pediatrics, a young patient sat with a care manager, learning how to manage anxiety through guided breathing techniques. Just weeks earlier, severe depression had left the patient struggling to attend school, but now, with the help of a dedicated care team, there was a path back to stability.
This scene is part of a broader shift at PAMF Pediatrics. When a primary care doctor identifies a mental health need, a care manager steps in to offer support, coordinate care, and connect the patient with additional resources. By acting as a bridge between the patient, their family, and the healthcare team, care managers ensure that treatment plans are effective and collaborative.
Led by Dr. Kelly Buckman, associate medical director, Behavioral Health Innovation at PAMF, and Lori Durand, LCSW, clinical manager, Pediatric Integrated Behavioral Health at PAMF, the Collaborative Care Model pilot, which began in August 2024, enhances mental health support and care coordination for children and adolescents.
“These are some of the hardest times of these young people’s lives,” said Dr. Buckman. “If we can just help a little bit and make it a little smoother, it really does make a difference.”
Transforming Patient Outcomes
Since launching, the program has enrolled 251 patients, most with moderate to severe symptoms. Engagement is strong, with 64% remaining enrolled for over a month. Encouragingly, 44% of patients with severe symptoms have shown clinical improvements, with many reporting progress within just 22 days.
“Seeing someone who was struggling begin to feel better so quickly is pretty amazing,” said Dr. Buckman.
Care managers track progress using standardized mental health questionnaires and adjust care plans accordingly.
“One of the first things the care manager does is create a proactive safety plan with the patient and family,” said Durand. “Instead of waiting for a crisis, we’re helping them develop healthier habits upfront.”
Dr. Melanie Klein, a primary care physician at PAMF Sunnyvale Pediatrics, emphasized the impact of having a mental health specialist embedded in care.
“Having that extra layer of support means we’re able to provide better, more informed care—whether it’s getting advice on ADHD medication or helping a family find the right therapy,” she said.
Teenager receives mental health support during a scheduled session.
Navigating Challenges with Collaboration
While challenges like insurance limitations and patient engagement arise, care managers remain adaptable.
“We sometimes encounter families who struggle to keep up with appointments,” said Durand. “Our approach is to consistently show up as a supportive resource, offering help without pressure.”
Dr. Lori Kandel, shared how the team ensures patients receive appropriate care.
“When supporting a young patient through a crisis, we use our network of specialists and coordinate with schools and community partners,” she said.
A Model for Growth
As Sutter expands the Collaborative Care Model, lessons from the pilot at Sunnyvale and West Valley Pediatrics help refine the approach.
“We want this model in all primary care areas at Sutter,” said Dr. Buckman. “It’s all about helping as many patients and families as possible.”
Sutter’s partnership with Concert Health supports expanding behavioral health into primary care, particularly in rural communities.
“As we expand the Collaborative Care Model across Sutter, our goal is to create a standardized approach that provides timely mental health support,” said Tam Nguyen, Ph.D., Executive of Ambulatory Behavioral Health Service Line.
By embedding behavioral health into primary care, Sutter is making mental health support proactive, accessible, and integrated into everyday care.
