To improve the mental health (MH) referral process for children referred from primary care to community mental health clinics (CMHCs) by using a community-partnered approach.
Our partners were a multisite federally qualified health center and 2 CMHCs in Los Angeles County. We randomly assigned 6 federally qualified health center clinics to the intervention or as a control and implemented a newly developed telehealth-enhanced referral process (video orientation to the CMHC and a live videoconference CMHC screening visit) for all MH referrals from the intervention clinics. Our primary outcome was CMHC access defined by completion of the initial access point for referral (CMHC screening visit). We used multivariate logistic and linear regression to examine intervention impact on our primary outcome. To accommodate the cluster design, we used mixed-effect regression models.
A total of 342 children ages 5 to 12 were enrolled; 86.5% were Latino, 61.7% were boys, and the mean age at enrollment was 8.6 years. Children using the telehealth-enabled referral process had 3 times the odds of completing the initial CMHC screening visit compared with children who were referred by using usual care procedures (80.49% vs 64.04%; adjusted odds ratio 3.02 [95% confidence interval 1.47 to 6.22]). Among children who completed the CMHC screening visit, intervention participants took 6.6 days longer to achieve it but also reported greater satisfaction with the referral system compared with controls. Once this initial access point in referral was completed, >80% of eligible intervention and control participants (174 of 213) went on to an MH visit.
A novel telehealth-enhanced referral process developed by using a community-partnered approach improved initial access to CMHCs for children referred from primary care.
Children who are Medicaid insured and require specialty mental health care are often referred to community mental health clinics; however, nearly 80% of children who need mental health services do not receive them.
A novel telehealth-enhanced referral process developed by using a community-partnered approach to the intervention design improved initial access to community mental health clinics for children referred from primary care.
An estimated 15% to 20% of US children suffer from a mental health (MH) disorder, but nearly 80% of those who need MH services do not receive them.1,–4 MH needs that go unaddressed adversely impact child health and well-being, family functioning, and eventual adult health and productivity.5,6 Although MH disorders affect a significant proportion of the pediatric population, African American and Latino children living in poverty are often affected at higher rates and are consistently less likely to receive specialty MH services.2,7,–13
Explanations for poor access to specialty MH services are multifactorial, particularly for children in low-income and minority populations. Parents may be unaware of insurance coverage and benefits for MH services and how or where to find appropriate clinicians to provide these services.14,15 They may not recognize their child’s behavioral problems as a concern for which to seek medical care, and when they do, they may face barriers related to the stigma of MH disorders and specialty care clinics and clinicians.7,–9,15,–19 Children who are publicly insured face additional access barriers because of the requirement of specialty MH care referrals to community mental health clinics (CMHCs) for diagnostic and therapeutic MH services. These CMHCs may be more difficult to access because of various factors, including unfamiliarity with the clinic’s screening and enrollment process,20 stigma of attending a CMHC,21,–23 and clinic location.24
Providing MH services using primary care or specialty clinicians in fragmented systems of care often results in suboptimal care for children receiving care in either setting.25 Collaborative care models linking primary care with specialty MH care can improve use of MH services and outcomes for children and adolescents.26,–33
There are, however, multiple barriers to implementing these types of models for collaborative care, colocation, and integrated care to improve MH access for families. Telehealth34 provides a promising solution that allows primary care providers (PCPs) and specialty care providers to engage in systems for care coordination, communication, and collaboration, particularly when true, in-person integration of separate systems is not possible.35,–46
Under the current referral structure and process, parents must navigate a complex multistep referral and care process once the referral to a CMHC has been initiated by a PCP. To improve access to specialty MH care, we partnered with a multisite federally qualified health center (FQHC) and 2 CMHCs to design and test an innovative telehealth-based structure and process for the MH referral process, with a goal of enhancing access to subspecialty MH care. Using the Donabedian model47,48 to guide intervention development, we examined whether and how the structural and process elements of the current referral system of primary care to CMHC could be improved to increase the likelihood of a completed referral, leading to improved access to specialty MH care services for children in low-income communities.
Our study objectives were to develop and test an intervention to improve initial access to CMHCs. Our primary outcome was the completion of the initial access to the CMHC, namely, an eligibility screening visit. Secondary outcomes were parent satisfaction with the referral process and with care overall, family-centeredness of care, and child health-related quality of life.
Our partners were a multisite FQHC (with 6 clinics) and 2 CMHCs that serve a large population of children who are publicly insured. The 2 CMHCs are contracted by the Los Angeles County Department of Mental Health (DMH) to provide MH services to publicly insured children near the geographical areas served by 6 clinical sites of the FQHC.
We used a community-partnered approach for intervention development that has been used in previous studies to partner with clinic stakeholders in clinical delivery design projects aimed at improving care for children who are publicly insured.34 We systematically engaged the major stakeholders in a process that developed a new referral system to enhance FQHC patients’ access to and successful enrollment in these CMHCs. The project working group (PWG) was made up of 26 individuals (14 FQHC clinic providers and/or staff, 8 MH care providers and/or staff, and 4 parents) who reviewed qualitative data from key stakeholders (interviews of 7 parents and 13 providers and/or staff), identified key transition points in which access to and coordination of care were likely compromised, and developed solutions.20,49
The PWG outlined a workflow to support the newly developed referral system (called Telehealth-Coordinated Referral). The research team worked with the PWG to implement, refine, and pilot the new referral structure and process (henceforth, “referral system”) among 19 families. Additional adjustments were made to the intervention on the basis of the pilot data.
Usual Care Referral Process
Parents receive an MH care referral from their primary care clinician at the FQHC. The referral is faxed from the primary care clinic to the CMHC. The screening department at the CMHC initiates the first contact with the family for a phone eligibility screening, which can occur on any weekday. A case manager from the CMHC screening department asks the parent a series of questions regarding insurance coverage, their child’s MH concerns, and other issues to determine eligibility. This information is provided to a CMHC therapist, and the patient is then scheduled for a 2-hour in-person intake visit with a CMHC therapist.
Intervention Referral Process
The intervention process was designed to enhance patient access to the CHMC eligibility screening visit, the first step in the initiation of specialty MH care at the CMHC.
The intervention process is as follows: Parents receive a CMHC referral from their primary care clinician at the FQHC and watch a 5-minute video introduction to the referred CMHC or receive a text message link to watch the video at a later time. The parents schedule a return visit to the clinic for a telehealth eligibility screening visit with the FQHC’s telehealth care coordinator. These visits are available to be scheduled on 1 selected day per week at each clinical site. Upon return, the parents meet with the FQHC telehealth care coordinator, who connects via videoconference to the screening department at the CMHC. A case manager from the CMHC screening department conducts the eligibility screening process via a live videoconference visit with the parents and FQHC telehealth coordinator (located at the FQHC site). The parents answer a series of questions regarding insurance coverage, their child’s MH concerns, and other issues. The CMHC case manager makes an initial determination of eligibility for the family and provides this information to a CMHC therapist, and the parents are then scheduled for a 2-hour in-person intake visit with the therapist.
Study Design and Procedures
The 6 clinics were randomly assigned by the study statistician in blocks by their location and size (3 in the intervention and 3 controls) using computer-generated random allocation. The 3 clinics randomly assigned to the intervention implemented the new referral process for all MH referrals, and the 3 clinics randomly assigned to the control used the usual referral process. The study was approved by the University of California, Los Angeles Institutional Review Board.
Adult parents or legal guardians of a child age 5 to 12 years at the FQHC who received a referral to 1 of the 2 participating CMHCs in the past 30 days were invited to enroll in the study from April 2015 to December 2016. A trained bilingual and/or bicultural (English and Spanish) research associate (RA) called the parents within 30 days of the referral to invite them to enroll, and if the parents agreed, the RA consented the parent and collected baseline data, including demographics, at that time. Parents were asked to participate in a 6-month postenrollment phone survey and received a cash incentive for survey completion; data collection occurred through the end of the 6-month follow-up period (June 2017). Because of the cluster-randomized design, neither the participants nor the RAs were blinded to group assignment.
Of 542 parent-child dyads receiving a referral during the time of study enrollment, 483 were assessed for study eligibility, and 342 of these were enrolled (Fig 1).
Our primary outcome was completion of the CMHC eligibility screening visit. Data from CMHC visit logs (an electronic record of all visits) were used to determine completion of the initial screening visit within 6 months of referral. The CMHC screening visit logs are part of DMH-required documentation of services provided, which is required for CMHC billing to the DMH. The CMHC screeners follow a strict protocol with required documentation (electronically date stamped by encounter day in the electronic medical record) for every screening encounter; this did not differ by format of the screening visit. For all participants (intervention and control), all 3 data points of dates for referral at the FQHC, screening at the CMHC, and, if eligible, the CMHC intake visit were consistently available and chronologically sound. We also collected data from these visit logs on 2 additional outcomes closely related to this primary outcome, including the number of days that elapsed from referral to the day of the CMHC eligibility screening visit, and for those who were deemed eligible, completion of the subsequent in-person intake visit.
Secondary outcome measures at the 6-month follow-up included parent-reported measures of child health–related quality of life by using the previously validated Pediatric Quality of Life Inventory 4.0,50 family-centeredness of care (by using the 6-item family-centered care scale developed by the Maternal and Child Health Bureau in collaboration with the National Center for Health Statistics51 and used in the National Survey of Children with Special Health Care Needs and the National Survey of Children’s Health), and overall satisfaction with the referral process and the care received (by using 2 adapted items from the Consumer Assessment of Healthcare Providers and Systems [CAHPS] Health Plan Survey).52 Family-centeredness of care items were only asked of parents who had completed at least 1 CMHC therapy visit by the 6-month follow-up.
We also collected data on parental factors that may impact whether parents could successfully complete a referral for their child. These factors included family demographics, the child’s need for an MH assessment (as defined as scoring above the cut point for psychological impairment on the Pediatric Symptom Checklist [PSC]53,54), and parental risk for depression (score ≥10) by using the Patient Health Questionnaire.55 The trial protocol is available on request.
All analyses were performed by using an intention-to-treat analysis. Differences were examined between the intervention and control groups on baseline characteristics and on outcome measures. Main outcome measures were examined in regression models. Intervention status was the main independent variable; we used linear regression for the continuous outcome variable (number of days from referral date to screening date) and logistic regression for binary variables (completion of screening visit and intake visit). We first present models adjusted only for variables that were unbalanced at baseline. Next, we present these regression models further adjusted for child’s age and sex, household annual income, parents’ highest educational attainment, parental employment, PSC score, parent and child overall health, and parental depression. To accommodate the cluster design, we used a mixed-effect regression model (with random effects for the clinic) by using SAS proc (SAS Institute, Inc, Cary, NC) mixed for a continuously scaled outcome and GLIMMIX for a binary outcome. Results of regression models are presented as between-group differences for linear regression and odds ratios (ORs) for logistic regression with 95% confidence intervals (CIs). We used 2-sided tests with P < .05 for statistical significance. All analyses were performed using SAS version 9.4 (SAS Institute, Inc).
Our a priori power analysis was based on the primary outcome of initial access to a screening visit and required an analytic N of 320 for a minimum detectable effect size of 0.518 with 80% power, α = .05 (2-sided) with 6 clusters and a 1:1 randomization, and intraclass correlation coefficient of 0.01.
Overall, 342 parents of children who were referred to the CMHCs were enrolled and completed a baseline survey (intervention: n = 164; control: n = 178); completion data for the CMHC screening visit were available for all participants. For secondary outcomes, 289 parents (85%) completed the 6-month survey (Fig 1).
Baseline characteristics were similar across intervention- and control-group participants, with the exception of parents’ current employment status and annual household income (Table 1). More control parents (61.8%) than intervention parents (42.7%) were not employed, and more intervention parents (19.2%) than control parents (10.7%) reported an annual income of ≥$35 000. The mean child age at enrollment was 8.6 years (SD: 2.3). Of children, 87% were Latino, 7% were non-Latino white, and 2% were African American; 40.4% lived in households in which English was the primary language; 64.6% reported the highest household education level as high school or less. Approximately 27% of children had psychological impairment by parent report on the PSC (Table 1).
A greater proportion of children in the intervention (80.49%) completed the initial-access screening visit compared with control children (64.04%; Table 2). The number of days between referral and the initial-access screening visit was greater for intervention families (mean: 23.6 days) than control families (mean: 17.1 days). Among those families who were scheduled for an intake visit after the initial screening visit (n = 213), >80% completed the in-person intake visit, which did not vary by intervention status (80.2% vs 83.5%).
In the adjusted analysis, children in the intervention remained more likely to complete the initial-access screening visit compared with control children (adjusted OR 3.17 [95% CI 1.46 to 6.91]). The difference in time between referral and initial-access visit was not statistically significant after adjustment for covariates (Table 3).
Among parents who had completed at least 1 CMHC therapy visit by the 6-month follow-up, 86.3% of parents in the intervention and 75.3% control parents reported receiving family-centered care, but this difference was not statistically significant (P = .08). Parents in the intervention group reported higher satisfaction with the referral system and with care overall (Table 4). Quality of life did not vary by intervention status at the 6-month follow-up.
Using a community-partnered approach, our academic research team worked with a multisite FQHC, its 2 local CMHCs, and its families to develop a new referral system for children referred from primary care to the CMHC using new structural elements (ie, a telehealth care coordinator) and processes (ie, telehealth-enhanced screening by CMHCs) for referrals. Families in the intervention were more likely to complete the initial access point for enrollment in the CMHCs. For those who completed this initial access point (the CMHC eligibility screening visit), the families in the intervention took ∼6 more days to achieve this access compared with control families.
Our findings highlight the importance of this initial access point for a successful referral to the CHMC. Just 64% of control families successfully completed the CHMC screening visit compared with 80% of intervention families; however, once this step was completed, at least 80% of families from both the control and intervention groups were able to continue on to the intake visit and CHMC services.
The increased time to the initial access point was anticipated for the intervention clinics because the telehealth care coordinator and CMHC staff held all the videoconference screening visits on a single preselected day each week. This limited the availability of slots for the screening visits but allowed parents to have a coordinator at the FQHC provide personalized assistance in connecting with the CMHCs.
The PWG selected completion of the screening visit as the indicator of access because some families may be determined to be ineligible for MH services after the screening visit for a number of reasons (eg, income, MH condition, and zip code). Because our intervention was focused on this initial access point and was powered for it as a primary outcome, it is not surprising that we did not see any significant differences in health (ie, psychological impairment and quality of life) among those who successfully accessed care regardless of the study group assignment. However, with a longer study follow-up period, it is possible that variation in health outcomes could be studied among a sample of all who were initially referred, particularly if the higher rates of access for children in the intervention translate into a greater proportion of children receiving services.
Because the intervention referral system had multiple elements, including the videoconference visit, the FQHC telehealth care coordinator, and the CMHC orientation video, it is not clear which elements were responsible for the findings. The control families did not have access to any elements of the intervention but did have the opportunity to connect with the CMHC for the initial eligibility screening visit via phone, which could have been more convenient than returning to the FQHC for the videoconference eligibility screening visit with the telehealth care coordinator. Despite this, the intervention families were more likely to have completed an eligibility screening visit; we can hypothesize that the assistance from the telehealth care coordinator may have played an important role in access for families.
In other interventions, researchers have aimed to improve access to MH among low-income school-aged children by focusing on colocation of behavioral health within primary care,31,33 collaborative care models of care that may include midlevel MH providers working with the PCPs,56,57 and immediate access to psychiatry consultation for PCPs.58 Each of these models has been studied, with varying levels of evidence of effectiveness in increasing MH care access.31,33,56,–58 These models, however, may require a restructuring of services, staff, or financing.
In the new referral system implemented by the FQHCs and CMHCs, no changes were made to the actual services that parents and children received, to organizational structure and staffing (except for the telehealth care coordinator), or to billing arrangements. Thus, without drastic organizational level changes and with a focus on a key access point, a new referral structure and process can still lead to significant improvements in patients’ access to care.
Our findings are potentially generalizable to primary care and/or CMHC partners. Many counties and states use a similar “carved-out” system of MH referral for children who are Medicaid insured, and many CMHCs use a similar multistep process for enrollment for specialty care. Telehealth technology is increasingly used as an element of delivery of MH care, and thus, practices may have the technological tools and knowledge in place to use this intervention.59
There are some key limitations to our findings. First, the referral system was created to address the specific needs of the community partners and, thus, may need adaptation to be generalizable to other locations or settings. Second, our primary outcome was improved access to care after initial referral, but we do not address in our findings the quality of services that patients receive once they do gain access to care at the CMHC. Therefore, we cannot conclude that the telehealth intervention for improved referral is associated with improved clinical outcomes. Finally, the CMHCs did not involve the payers of MH care for this population, limiting our capacity to identify barriers and system solutions that may improve the intervention’s sustainability.
This study reveals that a novel telehealth-coordinated referral process developed by using a community-partnered approach to intervention design significantly improved initial access to CMHCs for children referred from primary care. Future research is needed to examine the effectiveness of the intervention by using a larger sample size of community-based MH clinics and a longer follow-up period to access clinical outcomes.
Dr Coker conceptualized and designed the study, coordinated and supervised data collection, analysis, and interpretation, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Park and Patel conceptualized and designed the study and reviewed and revised the manuscript; Drs Zima and Soares and Ms Porras-Javier made substantial contributions to conception and design and acquisition and interpretation of data and reviewed and revised the manuscript; Drs Zhang and Chung and Ms Tang made substantial contributions to data analysis and interpretation and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT02396576).
FUNDING: Supported through grants from Patient-Centered Outcomes Research Institute (IH-12-11-4168) and the California Community Foundation (BAPP-14-107111). All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute or its Board of Governors of the Methodology Committee.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3765.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.