Comparing First Contact Methods Within a Pediatric Behavioral Health Integrated Care Program Open Access

Primary care mental health integration aims to provide whole-person care by addressing emotional, behavioral, and mental health needs along with physical health care management in one setting. Integrated care, in the primary care setting, has been associated with improved patient outcomes as measured by numerous health indicators.^1,2 Others have expanded on this research to specifically examine how integrated models can be applied to pediatric behavioral health.^3,4 One consistent finding from these studies is that integrated care increases access to timely behavioral health treatment, reducing the time between receiving a referral and the first appointment.^1–4 

One integral component of primary care mental health integration is the warm handoff. During a warm handoff, the referring clinician introduces the mental health therapist to the patient during their primary care appointment and discusses the patient’s mental health concerns or needs with both the therapist and the patient as a team. Previous studies in adult populations have reported warm handoffs to be effective in increasing follow-through for referred services.^5,6 These workflows, however, have had mixed results when implemented in pediatric settings.

Studies that focused on patients with chronic diseases during transitions from pediatric care teams to adult clinicians found warm handoffs improved the workflow involved in transitioning patients to their new clinicians.^7,8 Additionally, some studies found that warm handoffs led to improved therapy use when compared with referrals made to outpatient therapy services.^9,10 However, other studies found that warm handoffs were not associated with increased initial appointment adherence in adult behavioral health patients¹¹ or in Latino adolescent patients referred for depression treatment.¹² 

Furthermore, results may vary based on the timing of contact. For example, one study comparing warm handoffs and electronic referrals at an inner-city pediatric primary care clinic found that warm handoffs were more effective at getting patients to engage with mental health services; however, this effectiveness persisted only among those who were contacted 3 or more days after the referral was made. When patients were contacted within 3 days of the pediatric visit, no differences were identified among contact methods.¹³ 

Despite evidence that warm handoffs may be beneficial, they may not always be possible because of staffing limitations, timing of appointments, cost of additional personnel, or other operational barriers such as room availability. It is important, therefore, to consider what other strategies might be effective in facilitating referrals in integrated primary care settings. This study examined the relationship between types of initial contact (ie, warm handoff or a centralized access and triage team) and initial appointment scheduling and completion to determine if one method resulted in higher initial appointment scheduling and adherence.

This study used a retrospective cohort design drawing from all patients referred to mental or behavioral health services, between July 1, 2022, and February 28, 2023, at an integrated primary care program in Southern California. This study was reviewed by The University of California San Diego Office of Institutional Review Board (IRB) Administration (IRB #805060) and determined to not be human subjects research.

The Transforming Mental Health Initiative (TMH) program and its operational procedures are described in detail elsewhere.¹⁴ Briefly, integrated health therapists (IHT) are embedded in several affiliated pediatric primary care clinics. This model, preferably, uses enhanced first contacts through warm handoffs where a primary care clinician brings the IHT into the examination room to make introductions and discuss the presenting concern and treatment recommendations collaboratively with the IHT, patient, and parent at the time of referral. To address referrals made when a warm handoff was not feasible because of the therapist being unavailable, the centralized access and triage team (CAT) was developed. When patients are unable to complete a warm handoff, the CAT team is notified and reaches out to patients by phone to explain the services provided by the program and then offers a brief telemedicine assessment visit to determine the next steps (eg, receive services within the program, refer out for services, or not receive treatment). Both methods spend comparable time interacting with the patient, and translation services are available for any language barriers. The CAT team initially began as a pilot at select sites and was fully established across sites by July 1, 2022.

Patients included in this study were those who received a referral for mental health services, between July 1, 2022, and February 28, 2023, at 1 of 7 integrated primary care locations. Data were collected through electronic health record-generated queries and validated medical record abstraction. The electronic health record (EHR) referral list included referral dates and patient demographics. Variables abstracted from EHR included methods of first contact (warm handoff or CAT), referral reason, the outcome of these first contacts, and adherence to scheduled initial assessments.

The referral date was when the electronic referral for behavioral health services was placed by the patient’s primary care clinician. The first contact date was when either the IHT or CAT team made first contact with the patient successfully. Scheduling the initial appointment was the date the patient scheduled their initial assessment with the IHT. The initial appointment date was the day patients completed their appointment with the IHT. The number of days between these various time points was used to assess if any specific scheduling checkpoint was taking longer between the 2 groups.

Patients with multiple referrals were included if they had distinct cycles of treatment that began after July 1, eg, they had previously been seen by TMH and had been discharged. For purposes of this analysis, only patients with a documented warm handoff or valid CAT phone triage were included in the analysis. Statistical comparisons between warm handoff and CAT patients were conducted using STATA 16.1 (College Station, Texas). Wilcoxon rank-sum tests were used to compare significant checkpoints in the initial appointment scheduling pathway to determine if either first contact group was quicker at completing them. Chi-square and Fisher exact tests were used to compare warm handoff and CAT initial contact patients on the percent of patients who scheduled and/or completed an initial appointment. Logistic regression was used to determine whether demographic differences contributed to initial appointment completion.

In total, 934 referrals were initially identified during the study period. Of these, 71 were excluded because the referral occurred before July 1, 2022, and 64 were not eligible for care (eg, the patient was too old for treatment, the family moved out of state, or the patient could not be contacted) resulting in 799 referrals. Also excluded were 13 patients that scheduled behavioral health appointments without a warm handoff or contact from the CAT team and 154 patients who did not fall clearly into the warm handoff or CAT category, eg, cold handoffs (handoffs that did not include the primary care clinician, patients referred for care coordination only, phone triage not conducted by the CAT team). This resulted in 632 patients who completed an eligible first contact to be included in this analysis. After their completed first contact there were 317 patients who had a warm handoff and 86 CAT patients who were instructed to schedule an initial assessment.

Patients with initial contact via warm handoff or CAT were similar with the exception of ethnicity (Table 1). Compared with 53.8% of warm handoff contacts, 37.3.0% of CAT initial contacts were Hispanic (P < .01); however, ethnicity was not a significant contributor to whether patients completed their initial evaluation when age, race, and first contact method were also assessed in the logistic regression. Referral reasons were similar for warm handoff and CAT cohorts. The majority of patients were referred for anxiety and depression, followed by behavioral or attention/concentration concerns (Table 1).

Among patients who were offered an initial assessment after their first contact, no statistically significant differences were detected between the warm handoff and CAT first contact patients with regard to scheduling, rescheduling, or completing initial appointment (Table 2). A slightly greater proportion of the CAT initial contacts (89.5%) scheduled an assessment appointment but also were slightly more likely to reschedule their appointments (17.9% and 22.1%, respectively). A power calculation of a nonsignificant result between the 2 cohorts and whether they completed their initial appointment or not (Table 2) with a significance criterion of α = .05 showed a power of 11%. Although far below the desired 80%, our study was designed to detect a significant difference of a small effect size based on benchmarks suggested by Cohen.¹⁵ After data collection, the effect size between our 2 groups was much smaller than anticipated.

The CAT initial contact patients were more likely to complete their initial appointment via telemedicine than the warm handoff group, which was expected given the workflow differences between the 2 groups.

The median days to initial scheduling were greater for CAT patients [4 (2, 8)] when compared with warm handoff patients [0 (0,0)] (P < .05); however, this difference is likely due to workflow differences in that IHTs walk patients to the front desk to schedule an initial appointment following a warm handoff whereas admin reach out in a separate phone call to schedule an appointment following a CAT outreach call (Table 2). Median days for the entire process from referral to initial appointment, first contact date to initial appointment, and date scheduling initial appointment to initial appointment were not significantly different.

No differences were found between warm handoffs or CAT initial contacts with regard to effectiveness in initial appointment scheduling, rescheduling, or attendance. There was also no significant difference in median days to initial appointments between the 2 groups. Although warm handoff patients were more likely to schedule their initial appointment immediately following the warm handoffs, patients contacted by the CAT team were typically scheduled in less than 5 business days which is sooner than typical community mental health programs. All initially identified differences did not persist when looking at the overall time to attend an initial appointment. Although telemedicine was the primary type of initial assessment conducted for patients in the CAT group, this was expected because CAT team appointments were created with the intention of being offered as primarily telemedicine appointments.

Results from other studies may help to explain why we found no difference between our 2 groups. Latino/a referred for depression treatment were less receptive to warm handoff when compared with electronic referrals in previous studies.¹² Although similar patients referred for treatment only made up a portion of our population, our warm handoff cohort was predominantly Hispanic and our primary reasons for referral were anxiety and/or depression.

Another explanation for not finding benefits associated with warm handoffs is the rapid outreach of our CAT team. In other studies, outreach that got in contact with patients within 3 days meant that warm handoffs no longer had significant differences in appointment outcomes.¹³ Because our CAT team had a median of 2 days until first contact then this may explain why we found no statistically significant difference between our 2 groups.

The CAT team has several strengths as well as some drawbacks. One major advantage is that by using the time of care coordinators to conduct phone outreach you reduce the amount of nonbillable tasks performed by the IHT. This is because if the therapists conducted the outreach themselves, those phone calls are typically longer and not billable under current policies. However, one potential disadvantage of the CAT team is the additional step of reaching out to patients at a later time which could result in some patients not being reached or scheduled. The CAT team would attempt to get in contact with the patient 3 times before patients are discharged. The warm handoff, in most cases, eliminates this time for initial appointment scheduling because patients are encouraged to schedule their initial appointment before leaving the clinic. It can sometimes be challenging to complete a warm handoff while also seeing patients with scheduled appointments. Additionally, there may not be space for an IHT or there may not be the patient volume to justify having a full-time therapist in the clinic. Therefore, the CAT team provides a useful alternative in cases in which an IHT is unavailable for a warm handoff.

Although the study had a low power level in the analysis, we believe the results are still clinically relevant. Given the effect size we found between our 2 cohorts, a sufficiently powered analysis would require thousands of patients without contributing any additional clinically relevant information. This study had several strengths, including a large sample size comprising patients from diverse racial and ethnic backgrounds as well as patients with various presenting concerns. It also has some limitations, including not having a control group of patients who did not receive any form of enhanced first contact.

In this study, neither enhanced first contact method was associated with improved scheduling follow-through of the initial appointment or likelihood of attending that appointment. Because both methods showed similar effectiveness, either could be used to improve initial assessment appointment adherence and follow-through. Further research is needed to better understand the clinical benefits of the warm handoff, particularly in pediatric patients, to determine if there are other benefits besides patient scheduling and initial appointment adherence or if this effect persists in improved follow-up appointment adherence. This information is crucial to determine which forms of enhanced first contact are most beneficial to promote patient engagement in treatment.

CAT

centralized access team

EHR

electronic health record

IHT

integrated health therapist

TMH

Transforming Mental Health Initiative