Does a Video Chat Referral Process Help Families with Children Who Have Medicaid to Initiate Mental Health Care?

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Abstracts

Public Abstract

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Nearly 80 percent of children who have Medicaid and mental health problems don’t get the care they need. To begin care, families must go through a complex referral process that can be hard for them to finish.

In this study, the research team developed a video chat referral process to help families with children who have Medicaid get mental health care. In this new process, health centers took a more active role in helping families start the referral process. The team wanted to learn if more families got through the referral process after video chat referrals than families who had usual referrals.

What were the results?

Compared with parents who had usual referrals, those who had video chat referrals were three times more likely to finish screening for mental health care. The research team didn’t find differences between the two groups in number of days between referral and screening or how many families had initial visits at the mental health clinic. After screening, more than 80 percent of families who qualified in both types of referrals had a visit at the mental health clinic.

Parents who had video chat referrals were more likely to say their doctors kept families informed and involved them in their care. They were also more satisfied with their referral process and overall care. The research team didn’t find a difference between the two groups in quality of life related to health.

Who was in the study?

The study included 342 parents of children ages 5 to 12 who had Medicaid. Families in the study lived in Los Angeles County, California. The children received care at one of six health centers. They received a referral to one of two mental health clinics. The health centers and mental health clinics serve a large population of families with low incomes. The average age of children was nine. Among the parents, 87 percent were Hispanic, 7 percent were white, and 2 percent were black. Most parents (96 percent) were women.

What did the research team do?

The research team assigned three clinics by chance to use video chat referrals and three clinics to continue their usual referral process. Video chat referral had these steps:

Either at the health center or later on their phones, parents watched a five-minute video about the mental health clinic.
Parents scheduled video chat referral appointments during their health center visit.
Parents met with a video chat care coordinator at the health center and had a video chat with a screener at the mental health clinic.
During the video chat, the screener asked parents questions to see if their child qualified for mental health care.
If their child qualified, parents scheduled a two-hour visit at the mental health clinic.

The usual referral process had these steps:

Staff at the health center faxed a referral form to screeners at the mental health clinic.
Screeners called parents and asked questions to see if their child qualified for mental health care.
If their child qualified, parents scheduled a two-hour visit at the mental health clinic.

Parents took surveys about the referral process and their child’s care at the start of the study and three and six months after their referral.

Mental health doctors, staff members, and parents gave input on the research and helped the research team design the study.

What were the limits of the study?

The research team designed the study to meet the needs of one specific health system. Other health systems might not be able to use the same process.

Future research could study how the process affects long-term mental health care. Researchers could also test video chat referrals in different health systems.

How can people use the results?

Healthcare systems could think about using video chat referrals when they are looking at ways to help families with Medicaid get needed mental health services for their children.

Professional Abstract

Objective

To test the effectiveness of a telehealth-based referral process, compared with usual referrals, in improving access to mental health care for children with Medicaid

Study Design

Design Element	Description
Design	Randomized controlled trial
Population	342 parents of children receiving Medicaid, ages 5–12, referred for mental health care
Interventions/ Comparators	Telehealth-based referral process Usual referral process
Outcomes	Primary: eligibility screening completion, days between referral and screening, intake visit completion Secondary: health-related quality of life, family-centeredness of care, satisfaction with referral system, satisfaction with care
Timeframe	6-month follow-up for primary outcomes

In this study, researchers developed a telehealth referral process designed to improve the mental health referral and care coordination process for children. Researchers partnered with six sites that are part of a federally qualified health center and two community mental health clinics in Los Angeles County, California. The health center and community mental health clinics serve a large population of families with low incomes.

Researchers randomly assigned three health center sites to implement the telehealth referral process and three sites to continue their usual referral process. Telehealth referrals included the following steps:

Parents watched a five-minute video introduction to the mental health clinic either at the health center or later on their phones.
Parents scheduled telehealth referral appointments during their health center visit.
At the appointments, parents met with a telehealth care coordinator.
Through live videoconference, parents connected with the screening department at the mental health clinic.
Screeners interviewed parents to determine the family’s eligibility for mental health care.
If their child qualified, parents scheduled a two-hour intake visit at the mental health clinic.

The health center’s usual referral process included the following steps:

Staff at the health center faxed a referral form to the screening department at the mental health clinic.
Screeners contacted and interviewed parents by phone to determine the family’s eligibility for mental health care.
If their child qualified, parents scheduled a two-hour intake visit at the mental health clinic.

The study included 342 parents of children ages 5–12 who had Medicaid insurance. The average age of children was nine. Among the parents, 87% were Hispanic, 7% were white, and 2% were black. Most parents (96%) were female.

Parents completed surveys at study enrollment and then three and six months after their initial referral.

Clinicians, staff members, and parents provided input on the research questions, study design, and study outcomes.

Results

Compared with parents who received usual referrals, those who received telehealth referrals were more likely to complete eligibility screening (odds ratio=3.02; 95% confidence interval: 1.47, 6.22; p<0.05). Researchers did not find differences between the two groups in the number of days between referral and screening or intake visit completion. After they completed eligibility screening, more than 80% of eligible patients in both groups went on to a mental health visit.

Parents who received telehealth referrals were more likely to report receiving family-centered care and had higher mean satisfaction scores with the referral system and overall care (all p<0.05) compared with those who received usual referrals. For health-related quality of life, researchers did not find differences between the two groups.

Limitations

Researchers designed the intervention specifically for the health center and mental health clinics in this study. The approach may not apply to other locations or healthcare settings.

Conclusions and Relevance

Compared with usual referral processes, the telehealth referral process in this study improved eligibility screening completion for mental healthcare services for families with low incomes.

Future Research Needs

Researchers could examine longer term outcomes, such as completion of mental health services. Future research could also test the telehealth referral process in other locations or healthcare settings.

This project's final research report is expected to be available by July 2019.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:

Reviewers asked why the effect of telehealth services on referral processes was the only variable tested despite researchers acknowledging that telehealth services could affect other factors as well, such as provider-to-provider communication and parent education. The researchers said they engaged with patient partners and local stakeholders to select the metric they thought would be most helpful to their community.
Reviewers noted that the study population of 87 percent Latino patients was not broadly representative, and they asked whether the researchers collected data on some of the cultural issues that might impact treatment effects, such as legal status. The researchers explained that the largely Latino population reflected the population served in the community clinic where the study was conducted, and legal status was too intrusive an issue to collect in the community.
Reviewers noted that the study did not assess whether mental health therapy improved outcomes in the children studied. The researchers responded that the six-month follow-up period of the study could not address this question given the shortage of providers and long waiting lists in this community healthcare setting.
Reviewers suggested that the tested intervention could be replicated with referrals from federally qualified health centers and community mental health clinics but that it may not work as well in other types of primary care centers because of different cost structures related to the need for a telehealth coordinator. The researchers agreed that a full cost analysis would be an important next step in this research to determine whether the intervention could be replicated in primary care centers with differing cost structures.

Conflict of Interest Disclosures

View the COI disclosure form.

Journal Articles

Article Highlight: Many children who are Medicaid participants with mental health problems don’t receive the care they need, in part because families must first undergo a complex referral process to community mental health clinics (CMHCs) for diagnostic and therapeutic mental health services. In this study, highlighted in Pediatrics, researchers used a community-partnered approach to develop a new system of video chat referrals in which health centers took an active role in the referral process to improve families’ initial access to CMHCs for children referred from primary care. Compared with parents who had usual referrals, those who had video chat referrals were three times more likely to finish screening for specialty mental health care at the CMHC. The study is also the subject of a related commentary.

Pediatrics

A Telehealth-Enhanced Referral Process in Pediatric Primary Care: A Cluster Randomized Trial

Ethnicity & Disease

Development of a Telehealth-Coordinated Intervention to Improve Access to Community-Based Mental Health

The journal of Behavioral Health Services & Research

Challenges to Effective Primary Care-Specialty Communication and Coordination in the Mental Health Referral and Care Process for Publicly Insured Children

More on this Project

PCORI Stories

Delivery of Mental Health Services to Children in Underserved Areas
A feature story about this study, which is testing whether telehealth helps children from low-income families get the mental health services they need.

Project Details

Principal Investigator

Tumaini Coker, MD, MBA

Project Status

Completed; PCORI Public and Professional Abstracts Posted

Project Title

Using Telehealth to Deliver Developmental, Behavioral, and Mental Health Services in Primary Care Settings for Children in Underserved Areas

Board Approval Date

May 2013

Project End Date

December 2018

Organization

Seattle Children's Research Institute^

Year Awarded

2013

State

Washington

Year Completed

2018

Project Type

Research Project

Funding Announcement

Improving Healthcare Systems

Conditions

Mental/Behavioral Health

Birth and Developmental Disorders

Project Budget

$1,715,453

Study Registration Information

HSRP20143009

NCT02396576

^Tumaini Coker, MD, MBA, was affiliated with University of California, Los Angeles when this project was funded.

Page Last Updated:

April 18, 2019