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‘Telereferrals’ improved mental health referral follow-through

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Technology offers broadening opportunities for mental health

Despite the challenges of meeting patients’ and their families’ mental and behavioral needs, Coker et al. “had the courage to think outside the box to solve a practice and community need,” Susan J. Kressly, MD, is in private practice in Warrington, Pa., wrote in an accompanying editorial.

Some practices have been able to fully integrate a mental health service within their practice, usually on-site, but that model does not work for everyone. Space and privacy can be problematic, depending on the practice, and payment models can become complex, especially when mental health benefits are not managed by the same payer or through the same plan as other health insurance benefits, Dr. Kressly noted.

“The innovative model in this study combines a ‘soft hand-off’ referral model and takes advantage of telehealth technology for implementation,” she wrote. Families frequently do not follow through on recommendations and referrals, but practices can improve follow-through when they make personal introductions and appointments from their own practice. And using technology to do so can particularly resonate with the generations of children and parents now coming to pediatric practices.

“As pediatricians, we have a unique opportunity to provide care to families who are digital natives,” Dr. Kressly wrote. “As part of the family’s health care team, if we truly decide to put the patient and family at the center, pediatricians should examine their own hesitancy and trepidation regarding telehealth and technology-enabled communications and work to overcome them.”

Other ways to use telehealth beyond the referral system described by Coker et al. might include providing actual telepsychiatry visits at the child’s medical home or connecting families to local resources.

“Those practices that innovate to solve their problems by extending their medical home to include care teams outside their practice walls will likely see improved family satisfaction and, hopefully, improved outcomes,” Dr. Kressly suggested.

Dr. Kressly is in private practice in Warrington, Pa. She used no external funding and has no financial conflicts to report. These comments are condensed and summarized from her editorial accompanying the article by Coker et al (Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-3765).



Children referred for mental health services in Los Angeles County using a telehealth referral were three times more likely to complete a community mental health clinic (CMHC) screening than children receiving conventional mental health referrals, a study found.

Illustration of telemedicine Getty Images

“Our findings highlight the importance of this initial access point for a successful referral to the CHMC,” Tumaini R. Coker, MD, MBA, of the University of Washington, Seattle, and Seattle Children’s Research Institute, and her colleagues wrote in Pediatrics. “We can hypothesize that the assistance from the telehealth care coordinator may have played an important role in access for families.”

Although this study was not powered to compare psychological health or quality-of-life differences, a larger study with a longer follow-up period may allow study of “variation in health outcomes … 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,” the authors wrote.

The research group partnered with two community mental health clinics (CMHCs) and six federally qualified health center clinics, the latter randomly assigned as control or intervention. The telehealth-enhanced referral process developed by the researchers involved patients at the intervention clinics viewing a video orientation to the CMHC and then participating in a live video conference for screening. Completion of the referral screening visit was the measure for CMHC access as a primary endpoint.

Among the 342 children, aged 5-12 years (average, 9 years), enrolled in the study, 87% were Latino, and 62% were boys.

Of children using the telehealth referral process, 80% completed an initial CMHC screening, compared to 64% of children receiving referrals via usual care procedures, resulting in three-times greater odds of a screening in the intervention group (adjusted odds ratio, 3.02).

It took approximately 6 more days for the telehealth-referred children to complete the screening.

“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,” which thereby limited availability of slots for screenings, Dr. Coker and her associates wrote.

Children who received telehealth-enabled referrals reported higher satisfaction levels with the referral system and with care, compared with those using usual care methods. Of the 342 children in the study, 213 were considered eligible to receive CMHC services. Reasons for ineligibility for services included presence of a developmental disability, lack of an mental health need, private health insurance coverage, a zip code outside of the CMHC’s catchment area, and not meeting income requirements.

Of those 213, 80% of the intervention group and 84% of controls subsequently had a mental health visit.

A study limitation is its personalization to the community partners involved, which may require different procedures in other settings, the authors noted. The study also did not look at the quality of mental health services received after initial screenings, precluding the ability to assess clinical outcomes. In addition, “the CMHCs did not involve the payers of mental health care for this population, limiting our capacity to identify barriers and system solutions that may improve the intervention’s sustainability,” the authors wrote.

The research was funded by grants from the Patient-Centered Outcomes Research Institute and the California Community Foundation. The authors reported having no relevant financial disclosures.

SOURCE: Coker TR et al. Pediatrics. 2019 Feb 15. doi: 10.1542/peds.2018-2738.

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