EquiCare Toolkit

Abstract – Introduction: There are disparities in child mental health treatment access and treatment retention in terms of race and ethnicity, socioeconomic status (SES), and insurance coverage. Institutions have invested in the integrated primary care (IPC) treatment model with the goal of improving treatment access and promoting child mental health equity. Objective: This study compared treatment attendance in an outpatient psychiatry clinic (OPC) versus an IPC clinic to assess whether the IPC was associated with reduced disparities in access to care and treatment retention. Methods: This study assessed whether there were differences in who is connected to care from the intake appointment to first follow-up appointment. Results: Results showed that the IPC clinic served a more diverse patient population than the OPC clinic in terms of SES, race, and ethnicity. Differences in treatment attendance in the IPC and OPC were also found. After controlling for race, ethnicity, insurance, and distance from patient’s home zip code to clinic, the IPC treatment setting was associated with poorer intake and follow-up appointment attendance. Conclusions: The IPC model may be more accessible to historically underserved youth, but the treatment setting does not inherently eliminate disparities in child mental health treatment retention. Replication of this study has the potential to contribute to the external validity of study findings, improve quality assurance policies, and develop equitable workflow policies. Future research is needed to identify factors that can improve treatment attendance for populations who face greater retention barriers and to shine light on ways that healthcare systems may inadvertently maintain disparity in treatment retention.

Joseph, H. L., Zhang, L. F., Best, C., Bancroft, C., James, M., Kapoor, S., Drescher, C. F., & Davis, C. L. (2024). Child mental health treatment access and retention in integrated primary care and traditional outpatient services. Journal of Pediatric Psychology, 49(10), 689-699. https://doi.org/10.1093/jpepsy/jsae057

Overview: This report discusses how expanding the number of non-physician clinicians and other medical staff on a team can improve access to primary care for underserved populations, particularly in the face of a primary care provider shortage.  

Kona, M., Clark, J., &Walsh-Alker, E. (2023). Improving access to primary care for underserved populations: A review of findings from five case studies and recommendations. Milbank Memorial Fund. Retrieved from https://www.milbank.org/publications/improving-access-to-primary-care-for-underserved-populations-a-review-of-findings-from-five-case-studies-and-recommendations

Abstract: The coronavirus disease 2019 (COVID-19) pandemic has consistently been described as an “unprecedented” global health crisis. While the focus has been primarily on the medical and economic impact of the pandemic, psychological sequelae are anticipated. Primary care is the main point of access for mental health care in the United States, making it the ideal locale to provide psychological services for a larger proportion of the population than traditional mental health care settings. The aim of this paper is to describe how our multi-state, multi-site integrated primary care program adapted and applied cognitive behavioral therapy in the context of COVID-19. Access to mental health care was disrupted despite burgeoning mental health concerns, necessitating novel approaches to providing care. A stepped-care approach was implemented within our primary care practice, which consisted of a combination of low-intensity, high-yield stress management and resiliency building resources and cognitive behavioral therapy that were delivered flexibly based on patient preference, technological capabilities, state ordinances, insurance coverage, and institutional policies. The lessons learned from this experience can inform other integrated primary care clinics in responding to the current and future pandemics.

Bogucki, O. E., Mattson, A. B., Leasure, W. B., Berg, S. L., Mulholland, H. L., & Sawchuk, C. N. (2021c). Adaptations of an integrated behavioral health program during COVID-19. Cognitive and Behavioral Practice, 28(4), 481–491. https://doi.org/10.1016/j.cbpra.2021.01.006  or https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983459/pdf/main.pdf

Abstract: Rural patients are characterized by high behavioral health needs and high barriers to service utilization. One promising approach to addressing health inequities in the rural population is to integrate behavioral health services into rural primary care clinics. This study compared behavioral health needs, service utilization, and functional improvement of adult patients receiving behavioral health services at rural (n = 116) and urban (n = 77) primary care clinics, both part of a large federally qualified health center. Patient demographic information, medical and behavioral health diagnoses, and service use were gathered from electronic medical records. Measures of psychological stressors and psychiatric symptoms were assessed at behavioral health appointments. Contrary to our hypotheses, rural patients did not evince higher medical or behavioral health symptoms than did urban patients. A larger proportion of patients from the rural clinic utilized behavioral health services and were more likely to reside in cities that were not in the same location as the clinic as compared to urban patients. Rural and urban patients attended a similar number of behavioral health sessions. A mixed analysis of variance revealed patients at both rural and urban clinics significantly improved in global functioning following an episode of behavioral health care; there was no significant effect of clinic location on observed improvements in functioning seen in patients. Integrated behavioral health care is a promising approach to increase access to behavioral health services for rural residents.

Scafe, M. J., Mapes, A. R., Guzman, L., E., & Bridges, A. J. (2021). Rural versus urban primary care patients’ behavioral health needs and service utilization. Journal of Rural Mental Health, 45(4), 268-280. https://doi.org/10.1037/rmh0000178

Abstract – Background and Objectives: Because of severe and protracted shortages of pediatric behavioral health (BH) specialists, collaboration between pediatric primary care practitioners (PCPs) and BH specialists has the potential to increase access to BH services by expanding the BH workforce. In a previous study, we demonstrated that phase 1 of a behavioral health integration program (BHIP) enrolling 13 independently owned, community-based pediatric practices was associated with increased access to BH services while averting substantial cost increases and achieving high provider self-efficacy and professional satisfaction. The current study was undertaken to assess whether the initial access findings were replicated over 4 subsequent implementation phases and to explore the practicality of broad dissemination of the BHIP model. Methods: After phase 1, BHIP was extended over 4 subsequent phases in a stepped-wedge design to 46 additional pediatric practices, for a total cohort of 59 practices (354 PCPs serving >300 000 patients). Program components comprised BH education and consultation and support for integrated practice transformation; these components facilitated on-site BH services by an interprofessional BH team. Outcomes were assessed quarterly, preprogram and postprogram launch. Results: Across combined phases 1 to 5, BHIP was associated with increased primary care access to BH services (screening, psychotherapy, PCP BH visits, psychotropic prescribing) and performed well across 7 standard implementation outcome domains (acceptability, appropriateness, feasibility, fidelity, adoption, penetration, and sustainability). Emergency BH visits and attention-deficit/hyperactivity disorder prescribing were unchanged. Conclusions: These findings provide further support for the potential of integrated care to increase access to BH services in pediatric primary care.

Walter, H. J., Vernacchio, L., Correa, E. T., Bromberg, J., Goodman, E., Barton, J., Young, G. J., DeMaso, D. R., & Focht, G. (2021). Five-phase replication of behavioral health integration in pediatric primary care. Pediatrics, 148(2), e2020001073. https://doi.org/10.1542/peds.2020-001073. https://doi.org/10.1542/peds.2020-001073  or https://publications.aap.org/pediatrics/article/148/2/e2020001073/179806/Five-Phase-Replication-of-Behavioral-Health?autologincheck=redirected

Abstract – Introduction: Research examining the implementation and effectiveness of integrated behavioral health (BH) care in family medicine/primary care is growing. However, research identifying ways to consistently use integrated BH in busy family medicine/primary care settings with underserved populations is limited. This study describes 1 family medicine clinic’s transformation into a fully integrated BH care clinic through the development of an Integrated Care Clinic (ICC) and enhanced clinical pathways to promote regular use of behavioral health clinicians (BHCs). Method: We implemented the ICC at the Broadway Family Medicine Clinic serving a low-income (<$25,000 annual income/year) and minority population (>70% African American) in Minnesota. We conducted a pre- and postevaluation of the ICC during regular clinic activity. Results: Pilot findings indicated that the creation of ICC and the use of enhanced clinical pathways (e.g., 5–2–1–0 obesity prevention messages, Transitional Care Management, postpartum depression screening visits, warm hand-offs) to facilitate regular use of integrated BH care resulted in 6 integrated care visits per BHC per clinic half-day. In addition, changes in the behavioral/mental health therapy appointment time slot (from 60 to 30 min) reduced therapy no-show rates. Transitional Care Management (TCM) visits also showed improved pre- and postchanges in patient and clinician satisfaction and reductions in patient hospital readmission rates. Discussion: The transformation into a fully integrated BH family medicine clinic through the creation of ICC and enhanced clinical pathways to facilitate regular integrated BH care showed promising pilot results. Future research is needed to examine associations between ICC and patient outcomes (e.g., weight, depressive symptoms).

Berge, J. M., Trump, L., Trudeau, S., Utržan, D. S., Mandrich, M., Slattengren, A., Nissly, T., Miller, L., Baird, M., Coleman, E., & Wootten, M. (2017). Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low income, minority population. Families, Systems, & Health, 35(3), 283–294.

https://doi.org/10.1037/fsh0000285

Abstract: With persisting health disparities contributing to a disproportionate impact on the health and well-being of socially disenfranchised and medically underserved populations, the emerging patient-centered medical home (PCMH) model offers promise in bridging the health disparities divide. Because behavioral health care is an important component of the PCMH, psychologists have significant opportunity to contribute to the development and implementation of PCMH services in settings that primarily serve medically underserved communities. In this article, after briefly defining the PCMH model and its role in clinical settings for medically underserved populations for whom health disparities are present, roles of psychologists as interprofessional collaborators on PCMH medical care teams are explored. Next, the constellation of competencies that position psychologists as behavioral health specialists to contribute to PCMH care teams for medically underserved groups are characterized. The article concludes with reflections on the prospects for psychologists to make tangible contributions as health care team members toward reducing health disparities and promoting health equity in patients served in the PCMH. 

Farber, E. W., Ali, M. K., Van Sickle, K. S., & Kaslow, N. J. (2017). Psychology in patient-centered medical homes: Reducing health disparities and promoting health equity. American Psychologist, 72(1), 28–41. https://doi.org/10.1037/a0040358

Abstract: Poverty is a common experience for many children and families in the United States. Children <18 years old are disproportionately affected by poverty, making up 33% of all people in poverty. Living in a poor or low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.

Hodgkinson, S., Godoy, L., Beers, L. S., & Lewin, A. (2017). Improving mental health access for low-income children and families in the primary care setting. Pediatrics, 139(1), e20151175. https://doi.org/10.1542/peds.2015-1175 or https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5192088/pdf/PEDS_20151175.pdf

Abstract – Introduction: Much of behavioral health care takes place within primary care settings rather than in specialty mental health settings. Access to specialty mental health care can be difficult due to limited access to mental health providers and wait times to receive mental health care. The purpose of this study is to determine patient satisfaction with behavioral health consultation visits that take place within the context of the primary care behavioral health consultation model. Patient likelihood to seek out specialty mental health care services if behavioral health consultation services were not provided was also examined. Method: Two primary care clinic systems were examined in this study. The first was a primary care clinic predominately serving low-income patients: 100 individuals participated. The second was primary care in the context of military treatment centers: 539 individuals participated. Results: Results show that 61% of the patients in the low-income primary care clinic would not attend a specialty mental health appointment versus 30% in the military population. Discussion: This study suggests that primary care behavioral health is a patient-centered approach to care and reaches populations that otherwise may not receive behavioral health services.

Ogbeide, S. A., Landoll, R. R., Nielsen, M. K., & Kanzler, K. E. (2018). To go or not go: Patient preference in seeking specialty mental health versus behavioral consultation within the primary care behavioral health consultation model. Families, Systems & Health, 36(4), 513–517. https://doi.org/10.1037/fsh0000374

Abstract – Objective: This systematic review focused on Primary Care Behavioral Health (PCBH) services delivered under normal clinic conditions that included the patient outcomes of: 1) access/utilization of behavioral health services, 2) health status, and 3) satisfaction.
Method: Following PRISMA guidelines, comprehensive database searches and rigorous coding procedures rendered 36 articles meeting inclusion criteria. The principal summary measures of odd ratios or Cohen’s d effect sizes were reported. Results: Due to significant limitations in the methodological rigor of reviewed studies, robust findings only emerged for healthcare utilization: PCBH is associated with shorter wait-times for treatment, higher likelihood of engaging in care, and attending a greater number of visits. Several small, uncontrolled studies report emerging evidence that functioning, depression, and anxiety improve overtime. There was no evidence of greater improvement in patient health status when PCBH was compared to other active treatments. The limited available evidence supports that patient satisfaction with PCBH services is high. Conclusions: The implementation of PCBH services is ahead of the science supporting the usefulness of these services. Patient outcomes for PCBH are weaker than outcomes for Collaborative Care. More rigorous investigations of patient outcomes associated with PCBH are needed to allow for optimization of services.

Possemato, K., Johnson, E. M., Beehler, G. P., Shepardson, R. L., King, P., Vair, C. L., Funderburk, J. S., Maisto, S. A., & Wray, L. O. (2018). Patient outcomes associated with primary care behavioral health services: A systematic review. General Hospital Psychiatry, 53, 1–11. https://doi.org/10.1016/j.genhosppsych.2018.04.002