Many barriers have been proposed to explain why rural residents do not receive adequate behavioral health services even though the need for such services is great. One solution proposed to address the need in rural settings is to offer these services within primary care. This study was designed to examine child attendance rates at integrated behavioral health clinics (BHCs) in rural primary care offices. Referral forms for all children recommended to attend three BHCs were reviewed by research assistants. Attendance at appointment, length of time on waiting list, severity of the problem, referral reasons, and parent stress were coded. Across the three BHCs, nearly 88% of children referred were scheduled for an initial appointment, and 81% of children referred for behavioral health services attended the initial appointment. Follow through for children referred by their primary care physician to a colocated behavioral health specialist in rural settings was much higher than found in other studies. These data suggest that in rural settings integrated care may increase access to and continuity of care for a population that is often neglected.
Keywords: children, integrated care, attendance, behavioral health, rural
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It has long been recognized that rural communities have limited mental health resources (Campbell, Kearns, & Patchin, 2006; Fox, Merwin, & Blank, 1995). This is a significant liability for children and adolescents with behavioral disorders who live in rural areas. For example, one recent study found that nearly one out of every four children from rural areas between the ages of 4 and 17 has a mental health problem, and the majority (80%) live in counties that do not have community mental health centers (Moore, Mink, Probst, Tompkins, Johnson, & Hughley, 2005). These results are supported by another recent study showing that one in four visits to a rural pediatric primary care practice included a behavioral concern raised by either the parent or the physician (Cooper, Valleley, Polaha, Begeny, & Evans, 2006).
Thus, primary care physicians are increasingly de facto mental health care providers (Fox et al., 1995; Reiger, Goldberg, & Taube, 1978), and this is especially true in rural communities. Placing the burden of specialty mental health services on rural primary care physicians, however, is not a viable solution. Nearly two thirds of family practice physicians in rural areas report fair to marginal/poor ability to manage child mental health problems (Gerdes, Yuen, Wood, & Frey, 2001). There have been volumes of literature discussing reasons for physicians' reluctance to address child and adolescent behavioral disorders, including too many demands, lack of training, poor reimbursement for such services, and lack of time (deGruy, 1997; Perrin & Stancin, 2002; Wolraich, 1999).
One solution to 'ease' the burden of mental health needs presenting in primary care is the integration of primary care and mental health care services. Indeed, there has been a call to offer behavioral health specialty services within rural primary care offices so that these services are linked (Badger, Robinson, & Farley, 1999; Bray, Enright, & Rogers, 1997; Lambert & Hartley, 1998). Programs that have attempted to link primary care and mental health services include rural hospitals, health departments, rural health maintenance organizations, and rural physician practices (Bird, Lambert, Hartley, Beeson, & Coburn, 1995; Geller, Beeson, & Rodenheiser, 2006).
The colocation of behavioral and primary health care services appears to have numerous benefits, such as the affiliation with trusted physicians, ease of referral, and in creased confidentiality. First, this model capitalizes on the long-standing physician-patient relationship. For example, Hampton-Robb, Qualls, and Compton (2003) found that adults and children were most likely to attend mental health outpatient initial appointments when referred by trusted individuals (e.g., physicians, 68%, and religious leaders, 71%). In addition, adults from rural settings referred by a physician were more likely to remain engaged in treatment by returning for additional visits as compared with those referred by 'social control' agencies (Greeno, Anderson, Shear, & Mike, 1999). Thus, families may be more likely to follow through with mental health services when there is a clear link between the primary care physician and the mental health provider.
Second, ease of referral may also assist in improving appointment attendance. The physician and staff are able to provide descriptions of services in greater detail when working in close proximity with the behavioral health specialist. Indeed, Swenson and Pekarik (1988) found that providing prospective clients in urban and rural settings with orientation prompts (e.g., reminder of appointment along with a description of services) before the initial appointment significantly increased attendance at scheduled appointments (78%) as compared with a control group (57%).
Third, a unique advantage to the colocated model in rural areas is the increased confidentiality it affords. The lack of anonymity in small towns and rural areas is often a barrier for rural residents in need of mental health care (Solomon, Hiesberger, & Winer, 1981). When mental health care is provided within the same primary care clinic, however, the stigma of seeking services from a stand-alone mental health care facility may be decreased. For example, when attending behavioral health visits in a primary care office, neighbors and friends are not privy to seeing a family's car parked in front of the therapist's office (deGruy, 1997). In sum, rural families referred to a mental health care provider in an integrated practice may be more likely to follow through with referrals from their primary care physician owing to (a) the referral's being closely tied to a trusted service provider, (b) the ease of the referral process, and (c) the increased confidentiality associated with the service.
Indeed, engagement in treatment has long been an area of concern in mental health care. Hampton-Robb et al. (2003) summarized the literature on patients' failure to attend initial mental health care appointments, finding the range to be from 16% to 67% (M = 40%, SD = 15%) for those who have requested and scheduled an initial appointment. Furthermore, among adult patients recently discharged from a mental health treatment facility or emergency room, failure to attend recommended outpatient treatment services varies widely, with estimates ranging from 10% to 66% (Boyer, McAlpine, Pottick, & Olfson, 2000; Dobscha, Delucchi, & Young, 1999; Henry & Ball, 1998; Kruse, Rohland, & Wu, 2002).
Many factors have been identified that decrease the likelihood of an adult attending the initial appointment with an outpatient mental health provider, including being from a rural setting, waiting longer than 2 weeks, being a minority (Kruse & Rohland, 2002), and lack of contact with the outpatient setting before discharge from a psychiatric unit (Boyer et al., 2000; Olfson, Mechanic, Boyer, & Hansell, 1998). In rural areas, mental health service use for adults was mostly accounted for by the availability of those services when compared with urban counterparts (Lambert, Agger, & Hartley, 1996). Specifically, as the distance to a mental health care provider increases, the likelihood that the person will receive the necessary care decreases (Hauenstein, 2003). It appears that adults in rural settings are less likely to use mental health services.
Attendance at mental health care visits for children does not appear to be much better. An early study on treatment engagement for outpatient mental health services found that 29% of initial sessions scheduled for children were not kept (Shapiro & Budman, 1973). For children identified through mental health screening in pediatric practices, only 17% made it to an initial appointment with a colocated social worker in an urban area (Hacker et al., 2006). Furthermore, 18%-47% of children with identifiable mental health problems attended mental health sessions in an urban setting (Briggs-Gowan, Horwitz, Schwab-Stone, Leventhal, & Leaf, 2000). The variability in attendance rates appeared to be particularly tied to whether the parent discussed the concern with their child's primary care physician. In addition, Warzak, Parrish, and Handen (1987) found that attendance rates at scheduled appointments for children at an outpatient mental health clinic ranged from 53% (standard practice) to 84% (providing problem-solving assistance for keeping the scheduled appointment). Taken together, these studies indicate that when a behavioral health concern exists, many children are never scheduled for an initial appointment with a mental health provider, and of those who are scheduled for an initial appointment, many do not keep it.
To date, however, no studies have examined follow-through rates for children in rural communities referred by their primary care pediatrician when mental health treatment is colocated in the primary care practice. The purpose of this study was to examine families' attendance at colocated, collaborative behavioral health appointments when referred by a physician at their child's rural primary care office. In addition, this study examined other variables that may affect a rural patient's follow through with mental health treatment, including the amount of time patients were on the waiting list, physician's ratings of the severity of problem, referral reason, and child demographic variables (i.e., child's age and gender).
METHOD
Participants and Setting
Participants were patients referred to one of three integrated behavioral health clinics (BHCs) located within primary care offices in rural Nebraska. These primary care clinics were selected because of the existence of the BHC in partnership with the state's academic health sciences center, the University of Nebraska Medical Center. In each BHC, children and adolescents were referred by a physician, physician's assistant, or nurse practitioner within the primary care clinic for ongoing integrated behavioral health services with the affiliated BHC provider. The behavioral health specialists were faculty or postdoctoral fellows from the University of Nebraska Medical Center. All behavioral health specialists had training in working with children and in primary care. The BHC was integrated in that patients were referred by their primary care provider to an on-site behavioral health specialist who used clinic space for outpatient services. Collaboration on cases occurred through progress notes, informal hallway consultations, and in session (e.g., physician sitting in on portion of outpatient session). On some occasions, physicians would introduce the family to the behavioral health specialist at the time of the referral.
Referrals were tracked over a 17- to 24month period in each clinic spanning from January 2002 to May 2005. In total, 807 referrals were generated by the three clinics. The mean age of children referred was 95.10 months, and 64% of children referred were male. Table 1 provides detailed descriptive and demographic information regarding participants and clinics.
Procedure
The data used in this study were collected in the process of usual administrative practices in the three integrated clinics. This procedure differed slightly across the three clinics regarding specific information collected, who made the patient contact, and documentation of phone contact. Each behavioral health specialist worked with the physicians on how to complete the referral form. Furthermore, clinic staff were trained in the procedure of maintaining the waiting list, contacting families, and scheduling appointments. In Clinics A and B, a form was created by BHC staff to facilitate physicians' referrals to the integrated behavioral health service. Data included on this form were date of referral, referral source, reason for referral, overall rating of problem severity, and rating of perceived parental stress. The form allowed children with a higher problem severity rating to be offered appointments first. In Clinic C, a medical staff member maintained a list of referrals that indicated the date of the referral, reason for referral, and insurance provider.
Once a referral was initiated, it was maintained on a waiting list until an opening became available and the scheduling nurse or staff person contacted the family to schedule the appointment. In Clinics A and B, the nurse noted whether she left a message, scheduled the initial appointment, or was unable to reach the family (e.g., no answer or phone disconnected). If the scheduling nurse was unable to reach the family after numerous attempts by phone, a follow-up protocol was used that included sending a letter requesting families to call the clinic if they were still interested in receiving services. In Clinic A, problem severity and time on the list determined the order in which referrals were called. Specifically, those patients with higher severity ratings and longer time on the list were contacted first. Clinics B and C contacted patients in the order in which they appeared on the list.
Once the family was scheduled for an initial appointment or a letter was sent, the referral form was filed so that all referrals were maintained together. All referral forms generated during the specified period were collected. Pertinent information from the referral form was transferred by a research assistant to a data collection form that captured the variables of interest.
Measures
The primary variable of interest for this study was whether referred children and their families attended initial appointments with the clinic's integrated behavioral health provider. Additional data were collected regarding whether an initial appointment was scheduled, length of time between referral and being offered an appointment, number of attempts to contact each family, physician rating of the severity of the referral problem, and reason for referral. The length of time the patient had to wait was calculated as the length of time between the referral date and the first recorded phone contact for an available appointment. The number of attempts to contact the family was determined by counting the total number of phone calls recorded on the referral form, including the date on which the appointment was scheduled. Severity of problem was based on physician rating of the child's functioning (ratings between 0 and 100, with higher ratings indicating greater impairment). A list of 31 potential reasons for referral was developed on the basis of physicians' written description of the problems being experienced by the child and his or her family. Reasons for referral for behavioral health intervention included attention deficit/ hyperactivity disorder, aggression, anxiety, elimination disorders, medical adherence, oppositional defiant disorder, sleep, and weight or feeding problems. These referral reasons are common problems seen by primary care physicians (Arndorfer, Allen, & Aljazireh, 1999).
Reliability
Reliability checks were conducted on the accuracy of transferring written information from the referral form to data collection form, calculations of age in months, and days to intake. Reliability data were calculated by dividing the number of agreements by the total number of agreements and disagreements. Reliability of data collection procedures was determined as follows: total agreements/total entries was 95% (2,166/2,271); reliability ratings ranged from 88% to 100%. All categories were 90% or higher, with the exception of one category (referral reason) that required some additional judgment in interpretation of physicians' notes.
RESULTS
Overall Attendance Rates
Across the three rural primary care offices, 807 children were referred to the integrated BHC. Of these referrals, 87.11% (N = 703) scheduled an initial appointment and 81% (N = 650) of all children and families attended the initial behavioral health visit (see Table 2 for each clinic's show rate and average days patients had to wait). Failure to keep scheduled initial appointments (N = 703) across the three clinics was 7.5% (N = 53). A significant difference across clinics was found for likelihood of attendance, [chi square](2, N = 802) = 18.1, p < .001. Pairwise comparisons revealed that Clinic B's show rates were significantly higher than those for either of the other two clinics (p < .001). Clinics A and C were not significantly different from each other.
Variables Associated With Attendance
A variety of additional variables were associated with the likelihood that a family would attend the initial behavioral health appointment. Children who had to wait longer periods of time before an appointment was offered were less likely to attend, t(724) = 5.82, p < .001. Families who did not attend the initial appointment waited an average of approximately 44 days as compared with approximately 24 days for those who attended.
For Clinics A and B, analyses were run regarding how many attempts were made to contact the family to schedule the initial appointment. Clinic C was not included because of a lack of reliable data on scheduling attempts. Families who attended initial appointments had significantly fewer scheduling attempts, t(660) = 6.53, p < .001. Thus, those who had to be contacted numerous times were less likely to attend the initial appointment, with 2.62 average attempts as compared with 1.72. These contacts typically involved leaving a message for the family, receiving no answer at the telephone number, and/or the family not being able to make the offered appointment time.
Patient Factors Affecting Attendance
Chi-square analyses did not reveal differences in likelihood of attendance on the basis of either child's age or child's gender. The average number of reasons for referral for behavioral health services for all cases was 1.82, with a range of 1-6. Children who attended the initial appointment had significantly more referral reasons, t(770) = -2.69, p < .007. The average number of referral reasons for children who attended was 1.87 as compared with 1.64 for those who did not attend the initial appointment.
The top 10 referral reasons are listed in Table 3. Each of the 31 referral reasons was examined to determine whether certain referral reasons increased or decreased the likelihood of attendance. According to Fisher's exact test (two-sided), those referred for aggression (p < .05), noncompliance (p < .05), problems with a family member (p < .001), and peer problems (p < .053) were more likely to show than those who were not referred for these reasons. However, those referred for a mood (p < .05) or anxiety problem (p < .01) were less likely to attend an initial behavioral health outpatient session.
Physician Rating of Severity and Attendance
Physicians from Clinics A and B rated the severity of referral problems, with higher numbers indicating greater impairment of functioning. Children rated as more impaired by their physician were more likely to attend the initial appointment, t(606) = -2.67, p < .01. The average severity rating was 57.57 for those who attended the initial appointment as compared with 53.28 for those who did not. Furthermore, a significant correlation between physician's ratings of the severity of a child's problem and total number of referral reasons was also found (r = .085, p < .05). However, physicians' ratings of parental stress did not impact the likelihood of attendance to the initial appointment.
DISCUSSION
Overall, these findings show that a high percentage of physician referrals follow through and attend initial appointments. Variables related to the likelihood that a family showed for an initial appointment included shorter wait times before being offered an appointment, fewer attempts by staff to contact the family, having an externalizing referral problem, and having more severe behavior problems as rated by the referring physician.
The most significant finding from this study was that the majority (81%) of referrals made by a rural primary care physician to a behavioral health provider integrated into the practice were attended by children and families. These results are significantly greater than those in the literature (Briggs-Gowan et al., 2000), in which rates of attendance for nonintegrated community behavioral services have been reported at 46.8% for urban practices. Furthermore, for those who scheduled an appointment, only a few (7.5%) failed to keep that visit. This is far less than documented in previous literature (Hampton-Robb et al., 2003). Thus, primary care physicians in rural settings could expect that if they refer a child for behavioral health services and there is an on-site provider in the practice, the family is highly likely to attend at least the initial visit.
Although families are more likely to attend the initial appointment in an integrated BHC, behavioral health providers should be aware of factors that might decrease attendance and should consider methods to address these challenges. First, findings from this study are consistent with previous research indicating that the longer individuals have to wait for services, the less likely they are to schedule and attend an initial appointment (Kruse & Rohland, 2002). Thus, it is important to try to offer appointments soon after referrals are made. This solution, however, may continue to be a challenge in rural areas that have limited mental health resources and significant behavioral health professional shortages.
Furthermore, it may be worthwhile to explore whether procedures could be developed to improve attendance for children with fewer referral problems, less impairment, or mood or anxiety disorders. In two of the integrated BHC settings that participated in this study, children rated as more severely impaired were offered appointments before children rated as less severely impaired, demonstrating a further advantage in that physicians have opportunity to triage more needy patients in an integrated care model.
A variety of reasons can be proposed as to why families are more likely to follow through with initial appointments for services when behavioral health is integrated into the primary care setting in rural communities. The first may have to do with access to care. Families may be more likely to go to the provider recommended by the physician because there are few, or no, other service options available. This hypothesis appears to be supported by Clinic B's having the best show rate. Of the three clinics, it was the most rural, most lacking in alternative services, and furthest from a major metropolitan area, and it had the largest rural 'catchment' area.
Second, having a behavioral health specialist on site allows physicians to involve these professionals in the referral process. Ultimately, these integrated linkages may provide improved continuity of care for children and families (Adair et al., 2005; Wagenfeld et al., 1994). Although attempts were made in these clinics to introduce families to the behavioral health specialist, a systematic process to ensure that families meet the behavioral health specialist may also increase the likelihood of attendance.
LIMITATIONS
Although this study is the first to report high attendance rates for children referred for integrated, onsite behavioral health services by their primary care physician, some caution should be exercised when interpreting the data. First, there was no control group referred by primary care physicians for off-site, community behavioral health services. It is possible that initial behavioral health appointment attendance for children and families is higher in rural areas versus other populations in urban areas.
Another potential explanation for why appointments both scheduled and attended were high for this sample may be due to primary care clinic staff contacting families to offer an appointment. Parents were not required to make the first contact to schedule an appointment. This procedure may have improved continuity of care regardless of the specific model or the use of integrated practices. This would be a viable question for future research in developing strategies to improve attendance.
This study lends itself to future directions regarding integrated behavioral health services in rural primary care. Specifically, future studies could compare attendance rates between primary care referrals made to integrated (in-house) versus community-based (out-of-house) behavioral health agencies. This information could provide important information as to whether providing integrated care leads to better access to and continuity of care. Furthermore, it would be important to explore whether attendance rates between rural and urban settings are different for integrated clinics. Future research could also explore the impact of primary care staff making initial attempts to schedule appointments versus having patients make the first attempt to schedule an appointment.
CONCLUSIONS
In conclusion, one compelling advantage of integrating behavioral health into primary care is the potential for better patient follow-through. Indeed, there are a variety of mechanisms that may foster this benefit, including (a) the use of the trusted primary care physician to introduce BHC referrals, (b) increased anonymity in attending visits, and (c) more ready access to behavioral health providers. In theory, each of these advantages should increase patient attendance following referral from a primary health care provider and should be examined in future research.
This study is the first to document initial attendance rates for colocated, collaborative behavioral health services in rural primary care settings for children. Although previous research with adults has demonstrated lower attendance for mental health services in rural communities, this study illustrates that attendance can be quite high for children when these services are provided within the primary care office. These data provide a starting point for comparing attendance rates of children at behavioral health services in colocated versus free-standing sites in rural and urban settings.
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RACHEL J. VALLELEY, PHD
STACY KOSSE, PHD
ARIADNE SCHEMM, PHD
NANCY FOSTER, PHD
JODI POLAHA, PHD
JOSEPH H. EVANS, PHD
Rachel J. Valleley, PhD, Stacy Kosse, PhD, Ariadne Schemm, PhD, Nancy Foster, PhD, and Joseph H. Evans, PhD, Munroe Meyer Institute, University of Nebraska Medical Center; Jodi Polaha, PhD, Department of Psychology, East Tennessee State University.
This research was supported in part by grant #D40HP02597 Graduate Psychology Education Grant, Bureau of Health Professions, Health Resources and Services Administration.
Special thanks to Robert Larzalere for assisting with data analysis and Mandy Volkmer for providing referral list for Clinic C.
Correspondence concerning this article should be addressed to Rachel J. Valleley, PhD, Munroe Meyer Institute, 985450 Nebraska Medical Center, Omaha, NE 68198-5450. E-mail: rvallele@unmc.edu
Table 1 Summary of Demographic Information Demographics Clinic A Clinic B No. of referrals 451 242 Dates coded 1/2002-12/2004 8/2003-2/2006 (24 months) (18 months) Children's age (years) M 7.7 7.51 Range 7 months- 13 months- 19 years 17.58 years Male n 273 169 % 61 73 Female n 174 61 % 39 27 No. of physicians 3 7 No. of physician's 1 0 assistants Type of clinic Pediatric Pediatric Population of clinic 24,064 27,431 city Days per week 4 2.5 behavioral health clinic operated Demographics Clinic C Total No. of referrals 114 807 Dates coded 1/2004-5/2005 (17 months) Children's age (years) M 9.9 7.94 Range 13 months- 7 months- 20.58 years 20.58 years Male n 67 509 % 59 64 Female n 47 282 % 41 36 No. of physicians 6 15 No. of physician's 2 3 assistants Type of clinic Family practice Population of clinic 7,228 city Days per week 2 behavioral health clinic operated Table 2 Attended Initial Appointment Percentage who Average days attended waiting for Clinics initial visit (n) appointment Range A 78.9 (352) 27.78 0-246 days (SD = 32.98) B 89.3 (216) 27.22 2-222 days (SD = 38.75) C 71.9 (82) 21.59 2-131 days (SD = 19.42) Overall 81 (650) 26.89 0-246 days (SD = 33.55) Table 3 Top Referral Reasons Referral reason N (%) Attention deficit/hyperactivity 184 (23.6) disorder Oppositional defiant disorder 180 (23.1) Behavior problems 178 (22.8) Aggression 103 (13.2) School problems 83 (10.7) Elimination 72 (9.2) Depression 49 (6.3) Sleep 49 (6.3) Medical 48 (6.2) Mental retardation 46 (5.9)
