Associations of Family-Centered Care with Health Care Outcomes for Children with Special Health Care Needs

The objective of this study is to examine the association of family-centered care (FCC) with specific health care service outcomes for children with special health care needs (CSHCN). The study is a secondary analysis of the 2005–2006 National Survey of Children with Special Health Care Needs. Receipt of FCC was determined by five questions regarding how well health care providers addressed family concerns in the prior 12 months. We measured family burden by reports of delayed health care, unmet need, financial costs, and time devoted to care; health status, by stability of health care needs; and emergency department and outpatient service use. All statistical analyses used propensity score-based matching models to address selection bias. FCC was reported by 65.6% of respondents (N = 38,915). FCC was associated with less delayed health care (AOR: 0.56; 95% CI: 0.48, 0.66), fewer unmet service needs (AOR: 0.53; 95% CI: 0.47, 0.60), reduced odds of ≥1 h/week coordinating care (AOR: 0.83; 95% CI: 0.74, 0.93) and reductions in out of pocket costs (AOR: 0.88; 95% CI: 0.80, 0.96). FCC was associated with more stable health care needs (AOR: 1.11; 95% CI: 1.01, 1.21), reduced odds of emergency room visits (AOR: 0.90; 95% CI: 0.82, 0.99) and increased odds of doctor visits (AOR: 1.25; 95% CI: 1.14, 1.37). Our study demonstrates associations of positive health and family outcomes with FCC. Realizing the health care delivery benefits of FCC may require additional encounters to build key elements of trust and partnership.     

Food Insecurity,Dietary Quality,and Health Care Utilization in Lower-Income Adults: A Cross-Sectional Study

BackgroundFood insecurity and poor nutrition are prevalent in the United States and associated with chronic diseases. Understanding relationships among food insecurity, diet, and health care utilization can inform strategies to reduce health disparities.ObjectiveOur aim was to determine associations between food security status and inpatient and outpatient health care utilization and whether they differed by dietary quality in lower-income adults.DesignThis was a cross-sectional study of data from the 2009-2016 National Health and Nutrition Examination Survey.Participants/settingParticipants were 13,956 lower-income (<300% federal poverty level) adults 18 years and older in the United States.Main outcome measuresSelf-reported health care utilization in the past 12 months included no usual source of care, any outpatient visit, any mental health service use, and any hospitalization.Statistical analysesMultiple logistic regression was used to study the association between food insecurity and health care utilization. Analyses were stratified by diet-related comorbidities to account for potential confounding and mediation of health care utilization, and by dietary quality.ResultsIn a sample of lower-income adults <300% federal poverty level, 4,319 participants (27.4%) were food insecure, 2,208 (15.0%) were marginally food secure, and 7,429 (57.6%) were food secure. Food insecurity was associated with having no usual source of care (adjusted odds ratio [aOR] 1.30; 95% CI 1.11 to 1.52), any mental health service use (aOR 2.02; 95% CI 1.61 to 2.52), and any hospitalization (aOR 1.19; 95% CI 1.01 to 1.41). Food-insecure adults were more likely to report no outpatient visits if they had diet-related comorbidities (aOR 1.45; 95% CI 1.10 to 1.92) or the lowest dietary quality (aOR 1.53; 95% CI 1.06 to 2.23). Marginal food security was associated with having no usual source of care (aOR 1.22; 95% CI 1.04 to 1.44).ConclusionsAdults with food insecurity were more likely to be hospitalized, use mental health services, and have no usual source of care. Food-insecure participants with diet-related comorbidities or poor diet were less likely to have outpatient visits. Hospitalizations and mental health visits represent underused opportunities to identify and address food insecurity and dietary intake in lower-income patients.     

Veterans Health Administration and Medicare Outpatient Health Care Utilization by Older Rural and Urban New England Veterans

CONTEXT: Older veterans often use both the Veterans Health Administration (VHA) and Medicare to obtain health care services. PURPOSE: The authors sought to compare outpatient medical service utilization of Medicare-enrolled rural veterans with their urban counterparts in New England. METHODS: The authors combined VHA and Medicare databases and identified veterans who were age 65 and older and enrolled in Medicare fee-for-service plans, and they obtained records of all their VHA services in New England between 1997 and 1999. The authors used ZIP codes to designate rural or urban residence and categorized outpatient utilization into primary care, individual mental health care, non-mental health specialty care, or emergency room care. FINDINGS: Compared with their urban counterparts, veterans living in rural settings used significantly fewer VHA and Medicare-funded primary care, specialist care, and mental health care visits in all 3 years examined (P<.001 for all). Compared with urban veterans, veterans living in rural settings used fewer VHA emergency department services in 1998 and 1999 but more Medicare-funded emergency department visits in 1997. The authors found some evidence of substitution of Medicare for VHA emergency visits in rural veterans, but no other evidence of like-service substitution. Rural veterans were more reliant on Medicare for primary care and on VHA services for specialty and mental health care. CONCLUSIONS: These findings suggest that rural access to federally funded health care is restricted relative to urban access. Older veterans may choose different systems of care for different health care services. With poor access to primary care, rural veterans may substitute emergency room visits for routine care.     

High rates of primary care and emergency department use among injection drug users in Vancouver

BACKGROUND: Frequent use of emergency rooms by injection drug users (IDUs) has been attributed to a lack of access to primary care and barriers to health services. Using a community-based sample of IDUs, we examined rates of primary care and emergency room use among IDUs and identified correlates of frequent emergency department use. METHODS: From January to November 2003, we enrolled IDUs into a prospective cohort study involving a baseline questionnaire, comprehensive retrospective and prospective health record linkages. We examined rates of primary care and emergency department utilization, and diagnoses upon arrival in the emergency room. Logistic regression was used to determine factors independently associated with frequent emergency room use. RESULTS: Of the 883 IDUs included in this analysis, 687 (78 per cent) accessed a primary care clinic in the previous year, while 528 (60 per cent) participants accessed the emergency room (ER) during the years 2002 and 2003. Abscesses, cellulitis and other skin infections accounted for the greatest proportion of ER use. Factors independently associated with frequent ER use included: frequent crystal methamphetamine injection (AOR = 2.4, 95 per cent CI: 1.0-5.6); non-fatal overdose (AOR = 2.1, 95 per cent CI: 1.4-3.3); HIV-positive status (AOR = 1.5, 95 per cent CI: 1.1-2.1), having been physically assaulted (AOR = 1.5, 95 per cent CI: 1.1-2.1); and primary care utilization (AOR = 1.5, 95 per cent CI: 1.0-2.1). DISCUSSION: high rates of ER use were observed among IDUs, despite high rates of primary care use among this same population. ER use was due primarily to preventable injection-related complications that are less amenable to primary care interventions, and therefore educational and prevention efforts that encourage and enable sterile injection practices should be promoted.     

School-Based Health Center Access,Reproductive Health Care,and Contraceptive Use Among Sexually Experienced High School Students

PurposeThe current analyses compared receipt of reproductive health care, contraceptive use, and screening for sexually transmitted diseases (STD) among adolescents who are sexually experienced, with or without access to a school clinic.MethodsA total of 12 urban California high schools, selected from areas with high teen pregnancy and STD rates, half with school-based health centers (SBHCs), participated in an intervention study designed to improve sexual health among adolescents. Of the participating students, 44% indicated that they had ever had intercourse and were included in these analyses.ResultsAccess to an SBHC did not influence receipt of reproductive health care for either males or females and did not influence contraceptive use, either hormonal or condoms, for males. For females, however, those with access to an SBHC had increased odds of having received pregnancy or disease prevention care (adjusted odds ratio [AOR] = 1.45, 95% confidence interval [CI] = 1.16–1.80), having used hormonal contraceptives at last sex (AOR = 1.68, 95% CI = 1.24–2.28), and were more likely to have ever been screened for an STD (AOR = 1.85, 95% CI = 1.43–2.40). Also among female students, those with access to an SBHC were more likely to have used emergency contraception at last sex (AOR = 2.1, 95% CI = 1.08–4.22).ConclusionAlthough access to an on-site clinic does not seem to lead to increases in all types of reproductive care in the population as a whole, sexually active females are more likely to have received more specific care and to have used hormonal contraceptives if their school has an SBHC.     

Health Care Utilization and Costs Associated with Physical and Nonphysical-Only Intimate Partner Violence

Objective. To estimate health care utilization and costs associated with the type of intimate partner violence (IPV) women experience by the timing of their abuse.
Methods. A total of 3,333 women (ages 18–64) were randomly sampled from the membership files of a large health plan located in a metropolitan area and participated in a telephone survey to assess IPV history, including the type of IPV (physical IPV or nonphysical abuse only) and the timing of the abuse (ongoing; recent, not ongoing but occurring in the past 5 years; remote, ending at least 5 years prior). Automated annual health care utilization and costs were assembled over 7.4 years for women with physical IPV and nonphysical abuse only by the time period during which their abuse occurred (ongoing, recent, remote), and compared with those of never-abused women (reference group).
Results. Mental health utilization was significantly higher for women with physical or nonphysical abuse only compared with never-abused women—with the highest use among women with ongoing abuse (relative risk for those with ongoing abuse: physical, 2.61; nonphysical, 2.18). Physically abused women also used more emergency department, hospital outpatient, primary care, pharmacy, and specialty services; for emergency department, pharmacy, and specialty care, utilization was the highest for women with ongoing abuse. Total annual health care costs were higher for physically abused women, with the highest costs for ongoing abuse (42 percent higher compared with nonabused women), followed by recent (24 percent higher) and remote abuse (19 percent higher). Women with recent nonphysical abuse only had annual costs that were 33 percent higher than nonabused women.
Conclusion. Physical and nonphysical abuse contributed to higher health care utilization, particularly mental health services utilization.     

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

IntroductionFew studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.MethodsIn a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient–provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.ResultsA greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01–1.10), provider communication (AOR, 1.08; 95% CI, 1.002–1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02–1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88–0.99).ConclusionFor the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.     

Characterization and Comparison of Physical and Mental Health Profiles and Department of Veterans Affairs Health Care Utilization Patterns among Operation Iraqi Freedom/Operation Enduring Freedom Women Veterans in Puerto Rico versus the United States

BackgroundResearch on the physical and mental health profiles and patterns of health care use among women veterans receiving health care from the Department of Veterans Affairs (VA) on the island of Puerto Rico is lacking.MethodsThis cross-sectional study examines differences in physical and mental health conditions, and patterns of VA health care use, between women veterans of the Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) era who were using VA facilities in Puerto Rico (n = 897) and those using U.S.-based VA facilities (n = 117,216) from 2002 to 2015.ResultsResults of fully adjusted logistic regression models revealed that OIF/OEF women in Puerto Rico had heightened risk for global pain-related disorders (i.e., any pain) (adjusted odds ratio [AOR], 1.45; 95% confidence interval [CI], 1.22–1.71), back pain (AOR, 1.83; 95% CI, 1.56–2.14), diabetes (AOR, 1.42; 95% CI, 1.03–1.95), hyperlipidemia (AOR, 3.34; 95% CI, 2.80–3.98), major depression (AOR, 1.78; 95% CI, 1.53–2.06), and bipolar depression (AOR, 1.66; 95% CI, 1.34–2.04). They also evidenced greater risk for a host of reproductive health conditions and had higher average annual use of VA health care than their U.S. counterparts.ConclusionsOIF/OEF women receiving VA health care in Puerto Rico evidenced a greater burden of physical illness, depression, and heightened use of VA health care services relative to their U.S. counterparts. Providers’ increased awareness of the physical and mental health care needs of this population is warranted. Research efforts that help to identify efficient and effective strategies to provide culturally tailored and/or personalized health care for this population could also be useful.     

Primary Care,Economic Barriers to Health Care,and Use of Colorectal Cancer Screening Tests Among Medicare Enrollees Over Time

PURPOSE Colorectal cancer (CRC) screening remains underutilized. The objective of this study was to examine the impact of primary care and economic barriers to health care on CRC testing relative to the 2001 Medicare expansion of screening coverage.METHODS Medicare Current Beneficiary Survey data were use to study community-dwelling enrollees aged 65 to 80 years, free of renal disease and CRC, and who participated in the survey in 2000 (n = 8,330), 2003 (n = 7,889), or 2005 (n = 7,614). Three outcomes were examined: colonoscopy/sigmoidoscopy within 5 years (recent endoscopy), endoscopy more than 5 years previously, and fecal occult blood test (FOBT) within 2 years.RESULTS Endoscopy use increased and FOBT use decreased during the 6-year period, with no significant independent differences between those receiving care from primary care physicians and those receiving care from other physicians. Beneficiaries without a usual place of health care were the least likely to undergo CRC testing, and that gap widened with time: adjusted odds ratio (AOR) = 0.27 (95% confidence interval [CI], 0.19–0.39) for FOBT, and AOR = 0.35 (95% CI, 0.27–0.46) for endoscopy in 2000 compared with AOR = 0.18 (95% CI, 0.11–0.30) for FOBT and AOR = 0.22 (95% CI, 0.17–0.30) for endoscopy in 2005. Disparities in use of recent endoscopy by type of health insurance coverage in both 2000 and 2005 were greater for enrollees with a high school education or higher than they were for less-educated enrollees. There were no statistically significant differences by delayed care due to cost after adjustment for health insurance.CONCLUSION Despite expanding coverage for screening, complex CRC screening disparities persisted based on differences in the usual place and cost of health care, type of health insurance coverage, and level of education.     

Intimate Partner Violence and Health Care-Seeking Patterns Among Female Users of Urban Adolescent Clinics

To assess the prevalence of intimate partner violence (IPV) and associations with health care-seeking patterns among female patients of adolescent clinics, and to examine screening for IPV and IPV disclosure patterns within these clinics. A self-administered, anonymous, computerized survey was administered to female clients ages 14–20 years (N = 448) seeking care in five urban adolescent clinics, inquiring about IPV history, reasons for seeking care, and IPV screening by and IPV disclosure to providers. Two in five (40%) female urban adolescent clinic patients had experienced IPV, with 32% reporting physical and 21% reporting sexual victimization. Among IPV survivors, 45% reported abuse in their current or most recent relationship. IPV prevalence was equally high among those visiting clinics for reproductive health concerns as among those seeking care for other reasons. IPV victimization was associated with both poor current health status (AOR 1.57, 95% CI 1.03–2.40) and having foregone care in the past year (AOR 2.59, 95% CI 1.20–5.58). Recent IPV victimization was associated only with past 12 month foregone care (AOR 2.02, 95% CI 1.18–3.46). A minority (30%) reported ever being screened for IPV in a clinical setting. IPV victimization is pervasive among female adolescent clinic attendees regardless of visit type, yet IPV screening by providers appears low. Patients reporting poor health status and foregone care are more likely to have experienced IPV. IPV screening and interventions tailored for female patients of adolescent clinics are needed.     

The Impact of Intimate Partner Violence on the Mental Health of Pregnant Women Residing in Slum Areas: A Cross-Sectional Study

Background

Intimate partner violence is one of the most common types of violence, and the association between intimate partner violence and mental health has serious implications for public health. This article aimed at investigating the impact of IPV on the mental health of pregnant women who reside in slum areas.

Methods

A group of 456 women living in slum areas was investigated. The Conflict Tactics Scale was used to measure the respondent’s experience of different types of IPV during the past year. General Health Questionnaire-28 was used to measure the likelihood that an individual had a psychiatric disorder.

Results

A total of 456 pregnant women aged ≥ 20 years were interviewed using a shortened version of the Conflict Tactics Scale and the General Health Questionnaire. All types of intimate partner violence were found to be associated with various mental health problems (p < 0.05). Overall, physical (AOR: 3.61; 95% CI 2.11–6.17) and sexual (AOR: 1.72; 95% CI 1.01–2.94) violence increased the odds of probable psychiatric disorders in victims compared with their counterparts who had not experienced such types of violence.

Conclusions

Further research is needed on the relationship between intimate partner violence and other mental health problems, protocols to screen for intimate partner violence in healthcare settings, and supportive services.

     

Long-term effectiveness of the ACCESS program in linking community mental health services to homeless persons with serious mental illness

This study examined the long-term effectiveness of the ACCESS (Access to Community Care and Effective Services and Supports) project on service utilization and continuity of care among homeless persons with serious mental illness. A 3-year longitudinal analysis, using Medicaid claims data, tracked behavioral health service utilization among 146 Medicaid-eligible participants in the Pennsylvania ACCESS program. Utilization patterns of inpatient, outpatient, and emergency department services for psychiatric and substance abuse treatment were examined during the year prior to, during, and one year after the implementation of the ACCESS project. Use of psychiatric ambulatory care significantly increased among intervention participants and remained greater following ACCESS intervention. Better continuity of care following hospitalization was achieved during and after the intervention. The number of days spent hospitalized significantly decreased during the intervention. These results suggest that the ACCESS intervention was effective in linking hard-to-reach homeless persons with serious mental illness to the community mental health service system, and that this effect was maintained after termination of the intervention.     

Collaborative Care: a Pilot Study of a Child Psychiatry Outpatient Consultation Model for Primary Care Providers

A Child Psychiatry Consultation Model (CPCM) offering primary care providers (PCPs) expedited access to outpatient child psychiatric consultation regarding management in primary care would allow more children to access mental health services. Yet, little is known about outpatient CPCMs. This pilot study describes an outpatient CPCM for 22 PCPs in a large Northeast Florida county. PCPs referred 81 patients, of which 60 were appropriate for collaborative management and 49 were subsequently seen for outpatient psychiatric consultation. The most common psychiatric diagnoses following consultation were anxiety (57%), ADHD (53%), and depression (39%). Over half (57%) of the patients seen for consultation were discharged to their PCP with appropriate treatment recommendations, and only a small minority (10%) of patients required long-term care by a psychiatrist. This CPCM helped child psychiatrists collaborate with PCPs to deliver mental health services for youth. The CPCM should be considered for adaptation and dissemination.     

The Effect of a Housing First Intervention on Acute Health Care Utilization among Homeless Adults with Mental Illness: Long-term Outcomes of the At Home/Chez-Soi Randomized Pragmatic Trial

We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. Each group was randomized into intervention (HF) and treatment as usual groups, and 567 (98.6%) consented to link their data to health administrative databases. HF participants received a monthly rent supplement of $600 (Canadian) and assertive community treatment (ACT) support or intensive care management (ICM) support based on need level. Treatment as usual (TAU) participants had access to social, housing, and health services generally available in the community. Outcomes included all-cause and mental health-specific hospitalization, number of days in hospital, and ED visit. We used GEE models to estimate ratio of rate ratios (RRR). The results showed HF with ACT had no significant effect on hospitalization rates among HN participants, but reduced the number of days in hospital (RRR = 0.32, 95% CI 0.16-0.63) and number of ED visits (RRR = 0.57, 95% CI 0.34-0.95). HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-021-00550-1.     

Mental Health Screening of Adolescents in Pediatric Practice

This study examines routine computerized mental health screening for adolescents scheduled for a routine physical examination in a group pediatric practice. Medical records of adolescents aged 13 to 17 who were offered screening (n = 483) were reviewed. Approximately 44.7% (95% confidence interval (CI) 40.3–49.2) were screened, and 13.9% (95% CI 9.3–18.5) were identified as being at risk. Screening was associated with significantly increased odds of receiving either pediatric mental health care or a referral for specialty mental health care (adjusted odds ratio (AOR): 2.6 95% CI 1.2–5.6). Among patients who received either mental health intervention, those who were screened were significantly more likely to be referred to specialty care (AOR: 15.9 95% CI 2.5–100.4), though they were less likely to receive pediatric mental health care (AOR: 0.10 95% CI 0.02–0.54). The findings support the feasibility of routine mental health screening in pediatric practice. Screening is acceptable to many parents and adolescents, and it is associated with referral for specialized mental health care rather than care from the pediatrician.     

Primary care for low-income populations: comparing health care delivery systems

Amidst recent policy discussions about the health care safety net there has been relatively little information about whether the actual site of care affects care quality. We therefore used National Health Interview Survey data to describe low-income adults seeking primary care at different types of sites and the quality of access and preventive care at these sites. After adjusting for sociodemographic characteristics and illness burden, hospital-outpatient- department patients were more likely to receive vaccinations for influenza (adjusted odds ratio [AOR] 1.3, 95% confidence interval [CI] 1.0-1.6) and pneumococcus (AOR 1.4, 95% CI 1.1-1.8) than were those at clinics or health centers. Hospital-clinic patients were more likely to report delays in care due to office administrative difficulties (AOR 1.3, 95% CI 1.1-1.7) and more likely to have more than one emergency room visit (AOR 1.9, 95% CI 1.5-2.3). Physicians' office or HMO patients were less likely to report administrative delays in care than those at clinics or health centers, but there were no other differences in quality between these two site types. Policymakers and health care services analysts and providers must monitor quality as they decide how best to deliver care to vulnerable populations.     

Unmet Health Care Needs Among Children with Special Health Care Needs Enrolled in Tricare

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy access to care for children with military health benefits, particularly children with special health care needs (CSHCN). The objective of this study was to compare the health care experiences of CSHCN in TRICARE with those of CSHCN with other sources of health insurance. A cross-sectional analysis comparing unmet health care needs among CSHCN with TRICARE versus CSHCN with other sources of health insurance using nationally representative data from three years of the National Survey of Children’s Health (NSCH), 2016-2018. The NSCH includes a broad range of questions related to child health and health care to provide national level estimates, and the data allow for comparisons between insurance coverage groups and TRICARE. The survey data contain responses from over 100,000 parents or primary caregivers (parents) of children, representative of over 73 million children annually. This includes 804 children who were representative of approximately 367,000 CSHCN covered by TRICARE annually. Children with special health care needs. Overall, 21 percent (95% CI 19-24 percent) of parents of children covered by TRICARE reported their child had a special health care need, compared to 16 percent of children with commercial insurance (95% CI 15-16 percent) and 24 percent of children with public insurance (95% CI 23-25 percent). Eight percent of parents of CSHCN covered by TRICARE (95% CI 4-16 percent) reported any unmet health care needs in the prior 12 months, compared to 4 percent of CSHCN with private insurance (95% CI 4-5 percent) and 9 percent of CSHCN with public insurance (95% CI 8-11 percent). Among specific needs, 3 percent or fewer CSHCN covered by TRICARE had unmet needs for medical, dental, vision, hearing, or mental health care. Similarly, 5 percent or fewer reported difficulty or delays in getting services because of eligibility for coverage of the service, availability in the area, difficulty in getting an appointment, or cost. About 11 percent of parents of CSHCN covered by TRICARE reported usually or always being frustrated in getting needed services for their child during the prior 12 months, compared to 4 percent of those with private insurance and 9 percent of those with public insurance. About 12 percent of parents of CSHCN covered by TRICARE reported problems with paying for their child’s health care needs in the prior 12 months, compared to 23 percent of those with private insurance and 8 percent of those with public insurance. TRICARE is largely meeting the needs of the CSHCN for whom it provides benefits, but there are opportunities for improvement. CSHCN in TRICARE face higher rates of unmet needs than privately insured children, and their parents face higher levels of frustration in getting needed services. TRICARE should continue to work with families of CSHCN to identify specific unmet needs and sources of frustration with getting needed services.     

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

Publicly insured children needing referral to mental health (MH) services often do not access or receive services. The objective of this study was to identify gaps in communication and coordination between primary care providers (PCPs) and MH providers during the MH referral and care process for publicly insured children. Thirteen semi-structured interviews were conducted with 10 PCPs and staff from a federally qualified health center (FQHC) and 6 MH providers and staff from two local MH clinics. Interview participants identified multiple gaps in communication throughout the care process and different phases as priorities for improvement. PCPs described primary care-MH communication challenges during early phases, while MH providers described coordination challenges in transferring patients back to primary care for ongoing mental health management. Strategies are needed to improve primary care-specialty MH communication and coordination throughout all phases of the referral and care process, particularly at initial referral and transfer back to primary care.