Phone Consultation for Behavioral Health–Related Referrals in Integrated Primary Care

Abstract

Behavioral health (BH) providers add value to primary care teams. This descriptive study illustrates one such role that the BH provider can serve. The on-site BH provider responded to patient phone inquiries regarding BH topics for pediatricians over the course of 15 months. The majority of these calls were for children 10 years and younger and related to externalizing problems. Phone calls were relatively brief (ie, 11-15 minutes). More than half of these phone calls resulted in families scheduling an appointment with nearly 75% showing up for the initial session. Providing this type of adjunctive service may result in earlier access to care and efficiently assigning responsibilities to the appropriate team member.

Telephone triage services are commonly used to connect patients and medical staff in pediatric primary care (PC). ¹ When caregivers call a pediatric practice these concerns can include a behavioral health (BH) topic. ² This is especially true since pediatricians report that BH-related concerns are the most common problems seen in their practice and are commonly the first professionals with whom caregivers consult about these concerns. ³ Unfortunately, pediatricians spend more than twice as much time and are reimbursed significantly less for appointments during which BH concerns are discussed ⁴ ; thus, returning phone calls regarding BH concerns likely are viewed as time-consuming and inefficient.

Since integration of BH services into PC improves patient access to mental health services, decreases wait time to see BH providers, and increases communication among care teams, ⁵ another role that BH providers can play is providing intermediate responses to phone call inquiries from caregivers regarding BH concerns. BH professionals fielding these types of phone calls may allow medical staff to triage calls to appropriate professionals, thus allowing for minor concerns to be handled over the phone in an efficient manner. Also, given that families who wait longer between the referral and the intake appointment are less likely to attend the BH appointment, ⁶ an intermediate phone response service allows patient concerns to be addressed sooner and may increase the likelihood of appointment compliance.

There is little recent research investigating the impact of an adjunct phone response service that provides general recommendations related to BH concerns. One study ² found that caregivers were satisfied with BH call-in services addressing common concerns such as toileting, conduct problems, anxiety, and sleep. The current descriptive study extends this research by collecting data at a PC practice through which a psychologist provided brief phone consultation for BH concerns.

Method

Participants and Setting

The pediatric primary care clinic (PPCC) housed seven pediatricians and was located within a suburban area of Nebraska. The PPCC was selected because of the presence of a pediatric psychologist faculty member from the University of Nebraska Medical Center (first author) who had been integrated into the PPCC for four years. Patients with BH concerns were referred by their pediatrician to the psychologist who used clinic space for outpatient services 2 days per week. Participants included those patients who called the PPCC regarding a BH concern over a 15-month period and who received a return call from the psychologist. Pediatricians determined which BH call referrals were appropriate for the psychologist. However, no information was available on how many BH calls pediatricians or nurses made during this time.

Measures

Primary variables of interest included patient age and gender, length of phone call, concern, recommendations given, follow-up, and show rate for those patients scheduling a session. Length of call was recorded by the psychologist rounded to the nearest minute. A maximum of 3 BH concerns were recorded for each phone call. Additionally, these concerns were categorized as (a) internalizing (anxiety and depressive mood concerns), (b) externalizing (oppositional behavior problems and attention deficit/hyperactivity disorder–related concerns), (c) activities of daily living (ADLs; sleep, eating, and toileting), or (d) other (developmental disabilities and autism, adjustment issues, school problems, health, social problems).

The outcome of each phone call was coded as (a) the caregiver scheduled a BH appointment, (b) the psychologist gave recommendations over the phone, (c) the psychologist gave recommendations over the phone and scheduled an appointment with the patient, (d) parent indicated they would call back if interested in services, (e) the psychologist left a message for the caregiver with instructions on how to schedule an appointment and the caregiver subsequently scheduled an appointment, or (f) the psychologist left a message with no return call from the caregiver.

Procedure

At the PPCC, calls were routed by the pediatrician or nurses through the electronic chart program. The psychologist typically called families within a few days after receiving the message (mean = 1.23 days, range = 0-5 days) and documented the phone call in the patient’s electronic chart and a phone log for research protocol records. The psychologist did not provide phone consultation for cases involving suicidal ideation due to the psychologist not being on site every day. Pediatricians and nurses completed a suicide risk assessment and made treatment recommendations based on this information (eg, call 911, go to emergency department, lock- up sharp objects). Data were not available for these calls due to them not being handled by the psychologist. For each case, conversations included only the psychologist and a single caregiver.

Results

Over the course of the 15 months, 57 phone calls were made to caregivers who had contacted their pediatrician with a BH concern. Of those 57, a majority of the patients were male. The mean age for patients receiving calls was 7.4 years. Table 1 provides patient demographics and call information.

Table 1.

Patient Demographics and Phone Call Information.

	n (%)
Gender
Male	42 (74)
Female	15 (26)
Age (years)
≤2	7 (12)
3-5	13 (23)
6-10	24 (42)
11-15	10 (18)
≥16	3 (5)
Length of call (minutes)
≤5	4 (11)
6-10	8 (21)
11-15	16 (42)
16-20	7 (18)
>20	3 (8)
Concerns
Externalizing	32 (56)
Internalizing	22 (39)
Activities of daily living	16 (28)
Other	15 (26)

Of the calls that included having a conversation with a caregiver (79%, n = 45), mean length of call was 13 minutes. The majority of the calls lasted between 11 and 15 minutes. Data were not collected on length of call for seven of these phone calls. Referral concerns addressed with the caregiver over the phone are shown in Table 1. Of the 57 cases, the majority of calls (56%) indicated some concern related to externalizing problems, 37% indicated internalizing problems, and 28% indicated concerns regarding ADLs.

A 1-way analysis of variance revealed no significant differences between behavioral health concern and length of call variables when all 4 behavioral health concern groups were included in the model. However, an independent-samples t-test was completed and revealed that phone calls involving internalizing concerns were significantly longer in comparison to calls involving externalizing concerns; t(35) = −2.12, P = .04. The mean length for calls involving internalizing concerns (mean = 11.1, SD = 8.8) took almost twice as long as those calls that involved externalizing concerns (mean = 6.0, SD = 5.8).

Of the 57 caregivers who received a phone call from the psychologist, 9 of the caregivers (16%) were left a message but did not return the call or schedule an appointment. Three of the cases (5%) involved the psychologist leaving a message with detailed instructions on how to schedule an appointment and the caregivers subsequently making an appointment. A majority of the participants overall made an appointment with the BH provider (56%, n = 32), with 25% of caregivers receiving specific recommendations and scheduling an appointment (n = 8), and 42% simply scheduling an appointment (n = 24) after being given a brief introduction to the treatment approach. Eight cases (14%) involved caregivers receiving specific recommendations without scheduling an appointment and 5 (9%) involved the caregivers indicating that they would like to call the psychologist back if they needed services.

Of the 37 patients who scheduled an appointment, 27 attended (73%). Fifty-seven percent (n = 21) of those that scheduled an appointment had concerns related to externalizing problems, 35% (n = 13) had concerns related to internalizing problems, and 27% (n = 10) had concerns related to ADLs.

Discussion

This service was provided to address concerns related to medical care staff returning calls that involved content outside of their expertise and were often an inefficient use of time. BH providers are specifically trained to handle a wide variety of concerns, and while past research has established the value of integrated PC, the value of an adjunct phone service is still emerging. These results promote this type of service for a number of reasons. For instance, a majority of the phone calls resulted in the family scheduling an appointment with the psychologist; thus, assisting families in accessing BH services. Furthermore, a majority of those families that scheduled showed for their appointment, suggesting that having contact with a BH provider results in strong show rates.

A majority of calls were relatively short in duration (eg, 11-15 minutes). While this time would be considered an inefficient use of medical provider time, given that most medical appointments last 10 to 16 minutes, ⁷ it is a relatively short amount of time for BH providers in comparison to typical hour-long BH intake assessments. If presenting problems can be resolved within 15 minutes over the phone, patients would not have to make an appointment, allowing BH providers and pediatricians to serve more families. Handling internalizing concerns over the phone, however, often presents a higher degree of complexity and caregiver-clinician interaction (ie, assessment and treatment of cognitive processes as opposed to discrete behaviors). In the current study, these types of calls were found to take almost twice as long as those calls involving externalizing concerns.

Patients whose caregivers participated in phone calls also were relatively young (mean age = 7.4 years). Thus, if concerns cannot be addressed over the phone, presenting problems are still able to be addressed at an early age. When adding this information to the research that suggests integration of BH providers into PC lessens wait time,^4,6,8 this service allows for concerns to be addressed sooner in the child’s development.

More than one quarter of calls indicated difficulties with ADLs. These data relate to past research showing BH providers successfully addressing toileting and sleep behaviors over the phone. ² this type of service may be particularly amenable to common problems relating to ADLs given a long history of success with brief, straightforward interventions that may be easily specified over the phone.^9,10

This descriptive study has notable limitations. This service was delivered in 1 PPCC by 1 provider, limiting the generalizability. Preliminary statistical analyses did not show any significant relationships amongst variables, most likely because of the fact that this was small-n clinical sample. Unfortunately, this limits our ability to specify which variables are positively impacted by this phone response service in comparison to not contacting caregivers. Future researchers should investigate the direct effects of this service, including (a) whether this service increases the likelihood of attendance, (b) what relationships exist between the referral concern and the outcome of the phone call, and (c) the success rates of recommendations given over the phone.