Using Telehealth to Deliver Mental Health Services in Primary Care Settings for Children in Underserved Areas

There are three main parts to the basic template of this telehealth intervention:

1. Real-time videoconference patient visits. Patients who need a specialty visit with a
developmental/behavioral pediatrician will be scheduled for a telehealth visit (with the
patient at the primary care clinical site and the subspecialists located at a University
of California, Los Angeles (UCLA) telehealth site). Patients who need a psych/MH
referral will initially connect with the mental health clinic (MHC) via telehealth.
Therapy visits and the initial psychiatric assessment for medications are in person.
Follow up psychiatric visits are via telehealth.

2. Enhanced clinician communication and patient coordination. Providers will use telehealth
capabilities to communicate with each other about patient care and coordination issues,
including diagnostic decisions, management strategies, and other patient care
coordination activities.

3. Clinical educational sessions for clinicians. The telehealth equipment will also be used
for real-time videoconference educational sessions to help primary care clinicians and
specialty care clinicians share knowledge and experience that can translate into greater
improvements for patient care.

The investigators will compare the new customized telehealth-based patient visit,
coordination, and clinician education system to the usual in-person, community based referral
system at NEVHC. Patients scheduled for a telehealth visit will receive a phone reminder 2
days before the visit. The location of the telehealth visit will be at the same clinic
location as the index primary care provider (PCP) visit. Upon arrival for their telehealth
visit, parents will be sent to a typical patient encounter room at the clinical site. The
room will be set up for a telehealth visit with telehealth equipment, two chairs for the
parent(s) and a small table with chairs and toys for the child and any siblings that arrive
with the family. The camera will be set up to allow the specialty provider to have full view
of the examination room. The system uses a multifunctional camera with zoom and pan (side to
side) capabilities; the investigators will utilize a high-speed internet connection at NEVHC
for optimal connection speed.

A bilingual (Spanish and English) telehealth coordinator will greet the parents and
coordinate the visit at the NEVHC end. The telehealth coordinator is present at the NEVHC end
of the telehealth visit for the duration of the visit. The telehealth coordinator ensures
that the camera and microphones are operating correctly, positions the camera as necessary,
conducts a volume and vision check, and as the exam proceeds, provides Spanish language
interpretation if necessary.

The clinical encounter proceeds as a typical "in-person" encounter.

The developmental behavioral services in the telehealth-based patient visit will be provided
by a developmental behavioral pediatrician (DBP) housed at UCLA from Children's Hospital Los
Angeles (CHLA). The telehealth coordinator will call parent to inform parents of their DBP
appointment date/time and will explain the telehealth visit.

The mental health services will be performed by psychiatrists at CFGC and CFC. The telehealth
specialty physician will conduct the typical history, review of information brought by the
parent to the visit, focused behavioral observations, and a general visual inspection, with
assistance from the telehealth coordinator on the distal end. At the end of the visit, the
telehealth coordinator will assist the physician in setting up any follow-up plans with the
family. The telehealth coordinator will then prepare for the next scheduled patient.

The other two components of the telehealth system include clinical educational sessions and
clinician communication and patient coordination sessions. As part of our ongoing stakeholder
engagement process, the investigators will hold a telehealth primary care-mental health
educational session via videoconference monthly. These sessions are topic-based webinars and
case-based educational sessions for the transfer cases. Sessions will alternate between
webinars and case-based educational sessions. The session will include the child
psychiatrist(s), and the NEVHC PCPs; each session will be held during the clinic's lunch hour
for about 45 minutes, based on the NEVHC PCP availability. There will be 9 topic-based
webinar sessions during the intervention period. The first 4 sessions will focus on referral
indications and recommendations for the most common child MH symptoms. Topics include:
guidelines for referral to CFGC/CFC (e.g., when not to refer), diagnosis and management of
attention deficit hyperactivity disorder, anxiety, and depression, and diagnostic criteria
for Oppositional Defiant Disorder and PTSD. the investigators will also conduct some sessions
on primary care topics (e.g., anorexia nervosa) for mental health providers.

Inclusion Criteria:

- Parent or guardian with child between the ages of 5 to 12

- Must speak English or Spanish

- Child has been referred by primary care doctor for mental health or developmental
behavioral services

Exclusion Criteria:

- Parent /Guardian under 18 years of age

- Parent employed by Northeast Valley Health Corporation