Legislative Auditor's Conclusion:

Providers were satisfied with the consultation lines, which they said have improved patient access to mental and behavioral health care. The referral service has helped families find outpatient care, but it has struggled to meet timeliness goals and achieve statewide participation.

 

  
   
   

November 2022

Executive Summary

As directed by statute, UW and Seattle Children’s operate four phone lines for mental and behavioral health consultation and referral

Chapter 71.24RCWs 71.24.061-.068, the Community Behavioral Health Services Act, creates four phone lines for mental and behavioral health:

  • Three consultation lines connect health care providers with psychiatrists to discuss patient care.
  • A referral service identifies available providers for families whose children need outpatient mental or behavioral health care.

As directed by law, the University of Washington Department of Psychiatry & Behavioral Sciences (UW) and Seattle Children's (Children's) operate the lines under contract with the Health Care Authority. Between January 2019 and March 2022The Psychiatry Consultation Line (PCL) began in July 2019 and was fully operational in October 2019., the consultation lines served 9,600 providers in 38 counties. The referral service served over 6,700 families in 31 counties.

The 2020 Legislature directed the Joint Legislative Audit and Review Committee (JLARC) to evaluate the lines, including their ability to address access to care. Per RCW 44.28.076, JLARC staff must determine whether there are racial equity considerations directly related to each study mandate and scope. However, this study began prior to this requirement.

Three consultation lines connect health care providers with psychiatrists to discuss patient care, and a referral service identifies available mental or behavioral health providers for families whose children need care
•	The provider consultation lines allow providers to discuss patient’s mental or behavioral health issue with a consulting psychiatrist. 
              •	The Psychiatry Consultation Line (PCL) allows health care providers to call for adult patients 18 and over. It started in 2019, had 1,622 participants during the study period, and cost $6.8 million between fiscal year 2020 and 2022. The line is operated by the University of Washington. 
              •	The Perinatal Psychiatry Consultation Line (Perinatal PCL) allows health care providers to call for pregnant or postpartum patients of any age. It started in 2016 and was expanded in 2019, had 1,411 participants during the study period, and cost $1.2 million between fiscal year 2020 and 2022. The line is operated by the University of Washington. 
              •	The Partnership Access Line (PAL) allows health care providers to call for children aged 0 to 19 years old. It started in 2007, had 6,616 participants during the study period, and cost $2.3 million between fiscal year 2020 and 2022. The line is operated by Seattle Children’s. 
              •	The Family Referral Service provides a list of available outpatient mental or behavioral health providers. 
              •	The Mental Health Referral Service (MHRS) allows parents, guardians, or family members to call about children ages 0 to 17. It started in 2019, had 6,777 participants during the study period, and cost $2.6 million between fiscal year 2020 and 2022. The service is operated by Seattle Children’s.
Source: JLARC staff analysis of program records. Participants reflects total usage and not unique callers (e.g., some providers have used the consultation lines more than once).

293 providers

Gave feedback to JLARC staff about the consultation lines through:

  • Focus groups.
  • Online questionnaires.
  • Interviews.
  • Emails.
Photo of provider making a phone call.

Health care providers across Washington reported high satisfaction with the three consultation lines, which they said increased access to care

Health care providers who called the consultation lines reported that the consulting psychiatrists provided excellent, evidence-based advice. The providers appreciated being able to speak immediately or schedule a convenient time for consultation. Providers also noted that the lines allowed them to give reliable, same-day treatment to their patients. JLARC staff found no evidence of variation or disparities in satisfaction.

Providers reported the consultation lines increased their patients’ access to mental health care by reducing barriers. They also noted the lines helped address systemic health care access issues, such as the limited number of mental and behavioral health care providers in Washington. This feedback is consistent with published research and other surveys conducted by UW and Children's.

Families reported general satisfaction with the referral service. However, they were less satisfied with timeliness and access to care.

The referral process has five steps. Families that used the service reported that they were generally satisfied with each step. However, families were less satisfied with the amount of time between steps in the referral process. For example, 77% were satisfied with their appointment with a referral specialist, but only 26% were satisfied with the time from their initial call until the appointment. Family satisfaction did not differ significantly by race, ethnicity, language spoken, or location.

Most families (91%) received a referral letter with a list of providers from the service. Of those surveyed, 73% agreed that the list was consistent with their request and 62% reported that it helped them access care. The families choose whether to make an appointment with a listed provider. Families may face additional barriers to access outside of the control of the referral service, such as income, insurance coverage, or personal considerations (e.g., language, perceived stigma).

•	The referral service has five process steps. Families contact the referral service, schedule a referral appointment, meet with a referral specialist, receive a list of providers, and respond to a follow up call. 
              •	Families are satisfied with referral service process steps. 
              o	73% are satisfied with operating hours
              o	80% are satisfied with discussion to schedule a referral appointment 
              o	77% are satisfied with discussion with referral specialist
              o	73% agree the list of providers was consistent with their request
              o	82% are satisfied with follow up call
              •	Families are less satisfied with referral service timeliness. 
              o	48% are satisfied with time to receive a call back to schedule a referral appointment 
              o	26% are satisfied with time from calling referral service to having a referral appointment 
              o	32% are satisfied with time to receive a list of providers
Source: JLARC staff survey of families using the referral service in 2021. Total respondents: 1,607.

The referral service struggles to meet the statutory requirement to send referral letters within an average of seven days. Referral service participants are primarily from Western Washington.

State law requires Children's to send a referral letter within an average of seven days after the family meets with a referral specialist. Since 2019, only 28% of families received a letter within seven weekdays. The average time to send a letter was 17 weekdays. Children's cited rising demand, staffing shortages, and provider availability as factors affecting its ability to meet timeliness goals.

Although the referral service is available to families across Washington, 97% of calls were from families in Western Washington counties. It is unclear why families in Eastern Washington are underrepresented in the referral service data.

Legislative Auditor Recommendation

HCA and Children's should develop a plan to meet statutory and contractual timeliness requirements for the referral service and investigate disproportionately low participation from Eastern Washington families.

HCA, Seattle Children's, and OFM concur with this recommendation. You can find additional information in Recommendations.

Committee Action to Distribute Report

On November 30, 2022 this report was approved for distribution by the Joint Legislative Audit and Review Committee. Action to distribute this report does not imply the Committee agrees or disagrees with Legislative Auditor recommendations.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

1. Four phone lines support mental and behavioral health care

As directed by statute, UW and Seattle Children’s operate four phone lines for mental and behavioral health

The consultation and referral lines are established in state law

Chapter 71.24RCWs 71.24.061-.068, the Community Behavioral Health Services Act, creates four phone lines for mental and behavioral health. Statute requires the following:

  • The University of Washington Department of Psychiatry & Behavioral Sciences (UW) must operate two consultation lines for health care providers: the Psychiatry Consultation Line (PCL) and the Perinatal Psychiatry Consultation Line (Perinatal PCL).
  • Seattle Children's (Children's) must operate a third consultation line, called the Partnership Access Line (PAL). Children's also must operate the Mental Health Referral Service for Children and Teens (MHRS or referral service), which identifies available providers for families whose children need outpatient mental or behavioral health care.
  • UW and Children's operate the lines under contracts with the Health Care Authority (HCA).

There is no charge to providers or families that use the lines. Program costs are paid for from the state general fund and, beginning in fiscal year 2022, assessments on insurance companies (RCW 71.24.064). The lines have cost $12.9 million during the last three years (fiscal years 2020 through 2022).

Three consultation lines connect providers with psychiatrists who provide advice about care for different patient groups

The three consultation lines connect health care providers to psychiatrists for clinical consultations about patient care. Each line addresses the needs of a different population (i.e., adults, pregnant or postpartum people, or youth). The consulting psychiatrists answer questions about diagnoses, medication adjustments, treatment plans, and other topics.

UW and Children's also provide other tools for providers, including care guides, newsletters, and conferences. For example, Children's offers four free training conferences per year for the Partnership Access Line (PAL). Topics have included specific conditions (e.g., ADHD, anxiety, autism), screening and assessment methods, treatment strategies, and supports.

Although the lines are open to a variety of healthcare providers, most callers are either medical doctors (MDs) or advanced registered nurse practitioners (ARNPs). As required by contract, UW and Children’s promote the consultation lines with tools including direct-to-provider marketing.

Exhibit 1.1: UW and Children's offer three consultation lines that give health care providers access to consulting psychiatrists

•	The provider consultation lines allow providers to discuss patient’s mental or behavioral health issue with a consulting psychiatrist. 
              •	The Psychiatry Consultation Line (PCL) allows health care providers to call for adult patients 18 and over. It started in 2019, had 1,622 participants during the study period, and cost $6.8 million between fiscal year 2020 and 2022. The line is operated by the University of Washington and available 24/7 since July of 2020. Before July 2020 it was available weekdays from 8am to 5pm. 
              •	The Perinatal Psychiatry Consultation Line (Perinatal PCL) allows health care providers to call for pregnant or postpartum patients of any age. It started in 2016 with private funds and was expanded with state funds in 2019. It had 1,411 participants during the study period, and cost $1.2 million between fiscal year 2020 and 2022. The line is operated by the University of Washington on weekdays from 9am to 5pm. 
              •	The Partnership Access Line (PAL) allows health care providers to call for children aged 0 to 19 years old. It started in 2007, had 6,616 participants during the study period, and cost $2.3 million between fiscal year 2020 and 2022. The line is operated by Seattle Children’s and available weekdays from 8am to 5pm.

Source: JLARC staff analysis of statute and program data. The PCL was fully operational in October 2019.

The referral service identifies outpatient mental and behavioral health care providers that are available to meet the needs of a child

Exhibit 1.2: Children's operates a referral service to help families find mental or behavioral health care
•	The family referral service provides lists of available outpatient mental or behavioral health providers. The Mental Health Referral Service (MHRS) allows parents, guardians, or family members to call about children ages 0 to 17. It started in 2019, had 6,777 participants during the study period, and cost $2.6 million between fiscal year 2020 and 2022. The service is operated by Seattle Children’s and available weekdays from 8am to 5pm.
Source: Children's program information.

Children's operates a referral service that helps families identify psychiatrists, therapists, psychologists, and other mental or behavioral health professionals that can treat a child.

Based on information from the family, referral service staff send a letter that identifies providers with available appointments. Referral staff consider factors such as the care needed, location, family preferences, and insurance coverage. Staff also provide resources to families such as links to crisis services, online materials and apps, self-help books, and suggestions for other ways to find available providers.

Program data shows increased use over the last three years

UW and Children's collect data about consultation and referral line use. HCA submits an annual report to the Legislature.

Exhibit 1.3 shows that use of the consultation and referral lines increased between 2019 and 2021. In addition, the first three months of 2022 indicate that the trend continued. For example, the Perinatal PCL line received 66 calls in the first quarter of 2019 and 139 calls in the first quarter of 2022. The referral service completed 557 intakes in the first quarter of 2020 and 1,175 in the first quarter of 2022.

Given the time frame, it is difficult to know if the increase in calls is related to the COVID-19 pandemic, increased awareness of the lines, or other factors. As a result, it is unclear if the data is indicative of future demand.

Exhibit 1.3: UW and Children's data shows that the number of consultation line calls and referral service intakes have increased
•	The Psychiatry Consultation Line (PCL) received 20 calls in 2019, 454 in 2020, and 881 in 2021.
              •	The Perinatal Psychiatry Consultation Line (Perinatal PCL) received 284 calls in 2019, 461 in 2020, and 527 in 2021. 
              •	The Partnership Access Line (PAL) received 1,936 calls in 2019, 1,931 in 2020, and 2,171 in 2021. 
              •	The Mental Health Referral Service (MHRS) had 1,122 intakes in 2019, 2,035 in 2020, and 2,445 in 2021.
Source: JLARC staff analysis of UW and Children's data.

Studies identify multiple barriers that can limit access to mental and behavioral health care. Provider availability is of particular concern in many parts of Washington.

The Legislature directed JLARC to evaluate how the lines address access to mental and behavioral health care. The law creating the lines specifically directs UW, Children's, and HCA to identify systemic barriers to access.

Research indicates that:

  • Access to mental or behavioral health care is often measured by patient use (e.g., appointments), patient satisfaction, timeliness, and the existence of a sufficient workforce.
  • Barriers to access include income, health insurance coverage, personal and cultural factors (language, education, and stigma), location, and provider availability.

The availability of mental and behavioral health care providers is a barrier to receiving care in Washington. Reports from both the Office of Financial Management (OFM) and the Department of Health indicate that many counties have few to no psychiatristsOFM estimated in 2021 that 20 counties had fewer than three psychiatrists: Adams, Asotin, Columbia, Douglas, Ferry, Garfield, Grant, Grays Harbor, Island, Kittitas, Klickitat, Lincoln, Mason, Okanogan, Pacific, Pend Oreille, San Juan, Skamania, Wahkiakum, and Walla Walla. and the number of mental and behavioral health providers varies across the stateFor example, in 2021, Garfield County had one provider for every 2,230 people and Pierce County had one provider for every 210 people. .

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

2. Providers satisfied with consultation lines

Health care providers across Washington were overwhelmingly satisfied with the three consultation lines, which they reported have increased access to care

Provider Consultation Lines

Allow providers to discuss patients' mental or behavioral health issue with a consulting psychiatrist.

PCL Perinatal PCL PAL
Adults (18+) Pregnant or postpartum (any age) Children (0-19)

Combined, the lines received 9,600 calls.
(Jan. 2019-Mar. 2022)

Photo of a provider making a phone call.

The 2020 Legislature directed JLARC to evaluate how the consultation lines address access to mental and behavioral health care. Access can be measured by patient use, timeliness, satisfaction, and available providers.

JLARC staff contracted with the Social Development Research Group (SDRG) at the University of Washington to contact providers who used the lines between 2019 and 2021.

  • 293 providers from across Washington gave feedback about the consultation lines through focus groups, a web-based questionnaire, interviews, and emails.
  • 24% of the providers participating were located in Eastern Washington. This is consistent with line use, where callers from Eastern Washington range from 13%-26% of the consultations, depending on the line.
  • About 45% of respondents used either the Psychiatry Consultation Line (PCL)Consultation about adult patients. or the Perinatal Psychiatry Consultation Line (Perinatal PCL) Consultation about pregnant or postpartum patients.. About 55% used the Partnership Access Line (PAL)Consultation about youth patients.. Some providers used the lines once and others multiple times.

Appendix A provides more information about the engagement approach.

Provider feedback about the consultation lines was overwhelmingly positive

In surveys and focus groups, providers were asked to identify the "main thing" they wanted to share about the lines. The most frequent response was appreciation for the service and advice. Only three providers rated their satisfaction with the service as less than five out of five. Those providers rated their satisfaction as four out of five. Providers said the lines provided excellent, reliable, and timely advice that helped them diagnose and treat their patients.

  • Excellent advice: Providers said the consulting psychiatrists provided excellent and evidence-based advice, answered questions, and educated providers. Providers said they would use the service again and recommend the consultation lines to their colleagues.
  • Reliable and timely: Providers reported the lines offered reliable and timely advice. Providers found the lines easy to use and appreciated being connected immediately to a consultant or being able to schedule time to speak with the consultant. Providers also noted that the lines allowed them to give dependable, same-day care to their patients.
  • Help with diagnosis and treatment: Providers said the lines helped them diagnose or treat their patients. Some providers stated that they would not have been able to provide care without the consulting line. Specific examples included help diagnosing disorders, developing treatment plans, and providing advice on managing medications.

Data supports providers' perception of timeliness

Depending on the line, between 76% and 94% of health care providers spoke with a consulting psychiatrist immediately. Across the three lines, about 87-95% of remaining callers were contacted by a psychiatrist within 24 hours. Providers also may schedule a convenient time for the return call and consultation.

Providers reported the consultation lines increased their patients’ access to mental health care

Federal agencies, medical associations, and academic research suggest that collaboration between primary care providers and specialized mental health care providers can improve access to behavioral health care and health outcomes. Feedback from providers indicates the lines have increased access to care by:

  • Filling the gaps in the mental health care system: Providers reported that since some areas in Washington have few psychiatrists, the consultation lines bridges the gap between the patient needing mental health care and psychiatrists having a long wait list.
  • Overcoming barriers: Providers reported that the lines reduced the time it took patients to receive care. Providers also noted that the lines removed barriers to care (e.g., patients difficulty with accessing a psychiatrist due to insurance status, perceived stigma, or location).
  • Educating providers: Providers reported the information received during the consult increased their confidence in treating the patient. Providers reported what they learn during the consults often can be applied to other patients. They also appreciated the manuals and training conferences.

Providers also reported there is no resource equivalent to the consultation lines for them to access. Without the lines, providers reported they would have consulted a colleague, used an online resource, referred the patient to a psychiatrist or emergency room, and/or provided care with less confidence.

Lines were used statewide. The call rate was higher from counties with fewer psychiatrists.

Between January 2019 and March 2022, the lines received calls from 38 of 39 counties (only Wahkiakum had no calls). Counties with fewer psychiatrists had higher call rates (i.e., calls per 1,000 population) than those with more psychiatrists. For example, the six countiesOkanogan, San Juan, Walla Walla, Columbia, Garfield, and Ferry. with the highest call rates to the PCL (more than one call per 1,000 adult population) also had three or fewer psychiatrists per county.

The programs' own surveys and published research also find provider satisfaction and improved patient access

StatuteRCWs 71.24.061 and 71.24.063. requires University of Washington (UW) and Seattle Children's (Children's) to collect information about provider satisfaction with the consultation lines. Each consultation line sends a satisfaction survey to the providers that call. The programs' surveys also report overwhelming satisfaction with the service.

Other research and evaluations of Washington's and other state consultation line programs show that:

  • Providers use mental and behavioral health consultation programs and are satisfied with the services.
  • The programs can increase efficacy of treatment in primary care settings, improve identification and treatment of mental and behavioral health conditions, and reduce medication use.
  • The programs can address barriers to accessing mental health care (including lack of providers, finances, and personal and cultural issues) by allowing patients to receive care from their current provider.

Some providers told JLARC staff that the lines cannot address a broader lack of access to mental and behavioral resources (e.g., availability of psychiatrists and inpatient treatment options).

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

3. Families satisfied with referral service, less so with timeliness

Families surveyed were generally satisfied with referral service. However, they were less satisfied with timeliness and access to care.

Family Referral Service

Provides list of available outpatient mental or behavioral health providers.

Mental health referral service (MHRS)
Callers: Parents, guardians, family members
About: Children (0-17)
Hours: 8am-5pm, M-F
Participants: 6,777
Photo of a woman in front of a laptop making a call on a cell phone.

The Legislature directed JLARC staff to evaluate how the Mental Health Referral Service for Children and Teens (MHRS or referral service) has helped families access mental and behavioral health care.

Seattle Children's (Children's) operates the referral service, which helps families identify available providers in the community that fit the child's needs and accept the family's insurance. The referral service is a five-step process:

  1. Families contact the service by phone, or fill out an online form.
  2. An intake coordinator contacts families and schedules an intake appointment with a referral specialist.
  3. Families have an appointment with the referral specialist, who collects additional information.
  4. The referral specialist identifies community providers and sends a referral letter that lists available providers.
  5. Referral service staff follow up with families.

Families seek help for conditions such as anxiety, depression, ADHD, and trauma. The most commonly requested service is individual therapy. Survey respondents reported that the referral service was not their first attempt to find care. Only 8% of those surveyed had not consulted other resources, such as their health care provider, insurance company, or school counselor, before using the referral service.

Families that used the referral service in 2021 are satisfied with staff and service

JLARC staff contracted with the Social Development Research Group (SDRG) at the University of Washington to survey families that used the referral service in 2021. SDRG administered the survey online and by phone between January and April of 2022. Of the 2,965 families surveyed, 1,607 (54%) responded. Participants were asked about their experiences accessing care, care needs, satisfaction, and outcomes after using the referral service. Appendix A provides more information about the survey.

As shown in Exhibit 3.1, survey respondents were generally satisfied with referral service hours and specific points in the referral process. In addition, 88% agreed that referral service staff listened to their needs, and 73% of those who reported receiving a referral letter agreed that the referrals provided were located within a reasonable distance.

Survey results did not reveal significant differences in satisfaction among respondents of different race or ethnicity, language spoken, or location.

Exhibit 3.1: Families were satisfied with the referral service's operating hours, program staff, and services

•	The referral service has five process steps. Families contact the referral service, schedule a referral appointment, meet with a referral specialist, receive a list of providers, and respond to a follow up call. 
              •	Families are satisfied with referral service process steps. 
              o	73% are satisfied with operating hours
              o	80% are satisfied with discussion to schedule a referral appointment 
              o	77% are satisfied with discussion with referral specialist
              o	73% agree the list of providers was consistent with their request
              o	82% are satisfied with follow up call

Source: JLARC staff analysis of referral service survey data.

Families were less satisfied with the number of referrals

Children's sends each family a letter identifying mental or behavioral health providers who are accepting clients and meet the needs and preferences the family identified. Considerations can include provider specialty, gender, location, hours, experience, insurance coverage, and more.

Per the contract with the Health Care Authority (HCA), the letter includes at least two providers who are available to the family. However, only 56% of survey respondents who reported receiving a referral letter agreed that the number of referrals met their needs. Another 16% neither agreed nor disagreed.

Children's stated that it has become more challenging to find available providers in the community. Research supports this, and suggests provider availability is a challenge in Washington (see Section 1 for more detail about provider availability).

Less than half of families surveyed were satisfied with service timeliness

As shown in Exhibit 3.2, 26%-48% of survey respondents were satisfied with the time to receive services. This is consistent with feedback the referral service has received from families. Children's reported that families were happy with the service, but would like faster service and additional provider availability in the community.

Families with Medicaid were more satisfied with timeliness than those with other types of insurance. As discussed in Section 4, families with Medicaid also received faster service.

Exhibit 3.2: Families were unsatisfied with the length of time to speak with staff and receive a referral letter

•	Families are less satisfied with referral service timeliness. 
              o	48% are satisfied with time to receive a call back to schedule a referral appointment 
              o	26% are satisfied with time from calling referral service to having a referral appointment 
              o	32% are satisfied with time to receive a list of providers

Source: JLARC staff analysis of referral service survey data.

Despite positive reviews of referral staff and service provided, only 53% of families were satisfied with the referral service overall and 47% agreed that it met their needs.

Those who received a referral letter were more likely to agree that the service helped them access care

Between January 2019 and March 2022, 91% of families that had an intake meeting received a letter. Families that did not receive a letter either let the referral specialist know they already made an appointment with a provider, no longer needed services for another reason, or did not respond.

Families that received a referral letter were more likely to agree the referral service helped them access care.

  • 62% reported that the referral service helped them access care, compared to 49% of survey respondents overall.
  • 66% reported making an appointment with a community provider. Some families used a provider listed in their referral letter and others found a provider on their own.

Research shows follow up rates on referrals to mental and behavioral health care can range from 18% to 61%. The survey results described above are consistent with this range.

Survey results did not reveal significant differences in perceptions of access among respondents of different race or ethnicity, language spoken, or location.

Additional barriers may prevent families from accessing care

Families are responsible for contacting the providers listed in their referral letter to make an appointment. Children's staff follow up with families to find out if they made an appointment.

  • Some families do not make appointments because they have other priorities or barriers that the referral service cannot address (e.g., transportation).
  • Data is incomplete because only 53% of families responded to the follow up. As a result, Children's is unable to determine how the referral service affects access for all families that use the service. More information about the referral service follow up is available in Section 4.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

4. Referral service struggles with timeliness

The referral service struggles to meet the statutory requirement to send referral letters within an average of seven days

As described in Section 3, the referral service is a five-step process.

Exhibit 4.1: Referral service process includes five steps

•	The referral service has five process steps. Families contact the referral service, schedule a referral appointment, meet with a referral specialist, receive a list of providers, and respond to a follow up call.

Source: JLARC staff analysis of referral service.

For calls in 2021, the duration of the referral process from call to referral letter was 61 days (44 weekdays). This includes an average of 33 days (24 weekdays) from call to referral meeting and 28 days (20 weekdays) from the referral meeting to letter.

While there is no timeliness requirement for the entire process, Children's has statutory and contractual timeliness requirements for sending referral letters and following up with families.

Referral service has rarely met statutory timeliness goal

State lawRCW 71.24.061(3)(a)(iii) requires Seattle Children's (Children's) to send a referral letter within an average of seven days after the family meets with a referral specialist. Health Care Authority's (HCA's) contract with Children's also specifies that the referral letter must be sent ideally within seven business days.

JLARC staff's analysis identifies the total number of days and the number of weekdays it took for families to receive referral letters. After meeting with a referral specialist, 91% of families received a referral letter. Since 2019, only 28% of these families received that letter within seven weekdays.

As shown in Exhibit 4.2, the referral service has not met the statutory goal of providing referral letters within an average of seven days since 2020. The average time from meeting with families to sending a letter is 17 weekdays, or 23 days total.

Exhibit 4.2: The referral service met the statutory timeliness goal in seven of 38 months since 2019
•	The graph shows the average number of weekdays to send families a list of available providers each month between February 2019 and March 2022. The maximum was 30 weekdays and the minimum was four weekdays. The statutory goal is 7 days.
Source: JLARC staff analysis of referral service data.

Shorter wait times for families with Medicaid

Families with Medicaid received letters faster than those with private insurance. Those with Medicaid received letters in an average of nine weekdays and participants with private insurance received letters in an average of 19 weekdays. For letters to families with Medicaid, Children's met the seven-day statutory timeliness goal in 19 of 38 months since 2019. However, families with Medicaid only account for 27% of referral line intakes.

In 2021, Children's changed its process to streamline finding providers for Medicaid families, which they reported has improved timeliness by reducing the number of calls needed to find a provider for these referrals.

The referral service data indicates that callers for African American and Hispanic children received letters more quickly than callers for white or Asian children. Children's data also indicates that families with African American and Hispanic children are more likely than families with white or Asian children to have Medicaid.

Referral service follows up with 99% of families after sending a letter

The contract with HCA requires Children's to follow up with families within two weeks after sending a referral letter to determine if families accessed care. Children's has attempted to follow up by phone or email with 99% of families that received a referral letter. In early 2021, Children's reported pausing calls due to low staffing, instead sending families surveys. Calls resumed in April 2021.

As described in Exhibit 4.3, the referral service has struggled to follow up within two weeks. The average follow up time was 23 days.

Despite Children's follow up attempts, only 53% of families that received a letter between January 2019 and March 2022 responded to the follow up. Available data suggests that 30% made an appointment and 23% did not.

Exhibit 4.3: The referral service did not meet contractual goal to follow up within two weeks (14 days) in 2021. Timeliness has improved in 2022.
•	The graph shows the average number of weekdays to follow up with families after sending the list of providers each month between February 2019 and March 2022. The maximum was 48 weekdays and the minimum was 13 days. The contractual goal is 14 days.
Source: JLARC staff analysis of referral service data.

Children's cited rising demand, staffing shortages, and provider availability as factors affecting service delivery time

In interviews and reports, Children’s cited multiple factors that affect its ability to meet the statutory timeliness target, including:

  • Increased demand for the service during the COVID-19 pandemic.
  • Staff turnover and vacancies.
  • Limited provider availability (see Section 1 for more detail).

While families wait for appointments and letters, Children’s provides crisis support services, other ways to find a provider, apps, and recommended books.

Almost all referral service families are from Western Washington

Exhibit 4.4: Referral service participants compared to Washington child population
•	97% of referral service participants are located in western Washington counties and 3% are located in eastern Washington counties. 
                      •	76% of children in Washington live in western Washington counties and 24% live in eastern Washington counties.
Source: JLARC staff analysis of referral service data and 2020 American Community Survey data.

The referral service is available statewide. However, the service received 97% of its calls from families in Western Washington and only 3% from families in Eastern Washington. In contrast, 76% of the state's children live in Western Washington and 24% live in Eastern Washington.

While consultation line data, focus groups, and research indicated that there is a need for mental health services in Eastern Washington, it is unclear why families in Eastern Washington are underrepresented in the referral service data.

Most families reported that they learned about the service through the child's primary care provider. Children's has conducted cross promotional activities with the Partnership Access Line (PAL) program to share information about the referral service with health care providers.

Legislative Auditor recommendation

HCA and Children's should develop a plan to meet statutory and contractual timeliness requirements for the referral service and investigate disproportionately low participation from Eastern Washington families.

HCA, Seattle Children's, and OFM concur with this recommendation. You can find additional information in Recommendations.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

Appendix A: Additional detail about family survey and provider feedback

JLARC staff collected feedback from 1,607 families and 293 health care providers

JLARC staff contracted with the University of Washington Social Development Research Group (SDRG) to collect feedback from consultation line and referral service users. This included:

  • Survey of families that used the referral service in 2021.
  • Focus groups, interviews, or a questionnaire with health care providers who used one of the three consultation lines between 2019 and 2021.

Referral service survey of 1,607 participants from 2021

SDRG administered the survey to referral service users between January 7, 2022 and April 3, 2022 via the web and phone in both English and Spanish. Participants speaking a language other than English or Spanish were sent a paper survey in their native language. SDRG staff sent outreach letters, email reminders, and called referral service participants to encourage survey completion.

The survey was approximately 62 questions and asked participants about their experiences accessing care, care needs, satisfaction, and outcomes after using the referral service. It also included questions about caller and child demographics.

Of the 2,965 users surveyed, 1,607 completed the survey and another 96 responded to opt out. The survey sample included participants that received a referral letter and those that dropped out earlier in the process. The composition of survey respondents is generally similar to the composition of referral service participants.

  • Participants from 26 counties provided feedback. 94% of participants called for children in Western Washington and 2.4% called for children in Eastern Washington. Others did not provide location information.
  • 72% of participants called for children with private insurance, 24% for Medicaid insurance, and 3% for Military insurance.
  • 6% of participants called for Asian children, 3% for Black or African American children, 8% for Hispanic or Latino children, and 66% for white children, and 17% for children of other or multiple races.

Analysis of survey data for variation in satisfaction and perception of access

JLARC staff analyzed survey responses for variation in satisfaction and perception of access from respondents of different races, ethnicities, languages spoken, insurance type, and location. JLARC staff employed ordinary least squares regression analysis to estimate the effect of these participant characteristics while holding other factors constant. The analysis was performed for responses to each step of the referral service process (e.g., service hours; satisfaction with referral service staff and letter; perception of access from service). In addition, staff analyzed responses to questions about service timeliness.

  • Participants who reported making it further in the process (e.g. had intake appointment or received a referral letter) were consistently more satisfied with the referral service and reported increased access to care.
  • Participants with Medicaid were more satisfied with referral service timeliness (e.g., time to speak with referral staff or time to receive letter).
  • Overall, there were no consistent differences in satisfaction with specific points in the referral service process (e.g. staff interaction, referral letter), service timeliness, or perception of access among respondents of different races or ethnicities, languages spoken, or geography.

Feedback from 293 providers who used the Partnership Access Line, Perinatal Psychiatry Consultation Line, and Psychiatry Consultation Line

SDRG assisted JLARC staff with conducting focus groups, interviews, and an online questionnaire with providers who used the consultation lines sometime between 2019 and 2021.

SDRG staff administered the focus groups via Zoom and questionnaire between December 2021 and February 2022. Each focus groups had two to seven participants, lasted approximately 30 minutes, and used the same set of questions for each conversation. The moderator inquired about whether:

  • The line(s) helped patients access care, get quicker care, and/or overcome barriers.
  • Providers could treat patients/conditions they would not have otherwise.
  • Providers had alternative sources of psychiatry support or information; i.e. what would they have done without the line(s)?
  • The information provided was used for treating patients in the future.
  • The service met their needs, they were satisfied and would use it again, and would recommend to other providers.

The sample of providers was 1,577. From this sample, SDRG, JLARC staff, UW Department of Psychiatry and Behavioral Science, and Seattle Children’s Hospital coordinated to recruit providers to participate in the focus groups.

  • UW and Children’s each sent email/newsletters to providers who used the lines announcing the focus groups.
  • SDRG sent a recruitment letter to providers who used the lines and followed up via phone for reminders and additional recruitment.
  • The Washington State Hospital Association and the Washington Chapter of the American Academy of Pediatrics both advertised the focus groups in their monthly newsletters to providers.

There were a total of 293 participants, which accounted for 19% of the total sample. Providers who participated were located across Washington, had different specialties and/or credentials (e.g., MD; ARNP), some had used the line once and others had used the line several times. The feedback was uniformly positive. No new themes emerged from the focus groups and questionnaires.

Of the 293 participants, 92 participated via focus group. SDRG conducted 26 focus groups total. If providers were unable to attend a focus group and still wished to provide information about their experience, SDRG staff collected their feedback in one of three ways.

  1. Conducting individual interviews over the phone.
  2. Sending an online questionnaire to the providers.
  3. Receiving emails with provider feedback.

Below is a table of the consultation lines, the method of feedback, and the number of providers who provided feedback using that method.

Exhibit A1: Table of the consultation lines, the method of feedback, and the number of providers who provided feedback using that method

Method of feedback

PAL

Perinatal PCL

PCL

Total

Focus group

42

20

30

92

Questionnaire

103

20

40

163

Individual interview

9

10

3

22

Email

8

1

7

16

TOTAL

162

51

80

293

Source: JLARC staff analysis of provider feedback.

Providers were from three regions of Washington: Eastern Washington, Western Washington 1, and Western Washington 2. The categories are comprised of the following counties:

Exhibit A2: Map of Washington counties categorized into three regions for JLARC focus groups

•	The map of Washington shows three regions: eastern Washington, Western Washington 1, and Western Washington 2. 
              •	Eastern Washington includes the following counties: Okanogan, Chelan, Douglas, Kittitas, Grant, Yakima, Klickitat, Benton, Franklin, Adams, Lincoln, Ferry, Stevens, Pen Oreille, Spokane Whitman, Walla Walla, Columbia, Garfield, and Asotin. 
              •	Western Washington 1 includes the following counties: Clallam, Jefferson, Kitsap, Mason, Grays Harbor, Thurston, Lewis, Pacific, Wahkiakum, Cowlitz, Clark, and Skamania. 
              •	Western Washington 2 includes the following counties: Whatcom, Skagit, Snohomish, King, Pierce, San Juan, and Island.

Source: JLARC staff analysis.
  • 24% of providers practiced in Eastern Washington.
  • 19% of providers practiced in Western Washington 1.
  • 55% of providers practiced in Western Washington 2.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Report Details

Appendix B: Applicable statutes

RCW 71.24.061 - RCW 71.24.062

Partnership Access Line, Perinatal Psychiatry Consultation Line, Mental Health Referral Service for Children and Teens

RCW 71.24.061

(3)(a) To the extent that funds are specifically appropriated for this purpose, the authority in collaboration with the University of Washington department of psychiatry and behavioral sciences and Seattle children's hospital shall implement the following access lines: (i) The partnership access line to support primary care providers in the assessment and provision of appropriate diagnosis and treatment of children with mental and behavioral health disorders and track outcomes of this program; (ii) The partnership access line for moms to support obstetricians, pediatricians, primary care providers, mental health professionals, and other health care professionals providing care to pregnant women and new mothers through same-day telephone consultations in the assessment and provision of appropriate diagnosis and treatment of depression in pregnant women and new mothers; and (iii) The mental health referral service for children and teens to facilitate referrals to children's mental health services and other resources for parents and guardians with concerns related to the mental health of the parent or guardian's child. Facilitation activities include assessing the level of services needed by the child; within an average of seven days from call intake processing with a parent or guardian, identifying mental health professionals who are in-network with the child's health care coverage who are accepting new patients and taking appointments; coordinating contact between the parent or guardian and the mental health professional; and providing postreferral reviews to determine if the child has outstanding needs. In conducting its referral activities, the program shall collaborate with existing databases and resources to identify in-network mental health professionals. (b) The program activities described in (a) of this subsection shall be designed to promote more accurate diagnoses and treatment through timely case consultation between primary care providers and child psychiatric specialists, and focused educational learning collaboratives with primary care providers.

(4) The authority, in collaboration with the University of Washington department of psychiatry and behavioral sciences and Seattle children's hospital, shall report on the following: (a) The number of individuals who have accessed the resources described in subsection (3) of this section; (b) The number of providers, by type, who have accessed the resources described in subsection (3) of this section; (c) Demographic information, as available, for the individuals described in (a) of this subsection. Demographic information may not include any personally identifiable information and must be limited to the individual's age, gender, and city and county of residence; (d) A description of resources provided; (e) Average time frames from receipt of call to referral for services or resources provided; and (f) Systemic barriers to services, as determined and defined by the health care authority, the University of Washington department of psychiatry and behavioral sciences, and Seattle children's hospital.

(5) Beginning December 30, 2019, and annually thereafter, the authority must submit, in compliance with RCW 43.01.036, a report to the governor and appropriate committees of the legislature with findings and recommendations for improving services and service delivery from subsection (4) of this section.

Psychiatry Consultation Line

RCW 71.24.062

(1) To the extent that funds are specifically appropriated for this purpose or nonstate funds are available, the authority in collaboration with the University of Washington department of psychiatry and behavioral sciences shall implement a psychiatric consultation call center to provide emergency department providers, primary care providers, and county and municipal correctional facility providers with on-demand access to psychiatric and substance use disorder clinical consultation for adult patients.

(2) When clinically appropriate and technically feasible, the clinical consultation may occur via telemedicine.

(3) Beginning in fiscal year 2021, to the extent that adequate funds are appropriated, the service shall be available seven days a week, twenty-four hours a day.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

Legislative Auditor Recommendation

The Legislative Auditor makes one recommendation regarding referral service timeliness and statewide participation

HCA and Children's should develop a plan to meet statutory and contractual timeliness requirements and investigate disproportionately low participation in the referral service from Eastern Washington families.

  • The plan to meet timeliness requirements should be included in the existing annual report to the Legislature and should identify if additional resources are needed.
  • Investigate reasons that families from Eastern Washington are underrepresented in the referral service and include this information in existing annual report to Legislature.
Legislation Required: No legislation required.
Fiscal Impact: No fiscal impact to develop plan. Additional resources may be required to implement the plan.
Implementation Date: January 2024
Agency Response: HCA, Seattle Children's, and OFM concur with this recommendation.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

Health Care Authority Response

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22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

Seattle Children's Response

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22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

UW Medicine Response

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22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

OFM Response

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22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Recommendations & Responses

Current Recommendation Status

JLARC staff follow up on the status of Legislative Auditor recommendations to agencies and the Legislature for four years. The most recent responses from agencies and status of the recommendations in this report can be viewed on our Legislative Auditor Recommendations page.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

More About This Review

Audit Authority

The Joint Legislative Audit and Review Committee (JLARC) works to make state government operations more efficient and effective. The Committee is comprised of an equal number of House members and Senators, Democrats and Republicans.

JLARC's nonpartisan staff auditors, under the direction of the Legislative Auditor, conduct performance audits, program evaluations, sunset reviews, and other analyses assigned by the Legislature and the Committee.

The statutory authority for JLARC, established in Chapter 44.28 RCW, requires the Legislative Auditor to ensure that JLARC studies are conducted in accordance with Generally Accepted Government Auditing Standards, as applicable to the scope of the audit. This study was conducted in accordance with those applicable standards. Those standards require auditors to plan and perform audits to obtain sufficient, appropriate evidence to provide a reasonable basis for findings and conclusions based on the audit objectives. The evidence obtained for this JLARC report provides a reasonable basis for the enclosed findings and conclusions, and any exceptions to the application of audit standards have been explicitly disclosed in the body of this report.

Committee Action to Distribute Report

On November 30, 2022 this report was approved for distribution by the Joint Legislative Audit and Review Committee. Action to distribute this report does not imply the Committee agrees or disagrees with Legislative Auditor recommendations.

22-03 Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

More About This Review

Study Questions

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Proposed Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

More About This Review

Methodology

The methodology JLARC staff use when conducting analyses is tailored to the scope of each study, but generally includes the following:

  • Interviews with stakeholders, agency representatives, and other relevant organizations or individuals.
  • Site visits to entities that are under review.
  • Document reviews, including applicable laws and regulations, agency policies and procedures pertaining to study objectives, and published reports, audits or studies on relevant topics.
  • Data analysis, which may include data collected by agencies and/or data compiled by JLARC staff. Data collection sometimes involves surveys or focus groups.
  • Consultation with experts when warranted. JLARC staff consult with technical experts when necessary to plan our work, to obtain specialized analysis from experts in the field, and to verify results.

The methods used in this study were conducted in accordance with Generally Accepted Government Auditing Standards.

More details about specific methods related to individual study objectives are described in the body of the report under the report details tab or in technical appendices.

Proposed Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Contact

JLARC Authors

Casey Radostitz, Research Analyst, 360-786-5176

Amanda Eadrick, Research Analyst, 360-786-5174

Vivien Chen, Research Analyst, 360-786-5190

Rebecca Connolly, Research Analyst, 360-786-5175

Valerie Whitener, Audit Coordinator

Keenan Konopaski, Legislative Auditor

Graphics:

Emily Martin, Committee Communications Assistant, 360-786-5288

Proposed Final Report: UW and Seattle Children's Consultation and Referral Lines for Mental and Behavioral Health

November 2022

Contact

JLARC Members

Senators

Bob Hasegawa

Liz Lovelett

Mark Mullet, Assistant Secretary

Ann Rivers

Rebecca Saldaña

Shelly Short

Lynda Wilson, Vice Chair

Keith Wagoner

Representatives

April Berg

Jake Fey

Noel Frame

Keith Goehner

Larry Hoff

Ed Orcutt, Secretary

Gerry Pollet, Chair

Drew Stokesbary