UW and Seattle Children's Consultation and Referral 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

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 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

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. .

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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)

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).

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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

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

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

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.

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

Exhibit 4.1: Referral service process includes five steps

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

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.

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 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.

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