Innovative Mobile Clinics Serving Children and Families of Riverside County With Limited Access to Behavioral Health Services

Reducing disparities in mental health has become a national priority (1). All over the nation, people in ethnic minority groups tend to underutilize mental health services. With increasing numbers of people in the United States, a significant number never receive adequate psychiatric care. Often it is the case that individuals from underserved areas who have diagnosed disorders frequently face problems accessing psychiatric services (2). These medically underserved areas may include a whole county or groups of contiguous counties, in which the residents have a shortage of personal health services taking up to more than 30 minutes of travel time to reach (3). Medically underserved populations include groups of persons of a particular cultural background, gender, sexual orientation, spiritual belief, socioeconomic strata, or legal status, as well as persons residing in isolated geographic locations, that face barriers to health care (4). Underserved individuals can potentially lack insurance coverage and financial resources, as well as face cultural stigma, which may deter them from seeking mental health services. As a result, delayed identification and treatment of behavioral health issues can frequently lead to potentially negative outcomes. Therefore, it is imperative to individualize each patient interaction to explore options to remove barriers (5, 6).

Riverside County Mobile Mental Health Clinic

California's Office of Health Equity policy initiatives were developed at a state level to improve access and quality to care and to increase positive outcomes for individuals in certain racial/cultural communities in the public mental health system (7). Through California's Mental Health Service Act, Riverside County receives funds to implement and provide prevention and early intervention treatment in a non-traditional setting utilizing three mobile recreational vehicles as mental health clinics to reach families directly in their communities, with the goals of increasing access to services, reducing stigma, and providing services in geographically isolated areas (8). As of 2014, the U.S. Department of Health and Human Services reported an approximate shortage of 4,000 mental health professionals in medically underserved areas. From the data, it was concluded that it would take approximately 2,800 additional psychiatrists to eliminate these areas where there was a lack of access to mental health services (9). The University of California, Riverside, Psychiatry Residency Program has identified these alarming shortages and become involved in an ongoing project, initiated by Riverside University Health System-Behavioral Health, aimed at addressing the lack of access in mental health services. In order to bridge barriers and create more access to mental health services, Riverside University Health System-Behavioral Health implemented a mobile prevention and early interventions program, which provides prevention and mental health services intervention for children in the 0- to 7-year-old age range, assisting this patient population with the earliest signs of mental health concerns.

Method

Clinical Operations and Services

Clinical teams are comprised of two therapists serving on each mobile unit, with auxiliary support provided by a staff psychologist, mental health services supervisor, and psychiatry residents. The clinical team provides counseling, parenting classes, and consultation while on the mobile unit, periodically providing training for other mental health staff within Riverside University Health System-Behavioral Health. Mobile units rotate throughout various school districts to increase mental health service accessibility. Patients are enrolled in the clinical programs through self-referral and school referrals. The mobile clinics participate in the National Alliance on Mental Health Illness events and mental health fairs, providing information to caregivers, educators, and the community at large. The units are custom-built recreational vehicles, fitted with a playroom and observation room, with a one-way mirror for observation of therapy sessions, which are monitored in real-time during parent-child clinical treatment (10). Three principle therapy modalities are employed in the mobile units: 1) Parent-Child Interaction Therapy, 2) Trauma-Focused Cognitive Behavioral Therapy (CBT), and 3) Strong Kids group. Parent-Child Interaction Therapy is an evidence-based practice consisting of live coaching from a therapist directly to a caregiver of a child with behavioral problems designed to promote positive parent-child relationships and interactions while teaching effective child management skills (12). Trauma-Focused CBT is an evidence-based treatment approach shown to help children, adolescents, and their caregivers overcome trauma-related difficulties through age-appropriate play-based interventions. It is designed to reduce negative emotional and behavioral responses following child sexual abuse, domestic violence, and other traumatic events (13). Strong Kids group is a prevention and psycho-education group for children currently experiencing the impact of having an incarcerated family member.

Data Collection

Clinical therapists directly monitor patient therapeutic interventions and input demographic data such as ethnicity, gender, age, working diagnosis, and treatment outcome data into electronic health records to document and examine the children's and parents' progress during each clinical encounter. Preliminary data regarding Parent-Child Interaction Therapy services are presented in this article. The opportunity for continued collaboration with Riverside University Health System-Behavioral Health, Prevention and Early Intervention Mobile Services program and University of California, Riverside, psychiatry residents presents the prospect to initiate future practice improvement projects, along with possible further data analysis to track and improve patient outcomes and develop program initiatives (13).

Results

The mobile clinic served 132 clients, all of whom reported receiving mental health services for the first time. Having access to mental health services in underserved populations is paramount in providing early intervention through behavioral therapies and addressing mental illness through referral to behavioral health services. Through increased community outreach, preventative measures are set to assist children from developing future negative outcomes (i.e., psychiatric hospitalizations, poor academic/social development). A significant portion of the treated patients would not have otherwise had access to, or engaged in, ongoing treatment if it were not for the mobile clinics going to underserved communities in geographically isolated regions. The aim of serving the underserved population was reached, with treatment services provided primarily to children of Hispanic ethnicity (42%). Oppositional-defiant disorder (87.9% [cumulative]) and intermittent explosive disorder (86.4% [cumulative]) were the two most prominent diagnoses treated with Parent-Child Interaction Therapy in the mobile units, an evidence-based treatment for young children with behavioral problems. There was a statistically significant decrease across all regions on the average frequency and severity of children's behavior (p=0.008) using the Eyberg Child Behavior Inventory measuring pre- and postscores of caregivers of children (14).

Conclusions

Reducing mental health barriers and eliminating disparities in underserved populations is crucial in helping empower patients and families. Access to behavioral health services is a serious issue requiring innovative measures. Community involvement is pivotal in strengthening ties between communities and mental health by providing services to the people who need it the most, such as those residing in geographically isolated communities (15). Young children with defiant, aggressive, and hyperactive behaviors often meet criteria for oppositional-defiant disorder and intermittent explosive disorder. The significance of these diagnoses in underserved populations highlights the importance of early intervention, prevention, and identification regarding negative behaviors in children through improved access with mobile prevention and early intervention programs in order to provide support for parents and children to possibly decrease and prevent negative mental health outcomes (i.e., poor academic performance, loss of home placement, child welfare involvement, etc.) (16). Through completing full courses of behavioral therapies, such as Parent-Child Interaction Therapy, children and caregivers are jointly involved in treatment to improve the parent-child relationship, thus reducing the number of children referred for treatment due to behavioral problems (17). University of California, Riverside, psychiatry residents have the opportunity to serve in the role of patient advocate, focused on a patient-centered model. Approaching mental illness from a public health standpoint is central to improving mental health outcomes in communities. The challenge to eliminate mental health disparities and increase access to mental health services to underserved populations requires further research, patient education campaigns, and community outreach in non-traditional settings (per conversation with Lee Richard, M.D., and Girard. Emma, Psy.D., Dec. 1, 2015).

Key Points/Clinical Pearls