Inequities in the delivery of child mental health care are prevalent and of continued concern for medical and behavioral health service providers (Montoya-Williams et al., 2020; Robinson et al., 2017; Trent et al., 2019). Children from marginalized groups (e.g., racial minorities, low-income, and LGBTQIA+) are less likely to have access to high quality behavioral health care and can experience increased levels of stigma for attempting to seek mental health care (Hadland et al., 2016; Trent et al., 2019). Multiple levels of integrated primary care currently exist ranging from coordinated (i.e., off-site), co-located to fully integrated. Each type of integrated model has its strengths and shortcomings in addressing the behavioral health needs of the patient population (Burkhart et al., 2020; Hostutler et al., 2023; Yonek et al., 2020). There is increasing interest in whether combining models or levels of integrated care may help increase the reach and breadth of behavioral health services in a primary care setting.

The current analyses describe how a concurrent primary care behavioral health and co-located therapy service within a pediatric primary care setting impacts utilization and equity of services. The 12 pediatric primary care practices included in this study belong to a larger pediatric academic medical center in a mid-size Midwestern city. The sample included 9,284 children ages 0-21 years of age with a median age of eight years. Approximately 47% of the sample identified as Black, 16% Latino, 21% White, 10% biracial/multiracial, and 8% other. The primary care clinics serve patients of diverse socioeconomic backgrounds with 13% covered under commercial insurance, 82% Medicaid, 5% self-pay, and <1% other.

Retrospective observational analyses were conducted using electronic health records. Two separate chi-square analyses were conducted to evaluate the reach of different levels of primary care behavioral health services among the general pediatric primary care population and pediatric primary care patients with an identified mental health condition. Data were also disaggregated by race, preferred language, insurance type, and age to identify potential sources of inequities in accessing behavioral health services.

Results indicated general pediatric primary care patients who received specialty behavioral health care and then transitioned to receiving care from a psychologist in a fully integrated primary care setting were most likely to access behavioral health within six months of their primary care visit, X2(5, N=9,284)= 167.87, p<.05. Similarly, primary care patients with an identified mental health condition who received specialty behavioral health care and then transitioned to receiving care from a psychologist in a fully integrated primary care setting were most likely to access behavioral health services within six months of their primary care visit, X2(5, N=5304)= 162.21, p<.05; however, there were no variables that moderated the relationship between level of primary care integration and likelihood of accessing behavioral health services within six months of a primary care visit.

Two separate one-way ANOVA analyses were also conducted to assess treatment dose across integrated and co-located primary care behavioral health services among the general pediatric primary care population and pediatric primary care patients with an identified mental health condition. Data were also disaggregated by race, preferred language, insurance type, and age. Results indicated patients who received specialty behavioral health and then transitioned to receiving co-located care from a master’s level therapist accessed the highest number of treatment doses while patients who were only seen by psychologists in a fully integrated primary care setting accessed the fewest number of treatment doses, F(5,9278)=144.23, p<.05. Similarly, patients with an identified mental health disorder accessed the most treatment doses when they transitioned from specialty behavioral health to receiving co-located care from a master’s level therapist and accessed the fewest treatment doses when they only saw a psychologist in a fully integrated primary care setting, F(5,5298)=69.15, p<.01. For both one-way ANOVA analyses, there were no variables that moderated the relationship between level of primary care behavioral health and number of treatment doses.

These analyses highlight how previous exposure to mental health treatment may be a greater contributing factor to the likelihood of patients accessing behavioral health care rather than demographic factors such as race, socioeconomic status, preferred language, and age which further underscore the importance of empowering patients and families to attend their first behavioral health appointment. Secondly, each level of integrated behavioral health serves a unique purpose for patients’ mental health needs and thus, triaging patients appropriately continues to be an important practice for primary care behavioral health practitioners.