Bridging the gap: associations of provider enrollment in OKCAPMAP with social deprivation, child abuse, and barriers to access in the state of Oklahoma, USA

Methods

We performed this cross-sectional study utilizing data collected during OKCAPMAP’s first active 18 months – from October 2022 through April 2024. OKCAPMAP is a grant-sponsored, Pediatric Mental Health Care Access (PMHCA) program, sponsored by HRSA’s Maternal and Child Health Bureau, and aimed at providing P2P consultations between LMHPs/CAPs to other providers throughout the state. The overarching goal of the PMHCA program is to “promote behavioral health integration into pediatric primary care by utilizing telehealth modalities to provide high-quality and timely detection, assessment, treatment, and referral for children and adolescents, with behavioral health conditions, utilizing evidence-based practices and methods.” There are 56 PMHCAs in the Unites States spanning 46 states, the District of Columbia, the US Virgin Islands, the Republic of Palau, the Chickasaw Nation, the Red Lake Band of Chippewa Indians, the Federated States of Micronesia, the Commonwealth of Northern Mariana Islands, and Guam [13]. The program and this study were approved through the Institutional Review Board of Oklahoma State University Center for Health Sciences (#2022-004).

Data collected within the OKCAPMAP program utilized for this study include: 1) provider demographics: the county and zip code in which the provider practices, their credentials, field of practice, and sex; 2) the primary condition for which the consultation was made; and 3) physician-reported demographics of the child for whom the consultation is made – age group, ethnoracial group, sex, and if they are from a rural or medically underserved area (MUA). An MUA is a designation from HRSA for an area in which there is a known lack of access to primary care services [14], for which county-level designations were utilized to make this determination. Options for race groups that physicians may report include ‘American Indian or Alaska Native,’ ‘Asian,’ ‘Black or African American,’ ‘Native Hawaiian or Other Pacific Islander’ ‘White,’ ‘More than One Race,’ ‘Middle Eastern/North African,’ ‘Option not listed or do not know patient race,’ and if the data was ‘unrecorded’ during a consultation. Data for this study were de-identified and aggregated so that no personal identifiers of physicians or patients were included in this study’s dataset. Provider enrollment was aggregated at both the county and the zip code tabulation area (ZCTA) for analysis.

To determine whether OKCAPMAP was reaching areas of Oklahoma with an exceptional need for mental health services, we utilized the following measures.

Results

From October 2022 through April 2024, OKCAPMAP enrolled 384 providers from 37 counties across Oklahoma – with the most from Oklahoma and Tulsa Counties (Figure 1). Nearly 75 % of the providers were female (286, 74.5 %). The distribution of credentials among the providers showed that the majority were physicians (MD or DO; 266 [69.3 %]), followed by nurse practitioners (NP or Advanced Practice Registered Nurse [APRN; 55 [14.3 %]), and licensed counselors or social workers (35, 9.1 %). Nearly half worked in the field of pediatrics 193 (50.3 %), followed by family medicine (121, 31.5 %; Table 1). For these enrolled providers, the program completed a total of 493 consultations – 278 conducted by an LMHP, and 215 that needed psychiatric support.

Figure 1:

The distribution of OKCAPMAP-enrolled providers across Oklahoma.

These consultations were conducted for a total of 237 Oklahoma youth (unduplicated) – with their demographic profile showing that a majority were between the ages of 7 and 15 years old (61.6 %; Table 1). Additionally, the majority of the group was White (167, 74.2 %), followed in prevalence by American Indian/Alaska Native (23, 10.2 %). Among the 237 youth, 147 were male (62.0 %), 89 were female (37.6), and 1 was a transgender male (0.4 %). More than half (58.5 %) of these children were classified as living in an MUA, and 43.2 % were from rural areas.

Among consultation requests where providers listed specific conditions in which they needed mental health support (n=374), the most commonly cited condition was attention-deficit/hyperactivity disorder (ADHD) at 163 (43.6 %; Table 2). This was followed by anxiety disorders (113, 30.21 %), autism (71, 19.0 %), depressive disorders (63, 16.8 %), and trauma (61, 16.3 %). Among the consultation requests, a majority of 203 (54.3 %) listed multiple conditions.

Findings from the correlational assessments of provider enrollment to SDOH, SDI, and criminal filings of child abuse showed many significant relationships which are provided in Appendix 1. Significant positive correlations among the PLACES SDOH data showed higher rates of provider enrollment in zip codes with higher prevalence of housing cost burden (R=0.27, p<0.001), persons of racial or ethnic minority status (R=0.13, p=0.001), and single-parent households (R=0.09, p=0.018). Rates of provider enrollment were also positively associated with nearly all types of child abuse at the zip code level: failure to protect (R=0.16, p<0.001), neglect (R=0.13, p=0.002), physical abuse (R=0.40, p<0.001), sexual abuse (R=0.31, p<0.001), solicitation (R=0.28, p<0.001), witness of abuse (R=0.35, p<0.001), and total counts of abuse (R=0.39, p<0.001). Lastly, the SDI (R=0.10, p=0.013) and many of its components were significantly positively associated with provider enrollment including the percentage of single-parent families with dependents<18 years (R=0.17, p<0.001), percent of households with no vehicle (R=0.19, p<0.001), and percent households living in renter-occupied housing units (R=0.36, p<0.001). These results are indicative of the alignment of OKCAPMAP’s mission with the community and provider needs.

Discussion

Through a comprehensive analysis of provider enrollment in OKCAPMAP as of April 30th, 2024, our findings show that the recruitment efforts from this program are reaching its intended target – enrolling primary care providers in rural and MUAs – to better address child and adolescent mental health needs across Oklahoma. The significant positive relationships observed between the number of enrolled providers and indicators such as the frequency of child abuse filings, percentage of households who are renters, lack of access to a vehicle, and single-parent households, highlight the program’s successful targeting of areas’ with elevated risk factors for pediatric trauma and limited access to psychiatric services. These correlations suggest that OKCAPMAP is effectively reaching communities where the need for mental health support among children and families is particularly acute. Our findings underscore the importance of the OKCAPMAP in addressing critical gaps in mental health services, particularly in pediatric and primary care settings.

One of the notable findings is the positive correlation between the number of enrolled providers and the Social Deprivation Index (SDI). This indicates that OKCAPMAP is effectively reaching areas with persistent socioeconomic inequities where barriers to accessing mental healthcare services are often more pronounced. By establishing a network of providers in these areas, OKCAPMAP holds promise in reducing disparities in mental healthcare access and improving outcomes for vulnerable populations.

The successful recruitment of 384 providers across 37 counties of Oklahoma demonstrates the program’s ability to engage primary care professionals in addressing the mental health needs of children and adolescents. This achievement is particularly significant considering the geographical and logistical challenges inherent to reaching rural and underresourced communities. Thus, given the prevalence of unmet child and mental health needs in Oklahoma, continued investment and marketing of OKCAPMAP could likely be the supporting bridge in the gap between service needs and available providers.

Conclusions

In conclusion, the findings of this study underscore the critical role of OKCAPMAP in addressing mental health disparities among children and adolescents in Oklahoma through P2P consultations. By strategically targeting areas with elevated risk factors and leveraging existing primary care infrastructure, the program has the potential to significantly improve access to mental healthcare and outcomes for vulnerable populations across the state. Continued investment in and expansion of the program are essential steps toward building a more equitable and comprehensive mental health system for Oklahoma’s youth.