Availability of Outpatient Rehabilitation Services for Children after Traumatic Brain Injury: Differences by language and insurance status Megan Moore, PhD, MSW Sidney Miller Endowed Assistant Professor in Direct Practice University of Washington WASCLA 2016

Nathalia Jimenez, Ali Rowhani-Rahbar, Margaret Willis, Kate Baron, Jessica Giordano, Deborah Crawley, Fred Rivara, Ken Jaffe and Beth Ebel

Traumatic Brain Injury in the US A TBI is caused by bump, blow, or jolt or a penetrating head injury that disrupts the normal function of the brain Severity ranges from “mild” to “severe” Most TBIs are mild Not all blows or jolts to the head result in a TBI. CDC 2015

2.5 million people each year seek medical care Traumatic Brain Injury in the US 2.5 million people each year seek medical care 1/3 of all injury-related deaths caused by TBI 339,462 DoD TBI Worldwide Numbers since $77 billion indirect and direct medical costs Leading cause of death and disability in US UCSF/CDC

Causes

TBI by Age In 2010 0-4: 58 per 100,000 5-14: 23 per 100,000

TBI by Race African American persons have higher rates of ED visits, hospitalizations and death in most age groups American Indian/Alaska Native males have highest rate of TBI-related death CDC 2015

TBI Outcomes Cognitive deficits Impaired physical functioning Mental health symptoms and behavioral problems Headache, fatigue, sleep disturbance, irritability Cognitive deficits: recall, information processing speed, attention, executive functioning NINDS; CDC 2015

Availability of Outpatient Rehabilitation Services for Children Aims: Explore associations between English proficiency, insurance status and outpatient rehab availability and travel time to nearest service Access to rehab has been associated with better outcomes

METHODS Created a comprehensive statewide database of pediatric providers, services and geographic locations in WA state

METHODS Assessed services available to All children Those with Medicaid insurance Those needing language interpretation services

METHODS Assessed association between language need and availability of rehab by county Availability of multilingual services by county characteristics Defined language need as % of persons older than 5 yrs speaking a language other than English in home (American Community Survey)

METHODS Travel times compared for children with English and Spanish speaking parents Identified closest provider who met child’s need We adjusted for child’s age, child’s sex, education of parent, household income and Medicaid status. Household income and Medicaid status were significantly correlated (r=.42, p<0.001). Because our main variable of interest was insurance status, we removed household income from the model and presented those results in Table 4 (R-squared mental health=0.075; PT/OT=0.114; Speech/Language/Cognitive Therapy=0.100). When we included household income in place of insurance status in a sensitivity analysis, results were unchanged (R-squared mental health=0.065; PT/OT=0.127; Speech/Language/Cognitive Therapy=0.119). We also assessed the interaction between Spanish speaking parent and Medicaid status, but the interaction was not statistically significant.

RESULTS Provider and Service Availability Mental Health, n (%) 210   All services accepting children Accepts Children & Medicaid Accept Children, with Language Services Accept Children Medicaid & Language Services Mental Health, n (%) 210 (100) 77 (37) 19 (9) 16 (8) 293 service providers 385 services In each category there were fewer services for children whose families needed languge interpretations Mental health services represented more than half of all services available to children, however, only 8% were available to children with Medicaid and language service needs

RESULTS Provider and Service Availability   All services accepting children Accepts Children & Medicaid Accept Children, with Language Services Accept Children Medicaid & Language Services Physical and occupational therapy, n (%) 92 (100) 64 (70) 38 (41) 293 service providers 385 services In each category there were fewer services for children whose families needed languge interpretations Mental health services represented more than half of all services available to children, however, only 8% were available to children with Medicaid and language service needs

RESULTS Provider and Service Availability   All services accepting children Accepts Children & Medicaid Accept Children, with Language Services Accept Children Medicaid & Language Services Speech / language / cognitive therapy, n (%) 83 (100) 66 (80) 43 (52) 40 (48) 293 service providers 385 services In each category there were fewer services for children whose families needed languge interpretations Mental health services represented more than half of all services available to children, however, only 8% were available to children with Medicaid and language service needs

RESULTS Provider and Service Availability   All services accepting children Accepts Children & Medicaid Accept Children, with Language Services Accept Children Medicaid & Language Services Total pediatric rehabilitatio n Services, n (%) 385 (100) 207 (54) 100 (26) 94 (24) 293 service providers 385 services In each category there were fewer services for children whose families needed languge interpretations Mental health services represented more than half of all services available to children, however, only 8% were available to children with Medicaid and language service needs

RESULTS Provider and Service Availability Less than 20% of service providers accepted children with Medicaid and provided language services

RESULTS Availability of multilingual services by county characteristics Table 2. Univariate associations between measured county-level characteristics and number of multilingual pediatric services Characteristic PR 95% CI Percentage of persons using a language other than English in the home (per 10% difference)   0.60 0.43, 0.90 Median household income (per $1,000 difference) 0.95 0.93, 0.97 Percentage of persons living below the poverty level (per 1% difference) 1.00 0.90, 1.11 Percentage of persons with educational attainment of high school or higher (per 1% difference) 1.05 0.99, 1.12 Region of state East 0.86 0.17, 4.24 Northwest 0.42 0.11, 1.54 Central Referent South 0.46 0.12, 1.72 PR: prevalence ratio; CI: confidence interval for every 10% increase in percentage of persons speaking a language other than English at home, there was a 40% decrease in the number of multilingual services in the county The only covariate of interest significantly associated with the number of multilingual services was median household income. After adjusting for median household income, the proportion of persons with LEP in each county remained significantly associated with the number of multilingual pediatric services (PR = 0.66; 95% CI: 0.48, 0.90; per 10% difference in percentage of persons with LEP). For every 10% increase in persons speaking a language other than English at home, there was a 34% decrease in availability of multilingual services

RESULTS Travel Time to Nearest Rehab Service For children with Spanish-speaking parents Travel time was significantly longer across all service types +16.4 min to mental health +9.2 min to physical/occupational therapy +9.4 min to speech/language/cognitive therapy Average travel time to the closest rehabilitation provider was significantly longer across all service types for children in the cohort with Spanish-speaking parents relative to the children with English speaking parents (Table 4). Adjusting for age, sex, parental education and Medicaid insurance status, Spanish speaking parents needed to drive an average of 16.4 (CI: 2.0, 30.9) additional minutes to reach the nearest mental health service provider, and had to drive 9.2 (CI: 3.2, 15.2) additional minutes to reach physical, occupational therapy and 9.4 (CI: 3.3, 15.5) additional minutes to speech/language or cognitive therapy.

LIMITATIONS Information from providers was self-reported Sample of children for travel time analysis was small Likely residual confounders not accounted for in county level analysis Conducted in WA state Further research is needed to expand upon results

KEY POINTS <20% of providers accepted Medicaid and provided language interpretation Mental health services most limited Multilingual services lowest in counties with greater language diversity Spanish-speaking families had longer travel times

KEY POINTS Access to rehab is associated with better outcomes Limited availability of services at least partially explains noted disparities in outcomes Need: Research in other states Evidence-based standardization of care transitions Policies to train and incentivize providers to serve children with Medicaid/interpretation need

Partnership between: WASCLA, UW, WSU, HMC ONGOING COLLABORATION AND FUTURE DIRECTIONS Addressing Language Needs to Improve the Health Care Access and Utilization by Latinos in Washington (WA) State Partnership between: WASCLA, UW, WSU, HMC Funded by UW Latino Center for Health Contact: mm99@uw.edu