Patient Navigators for Children's Community Mental Health Services in High Poverty Urban Communities

Navigation to promote entry into health services, originally developed to address racia disparities in cancer screening and treatment, is only recently gaining prominence in mental health. Recent reviews recommend navigation for many health-related services including mental health services for transition-age youth and for children with medical complexity and comorbid mental health disorders. Logistical barriers are common across the health care system. However, for mental health services, stigma is also a prominent barrier. Paraprofessionals (PPs) have been key in efforts to reduce disparities in access to social services both nationally and internationally, presumably because their similarities to families can facilitate families' access to and retention in mental health services given their ability to relate to families' struggles. In this study, the investigators will examine paraprofessionals' (PP's) effectiveness as navigators for children's behavioral health services as compared to an active waitlist (AWL). For this study, AWL involves periodic check-ins by community agency intake staff with waitlist families to inquire about continued interest in services and provide resources as needed. For navigation, key elements of engagement and family support will be provided through in-person and virtual trainings including role play and feedback. Specific aims are to examine: 1. Initial entry into appropriate behavioral health services. Hypothesis: Caregivers assigned to a PP navigator will be more likely to initiate services for their child as compared to families on AWL, as mediated by reduced stigma and more positive attitudes towards behavioral health services. 2. Ongoing engagement in services Hypothesis: Caregivers assigned a PP navigator will be more likely to retain their child in more sessions of ongoing care as compared to families on the AWL, as mediated by PP's ability to act as a boundary spanner. 3. Child and caregiver outcomes at baseline, 6, 12, and 18 months post intake. Hypothesis: Children and caregivers in the PP navigator condition will evidence stronger outcomes as compared to families in AWL, as mediated by PP's integration into caregiver's social support network. 4. Key stakeholder perspectives. Navigator and caregiver experiences with navigation, and caregiver experiences with AWL, will be examined through semi-structured qualitative interviews to identify perceived barriers and facilitators to service engagement. The investigators will examine these hypotheses using an explanatory sequential mixed method design. Multi-level and longitudinal quantitative data will include information on (1) initial and ongoing use of services assessed via agency electronic medical record (EMR) data; (2) the type and rate of navigator services to families as assessed via EMR data and parent report of navigator endorsement of recommended services; (3) caregiver attitudes and services received, assessed through caregiver report; (4) integration of navigator into caregiver social support network assessed via caregiver report of a social support network; and (5) child and caregiver outcomes as assessed by the caregiver and therapist report collected during 6-month intervals up to 18 months post intake (baseline). Quantitative data will be analyzed by generalized estimating equations models (GEE) accounting for the clustering effect of agencies and navigators and adjusted for covariates. Qualitative analysis of independent interviews with PPs and caregivers will be conducted to contextualize and clarify the quantitative findings. Two community boards will provide an opportunity for inter-agency communication and support by sharing challenges and successes and providing insights into local and national policy. An Implementation and Sustainability Community Board will meet quarterly to address issues of fit within each organization and consistency with local system procedures, and a Public Policy Board will meet annually to consider how the research can inform local and national mental health policy