Children who suffer traumatic brain injuries can face a difficult road to recovery, requiring services such as physical therapy and mental health treatment for months or years to get their young lives back on track.
When those children come from low-income households with limited English proficiency, there can be significant barriers in getting them the care they need.
A recent University of Washington study found that less than 20 percent of rehabilitation providers in the state accepted Medicaid and also provided language interpretation to children with traumatic brain injuries. Just 8 percent provided mental health services to those children, and Spanish-speaking families had to travel significantly further to access services.
The findings highlight how already disadvantaged children are further impacted by limited access to the rehabilitation services that vastly improve long-term outcomes, said lead author Megan Moore, the Sidney Miller Endowed Assistant Professor in Direct Practice at the UW School of Social Work and a core faculty member at the UW Harborview Injury Prevention and Research Center.
"Rehabilitation after a brain injury is incredibly important, especially for kids with moderate to severe brain injuries," Moore said. "Ultimately, that limited availability is going to impact children's outcomes."
For the study, published in the American Journal of Physical Medicine & Rehabilitation in March, the researchers compiled a database of 293 health providers around Washington offering physical and occupational therapy; speech, language and cognitive therapy; and mental health services. A research assistant called each provider and asked about the types of services offered, whether Medicaid was accepted and if interpretation was available for non-English-speaking families.
The research found that:
- Only 46 percent of providers accepted children with Medicaid
- Children covered by Medicaid had fewer rehabilitation services available than those covered by private insurance
- In each of the three general areas of health care listed above, there were fewer services for children whose families needed language interpretation
- While mental health services comprised more than half of the rehabilitation services available, only 8 percent of those providers accepted children with Medicaid who needed language services
- Less than half of the physical and occupational services accepted children with Medicaid and provided language services
- In total, less than 20 percent of all providers accepted children with Medicaid and also provided language services
The researchers also looked at travel times for 82 children with moderate to severe traumatic brain injuries who were treated at Harborview Medical Center, using data from a previous study. They found that regardless of their child's insurance status, Spanish-speaking parents had to drive an average of 16 minutes more than English-speaking parents to reach a mental health provider, and they had to travel an additional nine minutes to get to physical, occupational, speech and cognitive therapy.
The study found that more diverse counties also had fewer multilingual rehabilitation services -- for every 10 percent increase in of non-English speakers over the age of 5 at home, there was a 34 percent drop in the availability of those services.
The inequities may be even greater than the study shows, the researchers note, since providers who accept Medicaid may routinely limit the number of Medicaid-covered children that they accept, due to lower reimbursement rates.
The study follows earlier UW research which found disparities in outcomes among Latino children after traumatic brain injuries. The researchers wondered whether the disparities might have to do with a lack of rehabilitation services generally, but instead identified an access issue for low-income children from families with limited English proficiency.
That gap is particularly worrisome given the state's increasing diversity -- more than 18 percent of households in Washington spoke a language other than English in 2012, the study notes, and almost half of children younger than 18 had Medicaid insurance in 2011.
Joana Ramos, co-chair of the Washington State Coalition for Language Access, said advocates regularly hear that families are being turned away from health care providers or being required to provide their own interpreters.
"It's a huge problem, and we definitely need to get everybody on board to address it, not just the advocates," she said. "Language services need to be a routine part of health care services, not a standalone thing."
Moore said since the bulk of rehabilitation after a brain injury takes place in the community, workers at the hospitals where children are initially treated should try to connect parents with services before they leave.
"We need to be thinking more critically about how we transition kids back to the community, particularly children we know have limited access to services," she said. "We really have to do a thorough job of linking them to these services on the outpatient side.
"Knowing what we know now, it's a social justice obligation."
The research was funded by the National Center for Advancing Translational Sciences of the National Institutes of Health and the National Institute of Child Health and Human Development.
Co-authors are Nathalia Jimenez, an anesthesiologist at Children's Hospital; Ali Rowhani-Rahbar, an assistant professor of epidemiology at the UW School of Public Health; Margaret Willis, a graduate student at Boston College; Kate Baron, a research assistant at Harborview Injury Prevention Center; Jessica Giordano, director of support programs at the Brain Injury Alliance of Washington; Deborah Crawley, executive director of the Brain Injury Alliance of Washington; Frederick P. Rivara, professor and vice president of academic affairs at the UW Department of Pediatrics; Kenneth M. Jaffe, a professor of rehabilitation medicine and adjunct professor of pediatrics and neurological surgery at UW Medicine; and Beth E. Ebel, a UW professor of pediatrics.