• Article
  • October 23, 2018

Kids in Crisis: Children's Hospitals Confront Behavioral Health Care Challenges

Children and adolescents across the country are facing behavioral health crisis more than ever before. Here's what five children's hospitals are doing to turn these lives around

By Megan McDonnell Busenbark

Spring 2018 cover

Suicide was the second-leading cause of death among 10- to 24-year-olds in 2016—up from the third spot in previous years, according to the U.S. Centers for Disease Control and Prevention (CDC). And the number of children and adolescents hospitalized for suicidal thoughts or attempted suicide has more than doubled since 2008. The majority who attempt suicide usually have depression. These sobering statistics point to a decline in mental and behavioral health among the nation's youth.

"We are at a crisis point right now," says Benjamin K. Maxwell, M.D., medical director of inpatient psychiatry, Rady Children's Hospital San Diego and assistant clinical professor, University of California, San Diego. "About 75 percent to 80 percent of the kids we deal with in the emergency department (ED) or inpatient units are coming in for depression with the risk of suicidality.

That's definitely the majority of our patients." But Maxwell and his team see countless other pediatric patients facing a wide range of mental and behavioral health crises—from children and adolescents with extreme anxiety, post-traumatic stress disorder or obsessive-compulsive disorder to autism, eating disorders, psychosis or mania.

Conditions, in some cases, that render these young people unable to leave the house or do any of the normal, everyday things they need to do to develop as a child. And this just scratches the surface of mental and behavioral health disorders that are increasingly coming through the doors of children's hospitals and pediatric primary care offices around the country today.

The question of why there are growing numbers of children and adolescents requiring this specialized care comes with many answers from many experts. There's socioeconomic status, but then there's the explosion of social media, leading to bullying and added pressures. Youth today often spend hours a day looking at TV, computer or phone screens, leading to less time for physical activity.

Then there's the overload of information available at the swipe of a finger, whether accurate or not, that older generations didn't have while they were growing up. And in some cases, this 24/7 access to information can clue kids in to bad or scary news quickly, which can fuel fear and anxiety. "The minute there's a school shooting, 30 seconds later, it's going around the school and increasing everybody's anxiety level," says Kyle John, M.D., medical director, Mercy Virtual Mental Wellness, Mercy Children's Hospital St. Louis.

An estimated 17.1 million children in the United States have or have had a psychiatric disorder—more than the number of children with cancer, diabetes and AIDS combined.

Despite the clear need for behavioral health care for pediatric patients, there is a shortage of care providers and care models focused on serving this patient population. Just like the reasons behind the growth of patients in need of this kind of care, the driving forces behind this shortage are many. "On one hand, there's still a lot of stigma," says Jennifer McWilliams, M.D., department chief of psychiatry at Children's Hospital & Medical Center in Omaha, Nebraska. "It's better, but there's a lot of stigma about mental health care not being real, not being real medicine, not being a real problem."

Then there's the fact that pediatric psychiatry is not one of the higher-paying specialties, and the residency is longer: five years versus three years for a pediatrician, leading to two additional years of accumulating debt. Many behavioral health care providers and state treatment centers have closed or are unwilling to see children for age or reimbursement reasons. However, the need for behavioral health care is pressing and has been for years, according to Joseph Kahn, M.D., president of Mercy Kids, Mercy Children's Hospital St. Louis.

"Our approach had always been to go into the community and say: 'What can we do? What support can we, as a health ministry, provide to you?'" says Kahn. "And no matter who we talk to, no matter where they are, no matter what their setting—from urban to rural and in between—the answer was always, 'We need more behavioral health services.'" Children's hospitals across the country are working tirelessly to meet the growing and changing demand and to do their part. The following are snapshots of innovative approaches five hospital are taking to ensure behavioral health resources and care is available to children and families when and where they need it most.

Screening tools, urgent care and psychiatric ED

In 2012, Rady Children's conducted fewer than 500 psychiatric evaluations in the medical ED. Now, that number sits at about 2,700 a year—more than quadrupling in just a few years. With such a dramatic increase in behavioral health visits, Rady Children's has taken a series of steps to care for these patients. In April 2016, the hospital began screening all patients over the age of 12 for at-risk behaviors of depression or suicide.

The screening begins with two questions:

  • Have you in the past two weeks felt down, depressed or hopeless?
  • Have you had little interest or pleasure in doing things?

Today, the team conducts about 4,000 screens a month. Between July 2017 and July 2018, there were about 49,000 screens, with 45 percent of them taking place in the ED. The hospital is currently averaging about 40 patients each week who screen positive for thoughts of self-harm or suicide, which prompts an immediate response from a social worker.

From there, the team ensures the children are safe and placed in a level of care appropriate for their clinical presentation. "Would anybody have noticed that these kids were suicidal before the screening was in place?" says Maxwell. "I don't think most of our providers outside of the behavioral health providers were routinely asking these questions to their patients."

Create a psych-response team that is trained and understands the system of care, the risks and how to deal with those risks associated with these patients.

In December 2016, the clinical opening of the hospital's Behavioral Health Urgent Care Center marked a new world of opportunity for families of children with behavioral health issues. Before that time, families typically had to choose between visiting an ED or waiting for what is often months for an appointment with a behavioral health specialist. The Behavioral Health Urgent Care Center now enables families to walk into a clinic setting without an appointment to see providers much more quickly.

And if a patient needs ongoing, outpatient care, the center can serve as a bridge, providing care as needed until that transition is complete, Maxwell says. As of early September, children and families in crisis accessed the center for approximately 1,500 distinct service visits. Maxwell sees this as a way of disrupting the current behavioral health care model. "I mainly work on inpatient units, but my goal is to put the inpatient units out of business," he says.

"How do we get kids the care they need when they need it and not have these long delays, leading to crises that require inpatient care? We often see kids on our inpatient unit who started having difficulties six or eight years ago and nothing was done until it got to a boiling point, and they needed to come into our inpatient unit. We're trying to find ways to change that."

Next up for Rady Children's: the creation of a separate wing in its current ED dedicated to behavioral health emergencies—the first pediatric psychiatric ED in the region. But Maxwell believes there also needs to be a strong focus on getting help to kids even closer to home. "It is important to talk about mental health integration in the primary care clinics or pediatric clinics," says Maxwell.

"How can we improve the knowledge base and access to good behavioral health care in the primary care setting? That's where kids are, and that's where kids and families feel comfortable." And that is the sweet spot for Mercy Children's Hospital, where the team is creating an entirely new model of pediatric behavioral health care.

Behavioral health care in the primary care office

As Kahn and John from Mercy Children's talk passionately about their approach to changing what they see as a broken behavioral health care model, they are reminded of what got us to this point—the critical shortage of pediatric psychiatrists and a lack of education.

"Primary care providers, pediatricians and family practitioners are not getting enough training in mental health care in residency and in medical school," says John. "If you talk to those folks, they'll tell you on any given day, 20 percent to 40 percent of what they're treating is mental health issues, which may come into the office in the form of a headache, a stomachache or a behavioral problem. But some of our pediatricians told me they get one or two hours of lecture on mental health issues in their entire three-year residency, so they don't feel adequately trained to diagnose and treat these disorders."

So the team is reeducating primary care providers, pediatricians, family physicians and nurse practitioners in the region to help them turn this around and be able to diagnose and treat these children in their offices. The hospital conducts two-hour training sessions and provides a manual and an electronic version of the training so the providers can go back and listen to it when needed. Then they develop care paths to help the providers make decisions while caring for children with mental and behavioral health care needs.

"If you've got a child diagnosed with anxiety or depression and it's moderate to severe, in addition to therapy, you're going to recommend medication," says John. "We will show them… these are the medications, explain the side effects and the benefits. Here's the starting dose, and how quickly you go up…and here's the max dose…and if that med is intolerable or it doesn't work, here's your next med."

Most of the kids are so comfortable with technology; it's just second nature to them to talk to somebody in that format.

The team at Mercy Kids focuses on attention-deficit hyperactivity disorder (ADHD), disruptive behavioral disorders like oppositional defiance, anxiety disorders and depressive disorders—the majority of what the providers see in their offices, says John.

Treatment algorithms in the electronic health record (EHR) give the team and the primary care providers a constant window into a patient's status. Cameras at Mercy Kids help the team use telemedicine to consult if needed. The goal: the children who leave the primary care offices have an accurate diagnosis and an accurate treatment plan on the same day as their visit.

"The more we can do in the medical home, the better off everybody will be," says John. "The more kids who can be cared for in their primary care provider offices, the more children and adolescents who really do need to see a child psychiatrist because they have a more severe illness have a better chance of getting in because the line is now a lot shorter. It's a win for those kids who really don't need to be in front of a child psychiatrist—and it's a win for the kids who do."

Additionally, John says the number of children presenting to urgent care or emergency rooms seeking psychiatric services will decrease. All intended consequences of this new care model avoid costs and decrease the illness burden to the patient and family. As of early September, the Mercy Children's team has trained 178 pediatric primary care providers across four states at 48 different practice sites.

Telemedicine for reach, care and comfort

For McWilliams and the team at Children's Hospital & Medical Center in Omaha, telemedicine is the key to reaching as many patients with behavioral health issues as possible. Rural states like Nebraska face a shortage of providers and long travel times to clinical settings.

So McWilliams and her team conduct telepsychiatry visits through physicians' offices in eight different locations across the state and across the border into Iowa with two other sites they plan to add to the roster soon. McWilliams has recruited and retained skilled providers who do not live in the same area as the hospital and created flexible scheduling so providers can see youth from different sites in the same day.

Children's hospitals need to start to think of themselves not as being a destination where kids go for care, but as the repository of expertise which they share with the community where the kids really live.

"We saved pretty close to 100,000 travel miles for the patients the team saw with telepsychiatry in just a year," says Mike Vance, Ph.D., director of behavioral health at Children's Hospital & Medical Center, the only full- service pediatric specialty health care center in Nebraska. "Imagine all the days of work that weren't missed, the days of school that weren't missed" because of traveling to Omaha from hundreds of miles away for a face-to-face appointment.

In 2017, the team conducted more than 900 telepsychiatry visits with than 300 unique patients. This led to a 50 percent initial reduction in psychiatry follow-up appointment no-show rates.  The convenience of telepsychiatry for patients can drive patient participation. This has also helped forge strong, trusted connections between provider and patient. "Some of my really anxious kids or kids who have been traumatized actually feel more comfortable being seen through telehealth because it provides a little bit of a comfort barrier," says McWilliams.

Cost-effective care model

Veronnica McDuffey-Taylor recalls a time only a few years ago when it would take anywhere from 12 to 18 months for a family to get a behavioral health appointment for their child—a year or more before a child who needed help could get it. So she and the leadership team at Children's of Mississippi got together to shorten wait times and improve access to and quality of care while driving better outcomes, greater patient satisfaction and lower costs.

They landed on a model that integrates child and adolescent behavioral health services through a centralized triage system that works to assess the child, identify what kind of help he or she needs and coordinate that help for the patient and family—all under one roof. "Parents don't have to go out in the community searching for resources. We're able to tailor care for that family," says McDuffey-Taylor, MHSA, director of operations, Center for Advancement of Youth (CAY), department of pediatrics, University of Mississippi Medical Center.

CAY is a multidisciplinary program, but the team takes a dyad approach when a child comes in through a referral. A developmental pediatrician and a licensed clinical psychologist assess the patient, and when families leave, they have a clear diagnosis, treatment plan and partner to navigate it all. McDuffey-Taylor says the CAY model of care has driven compliance with treatment plans, leading to fewer inpatient stays, fewer provider and psychological visits and more medication compliance—driving costs down.

Mental and behavioral health just doesn't get the attention  it needs. To me, it's just as serious as cancer.

The model has resulted in improved access to care, higher quality of care, improved outcomes, greater patient satisfaction and a lower total cost of care as compared to those who did not receive care using this model. Case in point: using Medicaid data, 908 patients were sampled from the CAY care model and from outside that model. The study showed for the non-CAY patients, the average cost of care per child was $11,408 versus $6,443 on average for the CAY care model child. "That's more than $4 million dollars' worth of savings for Medicaid for the patients seen through CAY versus the patients who felt their way through the system," says McDuffey-Taylor.

Another important component of CAY is the education of primary care providers in the community, showing them what to look for in patients who come in with mental or behavioral health issues. This increased understanding has led to faster care and diagnoses, and fewer referrals to Children's of Mississippi. This is also helping to streamline care and curb costs.

Building family insights into behavioral health care plans

When Children's Hospital of Richmond at VCU looked to move its Virginia Treatment Center for Children (VTCC) from a 50-year-old space into a modern facility, it enlisted help. "We've always valued the input of families and our patients in the care and services we offer," says Alexandria Lewis, Ed.D., VTCC's executive director. "When it came down to the detailed interior design of the new center—particularly the patient rooms and living areas—we got a lot of input from families."

VTCC tapped Healthy Minds, an organization of community members, and VTCC's family advisory council to infuse the family's point of view into the design. Their input led to the construction of a bright, airy facility with green spaces and soothing aesthetics. Its 32 private rooms represent a 33 percent increase over the former facility, with accommodations for families to stay overnight in each room.

Get the right people involved, and make sure you're listening to the family voice.

Architects designed the space to address the needs of modern mental and behavioral health care with updated safety features. Along with added inpatient beds, VTCC expanded its outpatient space—a move that will enable VTCC to triple the number of patients it can serve. Lewis says family involvement helps VTCC make the program more responsive.

The program is evolving, and the facility is an extension of that growth. But Lewis says the collaboration of the people is what drives success. "The building is just a building," she says. "It will not work unless you have a strong program."

Megan McDonnell Busenbark is a writer and founder and principal of Encore Communications, LLC, in New Fairfield, Connecticut. Send questions or comments.