There has been a growing epidemic in behavioral health issues among children and youth for more than a decade. Then the pandemic hit. Isolation, remote learning—and a new, unexpected way of life—exacerbated issues for children, their families and providers.
Children’s hospitals and health systems provide a range of services, but the pandemic highlighted the shortage of community and hospital-based resources available. The result is more children and youth in crisis presenting to children’s hospitals’ emergency rooms.
To start the conversation and begin to explore models and strategies to help hospitals and their communities improve care and services for behavioral health patients, Children’s Hospital Association (CHA) launched a Behavioral Health Learning Series.
The five webinars featured pediatric behavioral care experts addressing ways to accelerate services and programs. Here’s an overview of the discussions.
1. Learn from experience
Looking to open a behavioral health center? Here are four tips from organizations with experience.
The experts
- Moderator: Lawrence Wissow, M.D., Director, Child and Adolescent Psychiatry and Behavioral Medicine, Seattle Children’s
- David Axelson, M.D., Medical Director, Big Lots Behavioral Health Services, Nationwide Children’s Hospital
- Mark Ranatza, R.N., Behavioral Health Service Line Administrator, Children’s Hospital New Orleans
Rethink transport
It’s a Chevy Tahoe—not an ambulance—that transports pediatric patients to the Big Lots Behavioral Health Pavilion from the main Nationwide Children’s campus less than a mile away, David Axelson says.
The benefits:
- Less stigma, more comfort.
- No access to the driver, no way out of the car because of door locks.
- A faster ride. Axelson says a safe car ride to the pavilion from the main campus is about 15 minutes versus 45 minutes after waiting for an ambulance.
Engage the community
Mark Ranatza: “When you walk off our campus, you’re walking into a residential zone with houses surrounding us. So, it was imperative for us (when building the center) to be engaged, to have town halls and work with the community in terms of what this looks like. We took that community feedback and included it into our design.”
Prioritize your staff
David Axelson: “Employee retention during the pandemic is tough because you don’t do as much socialization as you’d like to do. But communicate the best you can. Having nursing leadership out on the unit is important. Interacting with staff is important. Just being out there interacting is important.”
Be ready to adapt
Mark Ranatza: “No matter what you’re planning for your new building, be prepared for it to change on Day 1.”
Getting started
Lawrence Wissow: “As a child psychiatrist, I feel like we’ve been the misunderstood child of pediatric medicine for a long time, trying to find ways to frame and finance what we do as being central to children’s care. And in some ways, our time has come.”
2. Save room
Consider strategies for reducing demand for acute care beds when treating youth and adolescents with mental health concerns.
The experts
- Moderator: Terrie Andrews, Ph.D., Administrator of Behavioral Health, Wolfson Children’s Hospital
- Victor Fornari, M.D., Vice Chair and Division Director, Child and Adolescent Psychiatry, Northwell Health
- Jennifer Havens, M.D., Interim Chair, Department of Child and Adolescent Psychiatry, NYU Langone Health
Intervene early
Jennifer Havens: “There are great models for transformational primary care that find and support high-risk mothers and their babies; there’s early intervention and early childhood mental health care. In addition to early intervention, we should have school-based mental health services in elementary schools. The longer you wait to treat a sick child, the more likely you will be to have a sick adult. And then the costs of care are higher.”
Rethink urgent care
Victor Fornari: “We have a walk-in behavioral health process—which I recommend everybody think about developing—but it’s not a one-time visit. It’s one time and until linkage is made. So, we can see people for follow up every day, for a week, for two weeks ... until we can find the linkage. This urgent-care model aims to keep kids out of the ER and out of inpatient services unnecessarily—and linked to services. It doesn’t have to be with a child psychiatrist. It has to be a child clinician who understands how to manage urgent matters.”
Partner with pediatric care providers
Victor Fornari: “More than 30 states have collaborative care programs in behavioral health. Find out what is available in your state. Work with your local pediatric association to help request that of the local government. One example: Project TEACH in New York trains primary care providers to assess, treat and manage mild to moderate pediatric mental health concerns—helping hospitals save room for patients in crisis.”
Taking action
Jennifer Havens: “We need to fight for the appropriate reimbursements for these services. But every service you set up that really works—that you can try to generate revenue for, that you can try to generate a political will for—then you can keep going. That’s the way to go.”
3. The warm touch of tech
There are many benefits to taking behavioral health care virtual. Here are just a few.
The experts
- Moderator: Michael Sorter, M.D., Director, Division of Child & Adolescent Psychiatry, Cincinnati Children’s Hospital
- Alecia Corbett, M.S.W., LCSW, Child & Family Therapist, School-Based Mental Health, Children’s Wisconsin
- David Brent, M.D., Academic Chief, Child and Adolescent Psychiatry, UPMC Western Psychiatric Hospital
- Rameshwari Tumuluru, M.D., Medical Director, Child and Adolescent Outpatient Programs, UPMC Children’s Hospital of Pittsburgh
Virtual therapy rooms
Alecia Corbett: “My virtual therapy room looks similar to how my office would look. There’s a chair, books and games. We can use these things like we were sitting in front of each other. It gives us better engagement and interaction, the ability to teach what our patients and families need to learn and give the patient a choice.
For example, at the end of a session, a patient may say, ‘I want to play Uno.’ Before, we couldn’t do that—but now there are websites, and you can share your screen or share links to play.” Privacy concerns? Don’t worry. Game-sharing sites let you create a room and share a link directly, so there will be no strangers in the room with you.
Safety planning app for suicide prevention
David Brent: “The first step (in using the app) is teaching kids about the emotional thermometer and how to use it to rate their level of distress...then going over reasons for living. They can populate the app if they are in a lot of distress—then they can access coping strategies and a list of folks they can reach out to with their numbers programmed in.”
A new window into the patient home
Rameshwari Tumuluru: “We’re now seeing what’s going on with families in their homes, which you never experienced before because patients were only talking about it. For me, it increased my empathy for the patients I was treating ... it also gave me opportunities to intervene in real time, because I could see them in real time and pull them in.”
4. Promising partners
Never underestimate the power of partnerships. Here are a couple reasons why.
The experts
- Moderator: Amy Herbst, MSSW, Vice President, Mental and Behavioral Health, Children’s Wisconsin
- Steven Jewell, M.D., DLFAPA, Division Director of Pediatric Psychiatry and Psychology, Akron Children’s Hospital
- Sue Schell, M.A., Vice President and Clinical Director, Behavioral Health, Children’s Health Dallas
Taking action
Steven Jewell: “Deepening relationships with community behavioral health providers highlighted significant gaps in available services in the community, especially for youth with more severe mental illness.”
Counting on the community
At Akron Children’s Hospital, the strategic plan for serving the needs of youth with mental illnesses includes a close partnership with the hospital’s own pediatric specialists—and with regional behavioral health centers.
Steven Jewell: “Our goal is to optimally integrate with county-based community mental health services by using the regional behavioral health care centers to plug gaps in services in the community but not compete with or duplicate services unnecessarily.
Overall, this strategic plan aligns with the broader Akron Children’s Hospital plan of an enhanced focus on population-based care and can serve as a platform for enhancing quality, research and training and education.”
Collaborating and sharing ideas
The team at Children’s Health Dallas is learning from Nationwide Children’s on an initiative for safe and secure rides for behavioral health patients. Nationwide Children's recently created a customized “safe car” specifically for patient transports to and from the behavioral health facility.
Sue Schell: “We saw this idea, and we all jumped on it right away. We’re in the process of looking at all the legal requirements, but our colleagues at Nationwide Children’s are sharing information with us—and we have another meeting scheduled with them to learn specifically about their clinical policies. We’re taking point from our peers who’ve had experience doing this.”
5. The power of knowledge
Hospitals are helping primary care providers elevate their mental health competencies and their comfort level treating pediatric patients.
The experts
- Sandra Fritsch, M.D., Child and Adolescent Psychiatry, Children’s Hospital Colorado
- Tami Benton, M.D., Psychiatrist-in-Chief, Executive Director and Chair of the Department of Child and Adolescent Psychiatry, Children’s Hospital of Philadelphia
- David DeMaso, M.D., Psychiatrist-in-Chief, Boston Children’s Hospital
Use a stepped are model
David DeMaso: “We help primary care providers think through whether there’s a concern or a problem with a patient. If there’s a concern, we have guided self-management tools that they can give to the patient's family. If there is a real problem, we get into how to conduct a focused assessment.”
That usually involves rating scales and clinical interviews, where we help the provider understand the patient's history, the severity—meaning mild, moderate, severe—the complexity and the safety. That sets in motion a triage system where mild and moderate ... can be taken care of in primary care or, if more severe, in specialty care.”
Small-group learning
Tami Benton: “Our method was didactic education with case-based learning in small groups ... and those small groups would continue through what would be a series of supervised Zoom calls monthly, which provided a learning environment for exploring professional identity, doctor-patient interaction, emotional responses to patient care and developing diagnostic, interviewing and treatment skills for the pediatricians.”
3 strategies for educational success
Sandra Fritsch says these types of events lead to effective learning:
- Lunch and learns. These events cover assessment and screening, depression, anxiety and suicide. (Currently virtual due to the COVID-19 pandemic.)
- Education sessions. These include parents who talk about what it’s like to work with primary care providers on their child’s behavioral health needs.
- Annual learning collaborative. This one-day intensive learning session covers topics such as how to talk with teens and how to coach parents on handling disruptive behaviors.
Taking action
David DeMaso: “If primary care providers can safely and effectively manage mild or moderate disorders, then scarce behavioral health specialists can be conserved for the management of severe or complex disorders.
View the Behavioral Health Learning Series on-demand.
