For Our Kids: Pediatric Behavioral Health Needs With UMass Memorial

00;00;00;24 - 00;00;38;21
Tom Haederle
Ever since the pandemic, kids have been presenting in the emergency department with elevated levels of behavioral health issues. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. When kids experience acute behavioral health needs, they need to be cared for at the right time, right place, and with the appropriate treatment and resources.

00;00;38;23 - 00;01;12;14
Tom Haederle
UMass Memorial Health's boarding practices reduce the length of time kids are hospitalized in the emergency department, allowing them to receive care in their homes, clinics and in psychiatric units as appropriate. To dig deeper into these initiatives, Julia Resnick, director of AHA Strategic Initiatives, chats with two people who are deeply involved with UMass Memorial's highly effective program. Dr. Brian Skehan and is director of Pediatric Emergency Mental Health Services, and Jemima Amankwah is nurse manager of emergency mental health at UMass Memorial Health.

00;01;12;16 - 00;01;27;08
Julia Resnick
Dr. Skehan and Jemima, thank you so much for joining me today to talk about pediatric mental health. So to really get things kicked off, I'd love if you could give us a little background about yourselves, your hospital and the population you serve. Dr. Skehan, and I'll start with you.

00;01;27;11 - 00;01;44;07
Brian Skehan
Hi. Thanks so much for having us. I am an adult and child psychiatrist that works primarily in the inpatient hospital setting in the Children's Medical Center, as well as our pediatric emergency mental health area, where Jemima is our fantastic nurse manager.

00;01;44;09 - 00;01;57;05
Jemima Amankwah
My name is Jemima Amankwah. I’m a nurse manager for emergency mental health. I worked in a department as a floor nurse for about seven years and now I'm in this role. It's exciting. 

00;01;57;08 - 00;02;19;11
Brian Skehan
It's probably also important to note that our hospital is an example of a safety net hospital, and so we get a large population of folks from western and central Massachusetts, as well as surrounding states and areas due to insurance means or where they're physically located when they have an emergency or mental health crisis.

00;02;19;13 - 00;02;25;07
Julia Resnick
Excellent. So can you talk about the trends you're seeing around pediatric mental health in your community?

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Brian Skehan
So I think like most areas of the country, we've seen a large increase lately, particularly during the pandemic. If you look at medical health complaints, there was a 20 to 30% increase in mental health reasons for coming to the hospital as opposed to medical reasons. And that was even higher than the increase that had been seen prior to the pandemic in 2019 when they last looked at the data.

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Julia Resnick
Yeah. Jemima, anything you want to add to that?

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Jemima Amankwah
No, pretty much the same. With the increase we're having more of a backlog here and then it's difficult to move patients out to where they need to be.

00;03;06;03 - 00;03;32;25
Brian Skehan
I think the backup is something that we can see across systems. So there's a 50% increase in ED boarding time over the same time period. And that's because at each stop in pediatric behavioral health management plan, there is a backup. So we can't discharge folks from the hospital because of the lack of outpatient providers. We can't get them to the hospital because there's a backlog in the hospital and we can't get them out of the ED because we're waiting for those beds to open up.

00;03;32;27 - 00;03;36;04
Brian Skehan
So it's it's an ongoing problem across all systems.

00;03;36;06 - 00;03;50;23
Julia Resnick
Yeah, it's a really hard time for kids and the people trying to treat them. So you mentioned this rise of kids coming into the ED with behavioral health conditions. Can you describe some procedures and programs that you're implementing to address these challenges?

00;03;50;26 - 00;04;18;23
Brian Skehan
Absolutely. So from a systems level, we've started having leadership meetings with the pediatric behavioral health leadership team that includes everybody in these care areas: nurse managers, pediatric hospitalist, senior directors and psychiatry to try to figure out where we can best serve these folks within our medical system. And so we meet 2 to 3 times a week to talk live about the folks that we have in our facilities.

00;04;18;26 - 00;04;47;08
Brian Skehan
We've also expanded the child consult service to go down to the emergency department and see folks either in the emergency mental health area or in the emergency department itself to provide consultation, which comes with medication recommendations, individualized therapy, child life, occupational therapy, as well as family work with our dedicated social worker. And I think Jemima can probably give the best context to how that actually works out in the ED.

00;04;47;11 - 00;05;06;29
Jemima Amankwah
Yeah, I mean, for us, when this started, I always said pediatric patients, I always knew and it's always like, okay, I need a plan for my patients. What am I doing for them? So as we get more patients in and then realizing, Oh my God, we need to get creative, it was literally that. We just said we have to get creative

00;05;06;29 - 00;05;28;25
Jemima Amankwah
what are we doing for the patients? What they need? So we we had our first alternative care space patient and I think that's what kind of like got all this move in where we had a patient that we had to move from a different area back down. And then as a team we realized that, okay, we need child life to come in to help us. with how many hours can give us?

00;05;28;25 - 00;05;46;17
Jemima Amankwah
And through that we were able to get a designated child life person for the behavioral patients. And then we got the consult team come in. And so right away we have a plan, a treatment plan for patients. We know what they need and what we need to start working out to help support the patient while they're here, so they can get there.

00;05;46;17 - 00;06;11;05
Jemima Amankwah
Before initially, like I would started plan maybe about a week in, because I didn't expect them to be here more than a week. Now, right away, we have to get creative and said, okay, this is what this patient needs. This is what the triggers that this is what their coping skills are, how do I support them? And it's only been I've been able to do that or our team has been able to do that because the consult team is seeing them. I know what medication recommendations they're making.

00;06;11;11 - 00;06;25;03
Jemima Amankwah
I know how therapy is done. I know what their strengths are, where they're working on. So it's been pretty good with all that. I feel like everybody came out the woodworks and we are now on the same page and it's magical.

00;06;25;05 - 00;06;49;06
Brian Skehan
There's been a few other additions in terms of we've also complemented our care in those spaces with our animal assisted therapy program. Big help for for kids. And we've done some staff interventions as well, including looking at our entire organization. We've done a trauma informed organizational assessment to make sure that we're giving trauma informed and trauma responsive care to kids in our in all of our care areas.

00;06;49;09 - 00;07;15;21
Brian Skehan
We've also increased staff training with the aide training to make sure that they are prepared for violence in the workplace when we do have those unfortunate incidents of aggression. And we've also collaborated with a lot of state agencies, the Department of Mental Health, which I know we'll talk about later on in the podcast, and as well as the Executive Office for Health and Human Services here in Massachusetts to help identify kids that have been displaced for a longer period of time.

00;07;15;23 - 00;07;24;12
Julia Resnick
Really sounds like you're focusing on that whole person care, which is wonderful and exciting to hear. Are there any stories that you can share that would bring this to light for our listeners?

00;07;24;15 - 00;07;54;15
Jemima Amankwah
I've got a good amount. Recently had my actually is probably the most challenging one that we've been part of, but it's probably the most rewarding after we completed it. We had a patient here who came and back in November was here for quite a while and it was heartbreaking to see that our team didn't have the services that they needed to be able to support them, despite everybody coming out to try to figure out how do we make this make sense of this patient that's here.

00;07;54;18 - 00;08;32;05
Jemima Amankwah
And relentlessly, our team, they kept fighting and they kept asking. And finally we were able to get an outside agency to come in to help give some real coaching as to how do we support this patient that's here. Our team had no ability to care for this particular patient, so it was good to get the resource come in and then eventually we to stabilize and support the patient to be able to get the patient moved and then to hear that the patient is thriving in this area that they went to is just so amazing to hear because it was one challenge that I was like, I think throughout my career, one of the most challenging

00;08;32;08 - 00;08;34;10
Jemima Amankwah
ones that I've ever had to deal with.

00;08;34;10 - 00;08;56;08
Julia Resnick
So yeah, that just really speaks to the power of collaboration and all hands on deck to meet the needs of kids. So Dr. Skehan, you brought this up briefly, and I want to dig into it a little bit.  In Massachusetts the Department of Mental Health has this emergency department diversion pilot project to explore different ways to provide urgent mental health care outside of the hospital.

00;08;56;15 - 00;09;02;05
Julia Resnick
So can you tell us a little bit about what that is and how UMass Memorial is leveraging that ED diversion program?

00;09;02;08 - 00;09;30;29
Brian Skehan
Sure. There's there's multiple levels of diversion programs, but the Department of Mental Health started with a program run by youth villages called Intercept. And so initially the idea was to provide intensive home based services, including family behavioral intervention specialists that can help support the youth up to three times a week for a period of several months at home in the community where they belong, so they can continue going to school and having the resources that they have.

00;09;31;01 - 00;10;01;13
Brian Skehan
In addition to that program, which has been very successful and is available to all of our community hospitals as well. Initially, it was designed as a diversion to get kids home from the emergency department. Being a good diversion program also means making sure that kids don't have to come to the emergency department. And so since the pandemic has started to shift, they've also shifted the way they run that program and helping folks even before they get to the hospital.

00;10;01;14 - 00;10;29;20
Brian Skehan
So our youth mobile crisis teams in the community can refer to these diversion programs as well. And they can come in either through the Department of Mental Health or other child serving agencies such as the Department of Children and Families here in Massachusetts. That's the first layer of diversion programs. Other communities have other diversion programs as well. We also have for our neuro-divergent youth, which are one of the folks, one of the categories of folks that get stuck in the hospital more frequently.

00;10;29;22 - 00;10;53;26
Brian Skehan
We have the Massachusetts Child Psychiatry Access Project, which is also known as MC-PAP. They have an autism spectrum diagnosis and intellectual disabilities diversion program that works with more specialized behavioral health clinicians and child psychiatrists who are familiar with those diagnoses to try to get kids out of the hospital and back to their communities and school programs.

00;10;53;29 - 00;11;01;07
Julia Resnick
It's wonderful to hear the state thinking about being creative. Can you talk a little bit about what that looks like when the kids get care in their homes?

00;11;01;09 - 00;11;32;10
Brian Skehan
So it usually comes with a family behavioral intervention specialist. Sometimes someone called a family partner, which is a parent with lived experience of having their own child that's received care in different parts of the behavioral health atmosphere. And so that will include several visits per week. They also have crisis clinicians available 24 hours a day. If a youth at home is struggling outside of one of their visits and the parent wants to know what can they do?

00;11;32;10 - 00;11;48;23
Brian Skehan
They can call that crisis line before they get to the broader youth mobile crisis that would start another crisis evaluation and potential emergency room visit. So there's multiple levels of intervention for them prior to coming back to the hospital and spending more time here.

00;11;48;25 - 00;12;00;06
Julia Resnick
It's wonderful. Great to hear about that prevention focus and keep kids at home where they belong. So I know it's still in the pilot phase. Are there any early outcomes from it that you can share.

00;12;00;08 - 00;12;26;23
Brian Skehan
In terms of data? From December, which was the last time that we looked at the data overall, 470 youth in the Department of Mental Health Massachusetts care area had been served by this Youth Villages Intercept program and about 91% of them had not had to come back to the hospital after involvement with that program, which is a huge intervention and huge benefit for for youth and families.

00;12;26;26 - 00;12;32;29
Julia Resnick
Absolutely. And Jemima I'm sure that clears up your space so you can focus on the the kids who really do need to be there.

00;12;33;00 - 00;12;34;06
Jemima Amankwah
Yes.

00;12;34;08 - 00;12;47;03
Julia Resnick
So as as we've been experiencing this just rise and youth mental health needs, I'm sure that you've learned some lessons along the way. Can you share with our listeners anything you know now that you wish you knew earlier in your career?

00;12;47;05 - 00;13;15;01
Jemima Amankwah
For me, honestly, I always say, Why didn't we come together sooner? We operated in a silo where we had the same patient population, we had the same goal, but we were going at it separately. So if we were operating out of the silos, as my boss would say, coming together has made it so much more effective. And so it's just better care for the patients that we're taking care of.

00;13;15;03 - 00;13;34;12
Jemima Amankwah
And as a team we can support each other. So it doesn't feel like a bargaining unit actually doing what we signed up to do. So I wish that when I started here, six years, six, seven years ago when I was a floor nurse, we were doing something like that. But it's okay, we're here, we're going to do it and we're going to keep going.

00;13;34;14 - 00;13;53;05
Brian Skehan
I think that the leadership team in particular the Department of Pediatrics, has realized that we have to care for these youth no matter where they're located. So there's been more forward thinking about how can we best serve this youth regardless of where they are physically located within our system and bringing the services to them?

00;13;53;07 - 00;14;12;24
Julia Resnick
Absolutely. So that value of interdisciplinary team based care thinking creatively and outside your walls, I think that's just where we're going as a health care system. And it's wonderful to hear that you are on that path. So looking towards the future, how is this work evolving and what's next for UMass Memorial on your work on pediatric behavioral health?

00;14;12;26 - 00;14;38;10
Brian Skehan
So I would say one thing for sure is I think our consult teams involvement in the emergency department is here to stay. I think that has been a really positive influence for the youth and families where access to a child's psychiatrist is so difficult in the community that if we have the opportunity and a captured audience here, we might as well leverage that intervention and the strength of our team to get them good recommendations.

00;14;38;12 - 00;15;03;12
Brian Skehan
This goes along with communicating with their primary care provider or pediatrician out in the community to make sure that there's a warm handoff of that care when they do get back home so that they know what our recommendations, where they know the interventions used, and they have some other opportunities to interact with us, either through MC-PAP, which is essentially a phone or friend program that's now mostly the standard nationwide.

00;15;03;14 - 00;15;36;03
Brian Skehan
We also have a bridging clinic here so that youth can, if they are seen by our child's psychiatry team here in the hospital, they can actually get referred to a clinic that will help bridge them to a community based psychiatrist or stabilize them in the community to get them back to their pediatrician after a period of time. And so I think we look to continue to refine those efforts from a quality improvement standpoint, make sure those handoffs are working, and then analyze the data that we've gotten as the pandemic starts to subside and see how see what the power of our interventions is that.

00;15;36;06 - 00;16;08;25
Jemima Amankwah
We're also working on the child advocacy team, which I'm really, really excited about across the three pediatric areas. We are trying to train staff on how to respond to the patients really get in that creativity that that child advocacy team is going to be like this kind of like the support for the patient wherever they are located and their ally and say, okay, how do I help the team understand what this patient is looking for and then make sure that we are doing right by both parties and doing what's best for the patient?

00;16;08;28 - 00;16;24;16
Jemima Amankwah
So I'm actually really excited to see how the child advocacy team, where it goes and the future for that too. I think that would be very beneficial in our work to try to be creative and focus on what the need of the individual is while they're here.

00;16;24;18 - 00;16;45;16
Julia Resnick
I'm also excited to hear how that work evolves, so please keep us updated. Dr. Skehan and Jemima, I want to thank you so much for spending this time with me. But mostly I want to thank you for your commitment to supporting the mental health needs of kids in your community. Can't overstate how important that is, and I think our health systems around the country have a lot to learn from the work that you're doing in Worcester.

00;16;45;18 - 00;17;06;05
Julia Resnick
So thank you so much for being here. And to our listeners, thank you for joining us. If you'd like more resources on maternal health and child health, you can visit our website at www.aha.org/better healthformothersandbabies. Again, Dr. Skehan and Jemima thank you so much for your time. We really appreciate you.