As need grows, Cincinnati Children’s innovates in mental healthcare
In January, February and March, Cincinnati Children’s saw a 25 percent jump in the number of patients coming to the ED for mental health services. This is the highest spike in the history of the Child and Adolescent Psychiatry program, according to division director, Mike Sorter, MD.
Why the increase? Sorter and his team attribute it to a cluster of suicides that happened in the northern community and on the west side of town. Parents grew very concerned about their children and began bringing them to the ED.
“The stress of those events may have exacerbated symptoms in some of the more vulnerable kids, which brought them to our attention,” says Sorter.
The heroin epidemic has also been a driver of the increased demand for help, but not because kids are abusing the drug. It’s the parents who are addicted, which means kids are dealing with the fallout, including living in more fragmented family situations. Some are also facing the loss of a parent at an early age.
Additionally, the pressures of school often prove challenging for kids with mental illness. Keeping up with studies, dealing with bullying and the push to get good grades can feed anxiety, depression and poor self-worth.
Psychiatry’s patient volume typically eases a bit with summer’s slower pace, and so far, June and July have been quieter than spring. But census is still higher than usual compared to summers past. “I think we’ve hit a new level of need for hospital mental health services,” says Sorter. “Most young people with mental health issues are not getting the services they need when stress increases in their lives.”
Positive changes
It’s tragic that the number of kids needing help is escalating, but there may be a bright spot among the reasons why – the stigma associated with mental illness is decreasing. More people are stepping forward to ask for what they need.
Cincinnati Children’s is partnering with community physicians and other agencies to provide children and their families with appropriate services as quickly as possible.
“We’d rather intervene before the child needs to come to the ED or requires hospitalization,” says Sorter.
That’s a challenge, considering the national shortage of mental healthcare providers. To adequately serve the number of patients in need of services across the country would require over 30,000 child and adolescent psychiatrists. There are currently 8,000. Consequently, waiting lists are long and getting longer.
Improvement efforts include:At Cincinnati Children’s, the wait to see a licensed social worker or clinical counselor is about a week. To see a psychiatrist or nurse practitioner takes one to two months. “That’s still too long,” says Sorter, “but it’s better than it was. We are constantly working to improve this.”
- Enhancing the recruitment of doctors and broadening the base of providers with psychiatric advanced practice nurses
- Increasing day hospital hours and services and adding acute care clinics as alternatives for inpatient hospitalization
- Refining emergency services processes, including better handoffs of care and assisting with acute needs other than hospitalization
- Launching the Psychiatric Learning Collaborative to help primary care providers manage patients with mental health diagnoses within their practices
- Partnering with local health centers, school systems and MindPeace to bring physician services to kids in the community
Says Sorter, “Cincinnati Children’s remains committed to improving care for kids with mental health disorders. It is a large focus of our 2020 Strategic Plan and a major component of ensuring that Cincinnati has the healthiest children in the US and the world.
“We realize that meeting the mental health needs of kids is very important to primary care providers. We want to hear your thoughts on ways we can help you and these children. Your opinion about this process is important and very welcome. Our goal is to provide the best care for these patients and their families.”
Psychiatry Learning Collaborative arms primary care providers with critical skills
In the US, the number 1 cause of childhood death is accidental injury. The number 2 cause of death in kids, ages 10-24, is suicide.
That’s a frightening statistic, and one that deeply worries primary care providers.
Says Wade Weatherington, MD, chief executive officer, Pediatric Associates of Fairfield, Hamilton, West Chester and Harrison, “If I have a patient who has a complicated case of pneumonia, I can refer the family to an infectious disease specialist, and they will be seen within 24 hours. But if I have a patient with a complicated case of depression, the system is so congested I sometimes can’t get them in to see a psychiatrist for a couple of months. This is a huge concern.”
Sorter understands. He and Jennifer Bowden, MD, assistant director of residency training, Psychiatry, applied for and received a grant from Ohio Medicaid for an education program that integrates many mental healthcare aspects into the primary care setting.
The program, known as the Psychiatry Learning Collaborative, consists of 12 online modules on various mental health topics, e.g., suicide, attachment disorders, psychopharmacology and more. It includes group supervision and case discussion so doctors can learn from each other.
Says Weatherington, “We were encouraged to bring cases we were dealing with in our practices and to ask questions. The psychiatrists made suggestions about medications and gave us direct access to how they were thinking through a problem. It bolstered our confidence.”
Participants in the collaborative also met with the Psychiatric Intake Response Center (PIRC) staff and learned about resource avenues at Cincinnati Children’s and in the community.
“We were assigned to a collaborating psychiatrist whom we could page if we needed help with a particular patient,” he added. “That was a big help in making us feel more comfortable.”
Weatherington calls the Learning Collaborative a brilliant innovation toward solving the mental healthcare crisis. “By elevating our training, it establishes us as new soldiers in this battle. The psychiatrists collaborate with the pediatricians on the straightforward cases, like ADHD or anxiety, which can be managed within our practice. This frees up their schedule to treat the more complex cases, like schizophrenia or bipolar disorder. Likewise, as they learn to trust our knowledge, we can get to a point where I call and say, ‘I have this patient you really need to see.’ And they can say, ‘Can the patient be here by 3:30 this afternoon?’ We can serve as a frontline triage for them.”
Caring for mental health patients in the primary care setting is a challenge. Just having knowledge of how to treat them isn’t enough, says Weatherington. There are logistical problems that have to be solved, as well.
“Primary care practices are usually set up for 10-minute appointments,” he explains. “For a patient with strep throat or an ear infection, that’s plenty of time. But patients with depression or anxiety require longer visits. And you can’t just prescribe a pill that will fix the problem in a few days. So there are multiple long and complicated visits.”
At Pediatric Associates, staff have worked out a system to handle patients with mental health needs. They created a developmental practice group (DPG) with protocols for doing assessments, scheduling visits, follow-up and reimbursement. A clinical care coordinator makes sure forms are filled out and everything the patient needs is obtained and organized ahead of the first visit. The wait time for that first appointment is two to three days.
“About 25 percent of our patients have a mental health diagnosis,” says Weatherington. “We probably get about five new mental health consultations a week. We can handle the majority of these patients with the right type of support.”
Weatherington was part of the first learning collaborative. A second one is going on now. It is offered twice a year. “There were about 10 doctors in our group – not quite enough to make a noticeable impact. But as more physicians are trained, I believe we’ll see a difference. The sessions are incredibly helpful, but I wished it could have gone on longer,” he says. “I felt like we were just getting started.”
For more information about the Psychiatry Learning Collaborative, contact the Division of Child and Adolescent Psychiatry at 513-636-4788.
