When children and adolescents are struggling with serious mental health issues, their families often bring them to the emergency department (ED) because they don’t know where else to turn. But the ED is not always the appropriate option.
This problem was a common one at Cohen Children’s Medical Center (CCMC), the largest provider of pediatric health services in New York State. If, say, a teenage boy with severe depression comes to the ED, he doesn’t need emergency or inpatient care, but he does need to be linked with services immediately — something for which the ED is not necessarily well-equipped.
To fill this gap, in early 2018, CCMC established a behavioral health urgent care center, known as the “BH Urgi.” Its full-time team consists of a child and adolescent psychiatrist, a licensed mental health counselor, and two patient engagement specialists. “It was born from the idea that kids don’t necessarily need the ED; they need access to mental health evaluation and a child psychiatrist . . . and then they need to be successfully transitioned to care in the community,” says Vera Feuer, MD, Director of Pediatric Emergency Psychiatry and Behavioral Health Urgent Care at CCMC.
When IHI, in partnership with Well Being Trust, convened the ED & Upstream (ED & UP) Learning Community, CCMC joined after recently launching the BH Urgi. In the Learning Community, they aimed to improve how they connected patients with the appropriate level of care in the community. A key part of achieving that aim was building stronger community partnerships — with schools, pediatric practices, and community mental health centers. The following are several highlights from their work:
Partnering with Schools
Schools are the largest source of referrals for pediatric mental health treatment at CCMC. Their relationships with CCMC often starts when schools or Departments of Education request speakers about mental health. At these meetings and through other channels, a CCMC representative provides information about how to make appropriate referrals to the BH Urgi. Sometimes “schools themselves want to come and see where this magical place is,” said Feuer. “We’ve been having tours, introducing them to the team.”
Improving Outpatient Behavioral Health Care Follow Up
After kids leave the ED or the BH Urgi, it’s crucial that they transition to longer-term care. But historically, rates of post-ED follow-up have been very low. CCMC has been working to change this. To ensure prompt appointments at CCMC’s outpatient clinic, the team has established dedicated open-access hours for patients referred from the ED or the BH Urgi.
For families who come from farther away and need to be referred to external agencies, the team is working with agencies to which they commonly refer to improve the process of providing assessments, sharing recommendations, and transitioning care. They are currently trying to establish efficient email communication channels and accelerate the process of setting up appointments. Feuer calls it “a work in progress.”
Connecting Families with Support
Another way to increase follow-up is to educate and engage families so they will understand the importance of ongoing care and emotional support. To pursue this goal, CCMC has cultivated a new partnership with a local chapter of the National Alliance on Mental Illness (NAMI). The NAMI representatives came to CCMC to conduct a 12-week course for parents who are caring for kids with a mental health diagnosis. The group met weekly and 20 families attended. Another cycle will be starting soon.
Making Post-Discharge Follow-Up Calls
A final strategy is simple but important: placing follow-up calls after discharge from the ED. As a result of the team’s work during the Learning Community, one of the ED’s three social workers places the first call within one week after the visit. If they don’t reach anyone, they try two more times.
The team doesn’t have the capacity to contact everyone — they call about 50 percent of patients — so they ask clinicians to identify the families they feel would benefit most from a phone call. This was the subject of their “first and most robust PDSA,” said Feuer. At first, they tagged patients by discharge acuity — that is, the higher the level of acuity, the sooner they tried to place a follow-up call. But Feuer said they soon realized that “in some ways that didn’t match the referral needs. A lot of kids who were high-acuity already had care and doctors.”
After a meeting to discuss alternative approaches, the team arrived at a new system: They prioritize families who seem reluctant about follow-up, patients who started on or changed medication, and patients who frequently return to the ED. On the calls, social workers ask if there have been any other ED visits, any suicidal events, and whether the family has followed through with instructions such as locking up lethal means. Finally, they make sure families have follow-up appointments. “At this point it’s working quite seamlessly,” said Feuer. “It did take almost 18 months to get here.”
CCMC has reduced the time it takes to get an appointment after a visit to the ED or the Urgi Center from about 14 days to 8 days. At their own clinic, the average time to appointment is now less than four days. Over eight months, they have referred 200 children and adolescents, with 90 percent keeping their appointments — an exceptionally high rate. With external clinics, the process presents more challenges, but the days to appointment have decreased significantly.
They have reduced the percentage of patients admitted to inpatient psychiatry. Before BH Urgi was established, about 21 percent of patients were admitted, and that figure has fallen to about 16-18 percent. Seven-day revisits to the behavioral health ED also declined from 7 percent in the first quarter of 2017 to 4 percent in the second quarter of 2019.
CCMC believes the ED & UP shared learning experience contributed to their progress. “The learning community was an invaluable resource and has helped us think about what we do differently, to embark on a systematic improvement journey, to be able to measure the change and to educate and engage our team,” said Feuer. “Learning from the other teams as well as the camaraderie and working towards a common goal has been especially helpful. This journey is by no means over for us, the skills and knowledge gained will no doubt continue to help in making further improvements and creating community partnerships.”
Editor’s note: For more on this topic — including practical tips and tools — download the full Improving Behavioral Health Care in the Emergency Department and Upstream white paper.