1. Bellevue Hospital Center
Creating an Integrated Mental Health Service Delivery Systems for High-Needs Youth
Jennifer F. Havens, MD
Vice Chair for Public Psychiatry Department of Child and Adolescent Psychiatry NYU School of Medicine
Director and Chief of Service Department of Child and Adolescent Psychiatry
Bellevue Hospital Center

2. Conflict of Interest
Dr. Havens serves on the medical advisory board of Mindyra

3. Learning Objectives
Participants will understand challenges in the existing child mental health care system to effective care for high-needs youth
Participants will become familiar with models for effective emergency psychiatric care for youth
Participants will understand the importance of integrating trauma-informed care into inpatient treatment
Participants will understand the needs for adaptation in outpatient care for youth in high-complexity families

4. Components of an Integrated Mental Health Service Delivery System
Effective psychiatric emergency services
Effective inpatient psychiatric services
Step-up and step-down intermediate level care
Outpatient services that can effectively address child acuity and family complexity

5. Youth at Higher Levels of Need in the Community
Movement to brief stabilization model of acute hospitalization
Much shorter lengths of stays
Youth discharged based on immediate risk
Whole system moving towards shorter intensive treatment periods (state hospitalization, residential treatment)
Move away from residential placement in Child Welfare and Juvenile Justice systems

6. Decreasing Access to Inpatient Care
Children and adolescents increasingly treated in emergency departments (Case et al, 2011)

7. National Service Utilization by Children with Mental Health Conditions
Annual Report on Health Care for Children and Youth in the United States: National Estimates of Cost, Utilization and Expenditures for Children With Mental Health Conditions (Torio et al., 2015)
Children ages 1-17
Sources:
AHRQ Healthcare Cost and Utilization Project National Inpatient Sample (2006 and 2011)
Nationwide Emergency Department Sample
Medical Expenditure Panel Survey (2006 and 2011)

8. National Findings: Inpatient Hospitalization
Increase in inpatient hospitalization between 2006 and 2011
Significant increase for children ages and ages 5-9
Increase related to suicide and self-injury (103.9%)
Mood disorders and ADHD most common principal diagnoses

9. National Findings: Emergency Department, Treat and Release
Significant increase treat and release visits between 2006 and 2011 (20.9%)
Significant increase in every age group, especially children ages 1-9
Increase related to suicide and self-injury
Largest increase was for children in lowest income household
Mood disorders and ADHD most common principal diagnoses

10. Challenges to Effective Management of Psychiatric Emergencies
Increasing volume with little system adaptation
Youth treated in medical or adult psychiatry settings
ER evaluations limited to risk assessment only
Over-utilization of inpatient services

11. Characteristics of Emergency Mental Health Visits
More likely to be brought in by ambulance/police
Higher rates of admission and transfer
More likely to have repeat visits
Disproportionate increase among under-insured
UPDATE

12. EDs Have Not Adapted to Growing Number of Pediatric Psychiatric Patients
Managed in medical or adult psychiatric settings
Often lack access to child and adolescent mental health clinicians
Limits appropriate diagnosis, treatment, and disposition planning
UPDATE

13. EDs Have Not Adapted to Growing Number of Pediatric Psychiatric Patients
Priority is triage patients out of emergency setting
When no inpatient beds available, children and adolescents “boarded” in ED for days or admitted to medical beds
Washington State recently ruled “boarding” in ED unconstitutional
Alienating and distressing experience for children and families
UPDATE

14. Pediatric Psychiatric Patients Have Significantly Longer ED Length of Stay
Psychiatric assessment requires more time than medical evaluation
Overutilization of inpatient care due to need for immediate treatment
Need for admission significantly increases length of stay
Admitted patients frequently require transfer because of lack of inpatient beds
UPDATE
Assessment longer--(Case et al, 2011)
Transfer (Case et al, 2011)

15. Inpatient Admission 19.4% 15% 34.4% 16.4% 15.7% 32.1% 30.5% 5.5% 36%
Transfers
Total
Sills and Bland, 2002
NHAMCS
19.4%
15%
34.4%
Case et al, 2011 NHAMCS
16.4%
15.7%
32.1%
Mahajan et al, 2009 PECARN
30.5%
5.5%
36%
UPDATE
Pediatric Emergency Care Applied Research Network
National Hospital Ambulatory Medical Care Survey

16. Underlying Reimbursement Issues
“ED Consultation” model associated with little to no revenue for psychiatry
Trainee-driven services in academic medical centers
Limited commercial insurance support for crisis intervention
Reliance on public or research dollars for program innovation
UPDATE

17. Enhanced Models of Pediatric Psychiatric Crisis Care
Community-Based
Home-based Crisis Intervention
Mobile Response Teams
Hospital-Based
Crisis Clinics
Emergency Department-Based
Dedicated Crisis Staff
Intervention and Follow-up
Blended Specialty Models

18. Blended Specialty Models
Comprehensive Psychiatric Emergency Program (New York State model)
Extended Observation Unit with brief stabilization capacity (up to 72 hours)
Interim Crisis Clinic Services
Mobile Crisis Services
Adequate reimbursement model
Extended Observation at inpatient rate
Enhanced evaluation rate for non-admitted patients
Moves revenue to psychiatry—mandates appropriate facilities and staffing

19. Children’s Comprehensive Psychiatric Emergency Program
Safe, child-friendly environment
Staffed 24/7 by child and adolescent psychiatrists and nursing; social work 16 hours/day
Extended Observation Unit for inpatient stabilization up to 72 hours
Interim Crisis Clinic—Acute outpatient services
Available until connection to longer-term outpatient care
Home-Based Crisis Intervention Program
Mobile Crisis Services

20. Children’s Comprehensive Psychiatric Emergency Program
7,969 children and adolescents (2-18) from January July 2016
Referrals for children and adolescents
Range of settings and locations
All five boroughs, nearby counties, nearby states
Coordination with HHC hospitals lacking psychiatric services for children and adolescents

21. Bellevue C-CPEP Utilization
Discharge
(Total = 5,204)
Observation
Evaluation
Admit BHC
Transfer–other hospital
C-CPEP
Crisis Clinic
10,063 34 2%
2,094
Visits 21%
996 patients
7,969
79%
2,474 31%
1,607 20%
3,854 48%
1,081
44%
1,350
54% 43
1,069 patients Referred

22. Challenges to Effective Inpatient Treatment
Brief stabilization model of care
What can you really do in 4-6 days - medicate and sedate and discharge
Diagnostic complexity associated with inappropriate treatment
Failure to identify trauma co-morbidities
Behavior guiding treatment not diagnosis
Lack of evidence-based acute programming models

23. Prevalence of PTSD in Youth
47% of year olds reported physical or sexual abuse/assault or witnessed violence (Kilpatrick et al, 2003)
Kilpatrick et al 2003, used a national household probability sample of 4,023 adolescents ages interviewed by telephone
Community Samples

24. Non-Recognition of Trauma Exposure and PTSD in MH Settings
Outpatient Settings (Mueser & Taub, 2008)
28% met PTSD research criteria (only 14% diagnosed in medical records)
PTSD associated with poorer functioning and increased likelihood of delinquent, run away and self-injurious behavior
PTSD associated with increased use of multiple psychotropic meds
Inpatient Settings (Havens, 2012)
Adolescents screening positive for PTSD
More likely to be diagnosed Bipolar on admission, Major Depressive Disorder at discharge
More likely to be on anti-psychotics on admission, anti-depressants at discharge
More likely to be on more medications
Higher rates of suicidal ideation
More prior hospitalizations

25. Discharge Rates per 100,000 Select Mental Illness: NYC, Ages 0 - 19
SPARCS, NYS DOH

26. Collusion with silence and self-blame
What Does Lack of Appropriate Identification of PTSD Mean for Treatment Planning and Service Delivery
Collusion with silence and self-blame
Poor understanding of behavior and poor treatment planning
Over-utilization of anti-psychotic medication
Failure to apply evidence-based treatments for PTSD

27. Facing Reality Addressing the Problem
Integrate trauma-focused approaches into treatment and service settings
Multi-disciplinary staff education
Systematic screening
Evidenced-informed therapeutic interventions
Leadership sustainability

28. Screening Tools Adolescents (January 2009) UCLA PTSD Reaction Index
Children’s Depression Inventory (CDI)
CRAFFT—Problematic substance use
Children ages 7-12 (March 2010)

29. PTSD Screening Results
Children
Adolescents
Total Screened
464
2,262
% Reporting Physical Abuse
32%
23%
% Reporting Witnessing Domestic Violence
30%
25%
% Reporting Sexual Abuse
19%
% Above PTSD Clinical Cutoff
26%
% Subthreshold Range for PTSD 9% 8%
43% adolescents screening positive for problematic substance use
also screen positive for PTSD

30. Depression Screening Results
Children
Adolescents
Total Screened
464
2,262
% Above Depression Clinical Cutoff
41%
% Subthreshold Range for Depression
13%

31. Evidence-Based Trauma Intervention (Adolescent Unit)
Skills Training in Affective and Interpersonal Regulation for Adolescents (STAIR-A) (Cloitre, M, 2008)
Evidence-based individual intervention shown to improve affect regulation and interpersonal skills in traumatized adolescents
Skills-building modules modified for inpatient group use
Structured skills groups focusing on:
Affect Recognition and Trauma Psychoeducation
Emotion Regulation & Coping Skills –individualized development of safety plan/card
Communication Skills

32. CARES Intervention
CARES (Children’s Awareness Regarding Emotional Stress)
Inpatient trauma group for children ages 7 -11, developed by a multidisciplinary team based on existing principles and modules from Trauma Focused-Cognitive Behavioral Therapy (Cohen, 1996) and Cognitive-Behavioral Intervention for Trauma in Schools (Jaycox, 2004)
Session 1: Psychoeducation
Session 2: Relaxation and coping skills training
Session 3 and 4: Cognitive Behavior Skills
Session 5: Imaginal stress & Graduation

33. Challenges to Effective Outpatient Mental Health Care
Increasingly acute children and adolescents managed in routine outpatient services
Dearth of intermediate care options for step down and step up
Partial Hospital
Intensive Outpatient
Day Treatment
Lack of capacity for management of acute patients and complex families in outpatient services
Work-force issues—access to child psychiatry
No capacity for active outreach and engagement

34. Family Complexity, Child and Adolescent Inpatient Psychiatry Discharges 12/13 - 05/15
Number of patients with any family complexity documented
Number of complex factors noted per chart, in patients with family complexity
822 charts reviewed
% of charts 3 2 1 4 5
Complexity
No Complexity

35. Family Complexity Definitions
Family Complexity Definitions
Outpatient Complexity (Active Cases 5/15)
ACS Involvement
Parents separated/divorced
Family history of mental illness
Family history of substance use
Unstable housing
Abuse
Neglect
Dept of Education issues
Most common
Separation/Divorce 201
Family history of mental illness  137
DOE concerns 124
Inpatient complexity
(12/13-5/15)
ACS Involvement
Single Parent
Family history of mental illness
Family history of substance use
Lack of family support
Most common
Single parent 361
Family history of mental illness  289
ACS involvement 240

36. Service Utilization Correlates of Family Complexity, n=822

37. Adapting Clinic Models to Care for High Complexity Youth and Families
Outpatients clinics (and their payors) need to adapt to provide care to high complexity families
Evidenced Based Treatments (MST, FFT)
Family–Based Maintenance OPD treatment
Integrated Case Management

38. Creating an Integrated Service Delivery System for High-Needs Youth
Inpatient
Partial
BHC Clinic
Crisis Clinic
CCPEP
(HBCI)
State Hospital or RTF
Outside Provider
Point of Entry
Pediatrics CL

39. Conclusions
Every region needs a robust and comprehensive mental health care system for children and adolescents
Care systems and payors must incorporate effective care models for high complexity youth and families