At #CrisisTalk, we are committed to sparking ongoing dialogue on behavioral health crisis and including diverse perspectives and experiences. Today’s guest author is Danna Mauch, Ph.D., President and CEO of the Massachusetts Association for Mental Health (MAMH). She also serves as the Court Monitor for the U.S. District Court of Western Washington, focusing on forensic services reforms at the intersection of health, disability, and justice systems.
Even in the most well-funded service systems, children and adolescents experiencing a behavioral health crisis often face delays in access to effective services. There are many reasons for this delay, but one of the most important is that the pediatric behavioral health system is overwhelmed by demand, especially for limited—and expensive—crisis and emergency services.
This overwhelming demand for crisis and emergency services is driven by a lack of care options that meet the specific needs of children, adolescents, and their families. For example, children and adolescents with urgent but not crisis level needs—such as behavioral dysregulation, role dysfunction, thought disorder, or thoughts of suicide falling short of an immediate risk—have few options for treatment other than to endure long waits for outpatient care, call emergency services, or go to the Emergency Department (ED). None of these options provide the appropriate “urgent care” response to needs, and some result in over-utilizing scarce services designed for children and adolescents in deep crisis.
An obvious consequence of limited service options and capacity is ED “boarding.” In Massachusetts, the Children’s Mental Health Campaign—a statewide network that advocates for policy, systems, and practice solutions to ensure that all children in the state have access to comprehensive mental health care—measured ED boarding in 10 hospitals during one week per month throughout 2016. During that period, 1,028 youth who boarded in EDs collectively spent about seven years of bedded days waiting for a placement.
In addition to ED boarding, systemic gaps for children, adolescents, and their families with urgent behavioral health needs include long waits for access to outpatient care; limited clinical and management information sharing across provider entities; poor continuity of care among emergency, inpatient, and outpatient settings; no behavioral health capacity at medical urgent care centers; and very limited crisis stabilization bed availability.
In 2017, with generous support from the Miller Innovation Fund, the Children’s Mental Health Campaign began to study one possible solution to this problem: developing the capacity to provide pediatric behavioral health urgent care. The study recommended a 3-pronged strategy to meet this goal, including enhancing core services available, filling selective service gaps, and implementing legal, regulatory, financing, and practice transformation support to facilitate uptake and broad-scale adoption.
At a very concrete level, the following steps are necessary to implement this approach. They include:
1. Enhanced functionality to Community Behavioral Health Clinics (CBHCs) to provide walk-in or same-day service, expanded night and weekend hours, rapid assessment and treatment initiation, integrated mental health and substance use interventions, medical clearance, close observation for up to 23 hours, care planning, and case management;
2. Improved response at Emergency Services Programs/Mobile Crisis Intervention to achieve ED diversion, provide stabilization services, and manage transitions in care across settings;
3. Defined triage function, possibly based in a call center staffed by a trained team that links to and backs up Mobile Crisis Intervention, primary care practices (PCPs) with integrated behavioral health, and/or CBHC outpatient clinics to deliver urgent care;
4. Additional child and adolescent and family/caregiver support and stabilization services, including crisis stabilization units or similar beds with 24-hour observation and treatment capacity; and integrated primary care and behavioral health practices that incorporate treatment for co-occurring conditions and have the authority to direct care to a broader array of behavioral health interventions.
In the proposed model for pediatric behavioral health urgent care, families, PCPs, specialty settings, or schools would be able to refer children for urgent care. While some children may continue to seek care through the ED, optimally they would be triaged to an established pediatric behavioral health urgent care program. These established programs might operate in any one of several settings, including Mobile Crisis Intervention services, integrated PCP settings, or Community Behavioral Health Clinics. In each of these settings, the child and family in need would receive a standardized evaluation, care planning, and expedited access to an array of ambulatory interventions, pharmacological treatment where appropriate, and crisis stabilization services within hours of presenting.
Over the next year, the Children’s Mental Health Campaign will begin planning for implementation of a Pediatric Behavioral Health Urgent Care pilot. In addition, with support from the Peter and Elizabeth C. Tower Foundation, the Campaign will explore the unique needs and urgent care service requirements for children and adolescents who have co-occurring autism spectrum disorders or intellectual and developmental disabilities.
For more information about our proposed model for Pediatric Behavioral Health Urgent Care, please read our report.