Across the United States, many children live below the poverty line (DeNavas-Walt & Proctor, 2015) and have to endure ongoing social inequalities. The cumulative effects of poverty, stress, and trauma can make these children more vulnerable to behavioral health issues and, for some, can lead to a behavioral health crisis. Hospitalization is clearly valuable and needed as a safety net, but for some children immediate assessment can identify underlying problems and brief interventions can ameliorate them without the need for hospitalization. Thus, hospitalizations, the most restrictive environment for the child and most expensive for society, may be avoided. This Practice Forum discusses the social worker’s role in a mobile crisis team (MCT) that screened children and intervened during pediatric behavioral health crises. In particular, we will be discussing one multidisciplinary model that was developed in metropolitan Detroit, Michigan. Although we refer to a “team,” only one person (a social worker) traveled to assess the child. However, the MCT social worker called and discussed the unique situation with other members of the team. The goal of the model was to reduce behavioral health crises to allow for solutions that were less restrictive for the child than hospitalizations. The social worker’s role in the MCT differed from those of social workers based in emergency departments (EDs) (see, for example, Groner, 1978, for one of the first descriptions, and Mahajan et al., 2007, for a more recent description). However, no standard configuration exists for handling a child behavioral health crisis in the ED (Janssens, Hayen, Walraven, Leys, & Deboutte, 2013). In the Detroit area, children (defined as <18 years of age) who present with behavioral health problems, such as aggression or self-mutilation, at EDs are typically screened by hospital-based social workers or psychiatrists. If hospitalization is deemed necessary, the hospital-based social worker (or psychiatrist) informs the attending emergency medicine physician and calls the appropriate payer to obtain authorization. Prior to implementation of MCT, one local public payer routinely offered one-day authorization for children after receiving the call from the ED. After an available bed for the pediatric psychiatric hospitalization was identified, the child was transferred. The receiving hospital then requested and justified the need for additional days. Development of Model Due to the high costs of pediatric hospitalization and readmission, a local public payer requested our group to come up with a strategy to lower the number of pediatric hospitalizations. Our group had previously developed and implemented a hospital diversion program for adults (Amirsadri, Mischel, Haddad, Tancer, & Arfken, 2015) that was physician driven. However, in discussing cases, it was clear that a prominent role for social workers was needed to effect similar reductions in hospitalizations for children. Another difference between pediatric behavioral crises and those of adults was the underutilization of alternatives to hospitalization for children (for example, partial hospitalization or residential crisis unit). Prior to creating MCT, these programs were primarily used after discharge from pediatric hospitalization. The first step of the MCT was to develop a tool to screen the child. Traditionally, children are recommended for psychiatric hospitalization if there is a danger to self or others. In addition to assessing harm, the tool included systematic assessment of prior medical and behavioral health history, vulnerabilities, need for specialized services, and common events precipitating the ED visit. The vulnerabilities assessed included grief, trauma, and lack of safety. Assessment of the need for specialized services included family resources, barriers to care, and drug use. Common events precipitating the ED visit included family disagreements, school problems, and bullying. The second step was determining the composition of the MCT. It was decided that the team needed to include different expertise and perspectives. As such, the MCT was composed of clinical social workers, psychiatric nurses, behavioral health adult peer support specialists, and psychiatrists. The social workers provided assessment, therapy, and case management expertise. The nurses provided expertise in disease management. The peer support specialists provided support to the families. The psychiatrists supervised and communicated with emergency medicine physicians as needed about medications and diagnoses, including potential physical problems that may be presenting as behavioral issues. The third step was deciding the boundaries of the program. In-person assessments, as opposed to telephone assessments, were used to promote engagement by the child and family. Availability of the MCT was uninterrupted, with screening and assessments of children taking place in the ED. In addition, social workers traveled to EDs and hospitals in surrounding counties if needed to assess children (covered by the local public payer) who had traveled outside the county. The screening summary was also shared with the child’s behavioral health outpatient clinic. Last, it was decided that interventions should continue after disposition. The MCT social worker conducted brief interventions as needed in the ED. These interventions included case management to connect the family with needed services and individual or family therapy to address issues such as acute grief, trauma, or depression. Each family whose child had been screened also received three follow-up phone calls after discharge from the ED or the hospital if admitted. The purposes of these phone calls were to provide support, answer any questions families had, assist with transportation referrals, and verify that the family had medications for the child if medications had been prescribed. The social workers also verified that the child had attended the scheduled outpatient clinic visit. If the child had not attended the scheduled visit, the social worker helped reschedule the appointment. Home visits were occasionally conducted by MCT members for families who appeared to need continuing support before outpatient visits could be completed. Although there was no limit on the number or duration of the home visits by the MCT, the emphasis was on transferring the family to an outpatient clinic for ongoing care. The social workers and other members of the MCT were chosen for their ability to engage children and families, respond quickly to calls for assistance, juggle diverse expectations, and communicate. They were also chosen for their empathy and ability to discern strengths and needs in the families. An example of providing enhanced patient access to the social workers was that the social workers gave the families their cell phone numbers and permission to call if they needed help. In the first two years of the program, only one family called for something that was not directly relevant to the child’s behavioral health. Implementation The MCT is contacted by a local public payer after it receives a request to authorize a pediatric psychiatric hospitalization. Prior to calling the payer, the child is medically cleared by the emergency medicine physician. The MCT social worker reviews the available medical and psychiatric history (including hospital ED admission and presenting issues, current outpatient attendance, and medications) from the payer and goes to the ED. At the ED, the MCT social worker meets briefly with the hospital-based social worker (if there is one), nurses, and the attending emergency medicine physician. Then, the MCT social worker meets and interviews the child and family in a safe and confidential area using the screening tool. If there appears to be tension between the child and family as evident by arguing or deliberate avoidance, the interviews are conducted separately. The focus of the screening is to determine the appropriate level of care. As such, it is a targeted assessment, not a comprehensive psychiatric evaluation. Throughout the assessment, the MCT social worker maintains a strengths-based approach with a warm, nonjudgmental communication style. For some families, this opportunity to communicate is sufficient to reduce tensions. One such interaction involved a 14-year-old girl who wrote a note at school expressing a desire to die. On learning of the note, the school social worker interviewed the child, called the mother, and told her that the child had to be evaluated before she could return to school. The hospital-based social worker recommended hospitalization. The payer called the MCT social worker. At the hospital, the MCT social worker found the mother denying that there was a problem and angry at the school. The MCT social worker was able to calm the mother, encourage the child to talk, and from there determine that the child was bullied at school. After a brief intervention to help facilitate the family’s development of an approach to the bullying, the child was discharged home with referral for follow-up at an outpatient behavioral health clinic. There were also times when collateral sources, with permission, were contacted for information, including Child Protective Services (CPS) workers and other family members. After the initial assessment, the MCT social worker calls the MCT psychiatrist and presents the case. This interaction is conducted using a computer tablet (with a HIPAA-compliant Internet connection) that the MCT social workers carries. The MCT psychiatrist then asks additional questions that the social worker in turn poses to the child and family. Rarely, the MCT psychiatrist requests to interact directly with the child or family. Finally, the MCT psychiatrist communicates as needed with the emergency medicine physician about medications and diagnoses. The MCT social worker then communicates the recommended disposition with the hospital-based social worker and the attending physician. Evaluation Prior to implementation of the MCT, the payer had authorized hospitalization for 100 percent of the children when the hospital-based social worker called for authorization. During the first year of the program, 42 percent of children screened were hospitalized. The remaining screened children were sent home with a scheduled visit to a behavioral health outpatient clinic (27.7 percent), admitted to partial hospitalization (15.1 percent), or admitted to a residential crisis unit (15.1 percent). During the second year of the program, 29 percent of the children were hospitalized. The remaining screened children were sent home with a scheduled visit to a behavioral health outpatient clinic (21.9 percent), admitted to partial hospitalization (26.5 percent), or admitted to a residential crisis unit (22.6 percent). During the second year of implementation, additional information was collected for a quality improvement project. That year there were 452 screenings of 336 children, with the youngest child being four years old. Most of the children were only seen once during the year (58.2 percent). However, one child presented seven times. Readmission was associated with higher hospitalization rate (49.7 percent versus 24.7 percent). Most of the children during the second year of implementation were female (57.3 percent), were African American (68.8 percent), lived in the city (60.8 percent), and were age 14 or older (61.5 percent). A third of the admissions were for children new to the publicly funded behavioral health system (34.1 percent). Not surprisingly, depression (69.5 percent) and substance abuse (53.1 percent) were the most common diagnoses. Involvement of translators (0.9 percent), the criminal justice system (9.3 percent), or CPS (10.4 percent) was infrequent. The children mostly arrived in the evening (48.7 percent), brought by family (57.5 percent) to the one pediatric hospital in the county (74.1 percent). However, the MCT social workers traveled to 18 different EDs during the year. Median time from arrival of the child at the hospital to the call to the local public payer for authorization was 180 minutes (three hours). This time also included medical review and clearance of the child by the emergency medicine physician. Median time from notification by the local public payer until team arrived was 40 minutes. Median time to complete the assessment and arrival at a disposition was 55 minutes. No information is available on time from disposition to discharge. Sustainability Sustainability of the interprofessional team was supported by billing for crisis screening, case management, and individual therapy (as appropriate). The assessment in the ED was billed as crisis screening for the MCT social worker. If case management or therapy interventions were commenced in the ED, they were billed as such. Home visits were billed as case management. Follow-up phone calls for each child screened were assumed to be five minutes or shorter; therefore, no attempt was made to bill for them. Sustainability also included emotional and financial support for the social workers and other members of the MCT. For emotional support, there were regularly scheduled case conferences to allow for exchange of ideas. Although some of the MCT members received a salary for shift coverage, the number of assessments did not support a dedicated salaried MCT. Instead, most of the MCT members were employed at behavioral health or integrated primary care clinics and volunteered for extra assignments on specific shifts. For each completed assessment and follow-up, the MCT social workers received a bonus payment. Conclusion Social workers played a critical role in the implementation of a unique child crisis team, the MCT. Important skills for this role include empathy; flexibility; awareness of issues; good clinical interviewing; ability to present a case; knowledge of behavioral health diagnosis; crisis management training; ability to engage and communicate with child, family, and medical staff; and knowledge of community resources. The team approach used by the MCT improved on the prior system. Previously, all requests for pediatric psychiatric hospitalization authorizations were granted and then the receiving hospital had to justify the length of stay. Under the new model, the MCT social worker, armed with the case history, screened the child at the ED. The screening was a targeted biopsychosocial assessment that included contacting collaterals when needed. The MCT social worker also performed crisis intervention for the child and the family, and brief therapy and case management services as needed. The MCT approach was successful as evidenced by reducing pediatric psychiatric hospitalization. References Amirsadri, A., Mischel, E., Haddad, L., Tancer, M., & Arfken, C. L. ( 2015). Intervention to reduce inpatient psychiatric admission in a metropolitan city. Community Mental Health Journal, 51, 185– 189. Google Scholar CrossRef Search ADS DeNavas-Walt, C., & Proctor, B. D. ( 2015). Income and poverty in the United States: 2014 (U.S. Census Bureau, Current Population Reports, P60–252). Washington, DC: U.S. Government Printing Office. Groner, E. ( 1978). Delivery of clinical social work services in the emergency room: A description of an existing program. Social Work in Health Care, 4, 19– 29. Google Scholar CrossRef Search ADS Janssens, A., Hayen, S., Walraven, V., Leys, M., & Deboutte, D. ( 2013). Emergency psychiatric care for children and adolescents: A literature review. Pediatric Emergency Care, 29, 1041– 1050. Google Scholar CrossRef Search ADS Mahajan, P., Thomas, R., Rosenberg, D. R., Leleszi, J. P., Leleszi, E., Mathur, A., et al. . ( 2007). Evaluation of a child guidance model for visits for mental disorders to an inner-city pediatric emergency department. Pediatric Emergency Care, 23, 212– 217. Google Scholar CrossRef Search ADS © 2017 National Association of Social Workers
Health & Social Work – Oxford University Press
Published: Feb 1, 2018
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