Episode Transcript
[00:00:00] Ellen Hallsworth: The really exciting thing about Bradley REACH is that it makes Bradley's world-class pediatric psychiatric care available virtually anywhere in the US. Right at the beginning of the pandemic in March 2020, Bradley started delivering this care virtually. When we analyzed the data from the program, we realized that although the patients entering our programs during the pandemic had worse problems than previously, the outcomes were at least as good as for in-person care.
We also, I think, quite excitingly, saw that there were several advantages for families and increased access. Family involvement is a huge part of our programs, but we know that it's a really big commitment for families to drive their kids to and from programs every day, and it makes it hard for some families to access care. We also know it's difficult for some parents to take time out of work for family therapy, but being virtual meant parents could even participate from their car in the parking lot at work and it gave them a lot more flexibility.
We're now expanding REACH regionally and nationally, where we've got active and growing partnerships with Boston Children's Hospital and with Connecticut Children's, and we're about to launch a partnership with a large community mental health center in Florida for a major expansion there. We're also talking to the tribal health centers about working with them to expand care in a way that's culturally appropriate and meet the huge needs and access challenges that they faced.
[00:01:29] Marthe Haverkamp: Welcome to A&M's Significant Healthcare Voices Podcast Series. I am Marthe Haverkamp, a Senior Director in Alvarez & Marsal's Healthcare Industry Group. The topic for today's podcast discussion has a profound impact on our societies across the country and in fact really across the world already before COVID, but the problems are importantly exacerbated throughout the pandemic. Today, we are talking about behavioral health problems in children and adolescents.
My guests today are tackling these problems in their community head-on and have developed some life-changing therapeutic programs to support their patient populations. It's my pleasure to welcome to the podcast Dr. Karyn Horowitz, the Chief Medical Officer of Bradley Hospital and the Director of Child Outpatient Psychiatry at Lifespan. Also joining us is Ellen Hallsworth, Director of Bradley REACH, the program we are going to spend much of our time today about at Bradley Hospital. Not only have I worked with both of you extensively as a consultant at A&M but I also know Ellen from my former life as a Harkness Fellow from the Commonwealth Fund. I'm so excited that you both are on this podcast. Welcome.
[00:02:45] Karyn Horowitz, M.D.: Thank you so much for including us and inviting us to participate to talk about such an important topic.
[00:02:51] Ellen Hallsworth: Thanks, Marthe. It's great to be talking to you.
[00:02:54] Marthe: All right. Well, let's jump right in. These past two years have made us aware of the need of more focus on mental health, and specifically, the pandemic accelerated a growing crisis in pediatric behavioral health. Karyn, can you explain to us what you have seen and the true scope of the problems? Which children are most at risk to develop COVID-related mental problems? Are these the same kids as were already having problems before? Do you see, for example, that with increasing [unintelligible 00:03:27] of COVID by the society, it's getting better with these children? What do you see?
[00:03:33] Karyn: Well, that's a really important question. You're right, we had a children's mental health crisis that preceded COVID but was really severely exacerbated by COVID. The kids that were impacted were really all children. Children's lives were incredibly disrupted by the virus and all of the limitations that were put on their normal development, kids not being able to go to daycare, not being able to go to school, not being able to play with their friends.
If you just look at kids over a developmental continuum, all of the ways that their normal development was disrupted. It took a big hit, childhood and adolescence and even those transition age people really, and their parents. The impacts were many, and the types of things that we've seen is really an escalation and the number of kids that are presenting with depression, anxiety, suicidal thoughts, and behaviors, eating disorders. Most mental health presentations we're seeing more of now than we were prior to the pandemic.
[00:04:51] Marthe: Yes. That continues, if I get the sense of your story. It's not getting better.
[00:04:58] Karyn: It's not getting better. I think that there are some things, that reopening created some additional challenges. If you had a child who was anxious, there may have been a way that being able to stay home was cozy for them, and now having to reintegrate after being out of school for an extended period of time, can really lead to more anxiety and more difficulty with attending school. Kids missed a lot of academic work, so that can create a lot of stress for kids. Yes, we're seeing that these problems continue and sort of new problems have entered the scene.
[00:05:36] Marthe: Yes, that makes much sense. Ellen, can you give us a bit of a broader perspective on this problem throughout other places in the developed world? Because it's not only the US.
[00:05:47] Ellen: Sure. There's obviously increased attention on this in the US right now, but it is definitely an issue globally. I think the pressure is on families that Karyn has just spoken about, have not just been felt in the US, they've really been felt almost everywhere in very similar ways. It's estimated that one in seven children across the world live with mental health problems and most don't receive treatment. In the UK where I spent a lot of my career, the health system is very different, but the problems around children's mental health are very similar.
There has been an 81% increase in referrals for mental health services and at a time when the National Health Service is very stretched. There are long wait times for a follow-up mental health care. I think there has been a particular increase in eating disorders, so we're seeing really very similar challenges there and pretty much everywhere in the developed world right now.
[00:06:37] Marthe: Yes, I feel-- I mean, the way you talk about, you're very passionate. You have also a personal feeling maybe for this subject. Why did you decide to come and work at Bradley and do something about this?
[00:06:51] Ellen: I was previously leading a large telehealth pilot in a foundation, but I've been hearing about the challenges to children's mental health coming out of the pandemic. I've got a young child myself, and I know the pressure this has put on families, and I was keen to work on a really big social issue, as we come out of the pandemic and to make a difference. I spoke to Karyn and the rest of the team at Bradley, and I was really impressed and excited by the mission and wanted to be part of it.
[00:07:16] Marthe: Thanks. Same thing for us, of course, as consultants working with people at Bradley, and what we did, and you're going to explain undoubtedly much more later on, but one of the things we did is try to expand your fantastic virtual and intensive outpatient programs throughout the larger portion of the US than only around the hospital through telehealth. One of the things that struck me is that those programs are often not available to many kids and that there was a clear breach in continuity of care. Karyn, is that a larger problem in kids' mental health care, the lack of continuity? Where else do you see that and what's the impact of the condition?
[00:08:06] Karyn: Well, I wish it was just an issue of a lack of continuum of care. I think that we actually have problem with just having services available from the level of prevention through our highest level of need patients. There's just a shortage of mental health services and clinicians to treat the amount of mental health illnesses that we see in children. It's important for people to realize that every psychiatric condition starts in childhood.
Any condition that you are aware of that an adult may experience, it can start early in life, whether it be anxiety, depression, ADHD, learning struggles, bipolar disorder, et cetera. We really need to be able to have early identification-- Well, let's say prevention, early identification, and then treatment for all of these children to keep them healthy and keep them living their lives. I guess that's a long-winded way of saying that we certainly do not have many parts of the continuum of care that's required to address the mental health issues of children.
[00:09:27] Marthe: Yes. Then not only have the problems that start early in life and affect them later in life but then also on the families of those people later in life. It's all generations carrying over. Thank you, Karyn. Ellen, I dropped the name of Bradley REACH, and I talked maybe a little bit about it, but you are of course are much better at it. Explain to us what Bradley REACH Program exactly is and help us understand how that increases access to care?
[00:09:57] Ellen: Sure, Marthe. Well, you're obviously an expert too because A&M were very involved in setting the program up. The really exciting thing about Bradley REACH is that it makes Bradley's world-class pediatric psychiatric care available virtually anywhere in the US through telehealth. Bradley had been running partial hospitalization programs in tens of outpatient programs for adolescents in person for years.
These are programs that run every day for several hours, either during or after school hours, and teenagers attending groups, receiving care from a multidisciplinary team including a psychiatrist, psychologists, social workers, nurses, and behavioral health specialists. They provide intensive care to teenagers who need something more than a weekly outpatient appointment can provide.
They also provide a step-down for teenagers who have been receiving inpatient treatment or who might need inpatient treatment but can possibly have something less intensive. At the beginning of the pandemic in March 2020, Bradley started delivering this care virtually. When we analyzed the data from the program, we realized that although the patients entering our programs during the pandemic had worse problems than previously, the outcomes were at least as good as for in-person care. We also, I think, quite excitingly, saw that there were several advantages for families and increased access.
Family involvement is a huge part of our programs, but we know that it's a really big commitment for families to drive their kids to and from programs every day and it makes it hard for some families to access care. We also know it's difficult for some parents to take time out of work for family therapy, but being virtual meant parents could even participate from their car in the parking lot at work and it gave them a lot more flexibility.
We're now expanding REACH regionally and nationally, where we've got active and growing partnerships with Boston Children's Hospital and with Connecticut Children's, and we're about to launch a partnership with a large community mental health center in Florida for a major expansion there. We're also talking to the tribal health centers about working with them to expand care in a way that's culturally appropriate and meet the huge needs and access challenges that they faced.
We're so excited about how this brings quality evidence-based care to children living in areas where this type of treatment would not normally be available. We think if we can increase access in this way, REACH can play a huge role in addressing the challenges that we all face nationally.
[00:12:16] Marthe: Yes, it's really exciting, Ellen, to hear about how Bradley has developed those partnerships and continue to develop them even after A&M was no longer involved. It's great. Talk about that involvement, what I'm really curious about and maybe that's a question for Karyn, when A&M came in to help you as a hospital to develop these kind of programs, of course, I myself I'm a doctor as well as background, I'm not a business person-- I became a business person through A&M, but I'm just wondering how you saw the combination, clinics and business thinking, specifically what are a few of the things you learned or that you noticed in that collaboration?
[00:13:00] Karyn: Well, I think that one of the things that we've realized, and this is something that we've always known, is that we need to meet children and families where they are. I think that we are thinking more and more about this. Children are in schools, they're in their pediatric offices. If they're receiving care, they're receiving care often in more community-based settings.
I think initially we thought that our strongest partners were going to be other academic medical centers. I think what we've really realized is that we need to be more boots on the ground in communities, partnering with the people that are already providing mental health treatment to children and families who are looking for this more intense level of care.
They may be doing individual therapy or family therapy, children, but they really are trying to prevent the child from requiring an inpatient stay, or they have a patient who's inpatient, that they're trying to bring them back home and they need more support than can be provided in a weekly therapy session. Those are really the places that we need to be meeting children and families more in the community.
[00:14:16] Marthe: Yes. In fact that really touches upon my next question as well, where this is more than pure clinical therapy. This really touches upon policy thinking and how to recreate the healthcare system when it comes to children's behavioral care. I was wondering if you felt that you really contributed to those policy discussions nationally or regionally.
[00:14:42] Karyn: I think that we're starting those discussions nationally, and we are hoping that we can become more engaged and more involved, but I do want to emphasize the point that you made that Bradley REACH really has three arms. There is the direct clinical treatment part through the partial and intensive outpatient programs and also we are offering and extending some of Bradley's experience. Bradley Hospital has been in existence for over 90 years committed solely to children's mental health and supporting children and families on their voyage to become healthier. We would like to be able to support people around the country with sharing some of this expertise.
This can include consultations. Many communities don't have levels of care and we are happy to share with other communities and other hospitals how to develop some of the programs that we have been able to develop here. In addition, there are organizations that are seeing more and more patients with mental health issues that they're not used to seeing.
We can support those organizations with providing care and support their staff in being able to do that. It can be challenging if you're let's say a pediatric nurse caring for a patient with a severe mental health condition or even caring for a child who's been suicidal, it can feel quite traumatic. We do have ways of providing education to staff who are now helping to care for more children and teenagers and families that have mental health conditions.
[00:16:35] Marthe: Speaking with that topic of policy initiatives, Ellen, can you tell us some of the challenges that Bradley REACH had scaling the telehealth initiative that Bradley REACH really is and what are the barriers to scaling such a program? I remember problems with licensing and recruitment. Are there larger policy solutions that need to be put in place to enable programs like REACH to reach intended people, children in areas that now do not have sufficient care?
[00:17:12] Ellen: Definitely. I'm so glad you mentioned licensure because that's one of the big problems we faced with scaling. As you know, states license clinicians separately generally. Some states are part of Licensure Compact, but often states in the Northeast where we started are not, although there's quite a lot of movement happening, in that Rhode Island is looking at joining the Interstate Medical Licensure Compact and the PSYPACT, Compact for Psychology, and similar things are happening in Connecticut and other states where we're working, but movement is slow.
I know there's also a lot of national federal policy energy around this issue too. It's something that the Department of Health and Human Services is concerned about. More flexibility in licensure would really help in getting care to kids who need it most in states where there's a shortage of child and adolescent psychiatric providers. That's huge. I think the other challenge we face is workforce.
As Karyn said, providers are often burned out right now and it's hard to find people, and that's true-- I think there are big advantages to providers from working virtually. I think that's the reason people are often very attracted to the program and what we offer, but the need for more providers in the future is huge, and it's a challenge.
[00:18:26] Marthe: Yes, because you are a telehealth initiative, the people you recruit do not necessarily need to live in Rhode Island. Right?
[00:18:35] Ellen: Absolutely. We've employed people in Baltimore, in New York. We're employing psychologists in Oklahoma. It's very exciting actually that we're able to build up a team of Bradley staff across the US.
[00:18:48] Marthe: The other thing that I think is great with REACH, is that it's really a prime example or proof of concept of how one hospital can try to take one of its programs and try to contribute to the solution of such a national problem. I was wondering what advice would you give other hospitals and your peers who similarly want to want to contribute to a change in the adolescent behavioral health space?
[00:19:21] Ellen: I would say that collaboration is key. I think we've realized that Bradley has got a huge amount to offer in terms of expertise in this area, but we're most successful when we collaborate with our partners and try to meet their needs, whether it's community mental health centers or large hospitals with EDs. This problem is so big and complex. I don't think any single institution or person has all the answers, but if we collaborate, I really think we can make some progress.
[00:19:46] Marthe: Yes, because, Karyn, there is a network that Bradley has started in the region.
[00:19:52] Karyn: Yes, we are working with Connecticut Children's Hospital to create a New England network to try to think together about other solutions around the children's mental health crisis, thinking outside of the box, including all of the partners that we have. There are so many organizations outside of hospitals, children's psychiatric hospitals, mental health providers who interface with children and are really part of the solution.
That network is trying to pull in all of the experts around children and caring for children, to think together about how to address the mental health crisis. We can't do this, like I said, without teachers, without families, without pediatric primary care and pediatric specialists. This is a real big problem, and it really needs to have a very inclusive group come together to try to address it.
[00:20:55] Marthe: Yes, and the potential of Bradley REACH is of course enormous, and coming back to the beginning of our discussion, the international scope of the problem is also something where Bradley maybe could play a role. You could imagine that even you would play in the international arena and serve children in other English-speaking countries and then vice versa also, learn about how these countries organize its continuum of care.
Like you say, Karyn, with people from schools and how you think about the bigger social environments of a child, that it's really child-centric and not institution driven. Well, I'd like to give both of you room for final comments, and then thank you for the amazing discussion and the time we spent together. Karyn?
[00:21:45] Karyn: I think that my final comment is that, if you're listening to this and you're a parent who has a child with a mental health condition, I want you to know that you're not alone and that there is treatment available. Always a good place to start is with your pediatrician, because they know you and your family the best and they can help you to figure out what's normal, what's typical, what might be something that could use more attention. I just want to be sure that if you have any questions about a child in your life, that you know that there is help available and that I would recommend starting close to home.
[00:22:28] Marthe: Thank you, Karyn. You, Ellen?
[00:22:30] Ellen: I just want to say that, although this problem is a really serious problem, that when we had our first meeting of the New England Pediatric Mental Health Network, Dr. Ashish Jha, who's now the White House COVID Advisor, said that the pandemic has actually created a window of opportunity to do something about the children's mental health pandemic, which has been going on for at least a decade, and this is a really exciting time and quite hopeful time, I think, to make progress in such an important issue.
[00:22:59] Marthe: Yes, and I think both comments are great and the fact that we go in this discussion from such high policy level back to the improvements you see actually in your patients and addressing parents and patients even here in this podcast, I think that's amazing. Thank you so much for your time and the discussion. For more information, please find us at www.alvarezandmarsal.com. Thank you for listening.
