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How Children’s Nebraska is Advancing Pediatric Mental Health Through Caring Contacts · Becker’s Healthcare - Clinical Leadership Podcast

0:00
Welcome everyone to the Becker's Healthcare podcast series.
0:02
I'm Mariah Muhammad, writer and moderator with Becker's
0:05
Healthcare. I'm thrilled to have with me today
0:07
Renee Rafferty. Senior vice president of behavioral health
0:10
and wellness is Sabrina Shally, director of behavioral
0:13
health integration and program coordinator at Children's Nebraska.
0:16
Renee and Sabrina, welcome to the podcast. We're
0:18
very excited to have you join us today.
0:20
To get a start, would you mind please
0:21
introducing yourself and telling us a bit about
0:23
your background? Yes. Thanks so much, Mariah.
0:26
I'm Renee Rafferty,
0:28
senior vice president of behavioral health and wellness.
0:30
I am a therapist by trade and have
0:32
been in a leadership role for over twenty
0:35
years. I have will worked in the full
0:37
continuum of care, outpatient,
0:39
inpatient residential crisis services,
0:43
as well as integrated behavioral health. And and
0:45
just I'm very excited to talk with you
0:47
today.
0:48
And, yes, it's lovely to meet you, Mariah,
0:51
and get a chance to share about our
0:53
program. My name is Sabrina Shalley. I'm a
0:55
licensed clinical social worker by discipline,
0:58
and this is actually my thirtieth year in
1:00
the field. I began as a,
1:03
clinical counselor and therapist for adolescents,
1:07
and working with kids and their families has
1:09
remained
1:09
my passion throughout my career,
1:12
and,
1:13
have also really been excited to lead Children
1:16
Nebraska's efforts for suicide prevention,
1:19
in hopes that we can accomplish zero suicides.
1:22
So excited to talk more about our efforts
1:24
in that space today.
1:25
Yes. Yes. Thank you both for giving us
1:27
that background and, obviously, amazing work that you
1:30
are doing, in that field. Sabrina, going to
1:33
you for,
1:34
my first question. How did the idea for
1:36
implementing caring context in a pediatric setting originate?
1:40
And what made Children's Nebraska decide to adopt
1:43
this historically adult focused intervention
1:45
and lead its utilization
1:47
for children and teens?
1:49
Well, thank you so much for giving us
1:51
a chance to tell this part of our
1:52
story.
1:53
I am celebrating eight years here at Children's
1:56
Nebraska. And prior to the role I'm in
1:58
now, I had the great opportunity to,
2:01
support and lead the medical social workers, which
2:04
included our emergency department
2:06
social workers who in our continuum of care
2:09
provided the mental health assessment for kids who
2:12
were coming in for suicide ideation or suicidal
2:15
behaviors.
2:16
And when I joined Children's in 2017,
2:19
it was right as we really began to
2:21
see a ramp up in the number of
2:23
kids needing to come in for those services.
2:26
And as I was supporting those social workers,
2:28
I was hearing
2:29
about how difficult it was for them, you
2:31
know, in a eight or twelve hour shift
2:34
to be working with child after child after
2:37
child.
2:38
And so we were doing some things to
2:40
try and support them.
2:42
The medical team that surrounded them was amazing,
2:44
but that was on my brain. At the
2:46
same time,
2:47
as a leader continuing to hear about we
2:50
were we were nearly doubling our rates of
2:52
kids needing new services.
2:53
And I'll be honest, it was,
2:56
fall season because I was watching a Kansas
2:58
City Chiefs football game.
3:00
We are in our glory years. I readily
3:02
admit that. But during commercials is when I
3:04
like to catch up on magazines.
3:06
And there was a Time magazine article in
3:08
the 2019
3:10
all about these handwritten note cards that were
3:12
used in adult substance use and misuse recovery.
3:17
And I thought, oh, I don't really want
3:18
to read this article right now. It's Sunday.
3:20
I'm watching football. And I thought, no. I
3:22
probably really need to read this.
3:24
And I read it and I just thought
3:27
that magic of that personal touch of when
3:30
you get to meet someone in their most
3:32
vulnerable moments
3:33
and,
3:34
they tell you their story and then you
3:37
help them make recommendations of what the next
3:39
step on their journey is,
3:41
but then you don't have contact with them
3:43
again potentially forever,
3:46
how that must feel to the patient, let
3:48
alone how that was feeling to the social
3:50
workers. So I brought it to our emergency
3:52
department social work team, and I said, what
3:54
would you think if we tried something like
3:56
this?
3:57
And they all immediately got on board,
3:59
and we're really excited about the opportunity. So
4:01
we really dove in. We learned
4:03
about zero suicide.
4:06
We traced the history of these handwritten caring
4:08
contacts note cards.
4:10
We did some benchmarking with the Children's Hospital
4:13
Association and found out this wasn't being utilized
4:15
in any sort of environment that we could
4:17
uncover. We had an amazing practicum student that
4:20
helped us roll it out. And I want
4:22
to bring back to attention the timeline that
4:24
we started this, which was fall of twenty
4:26
nineteen. We had no idea what was coming
4:28
in March.
4:30
We had set a go live date of
4:32
05/01/2020,
4:34
which took us about six months to develop
4:36
the program,
4:37
to create what we thought would be an
4:38
effective clinical intervention.
4:40
And I'm really proud to say that despite
4:42
the COVID pandemic happening, we did go live
4:44
on May 1.
4:47
And since that time, we just celebrated,
4:50
five years. We have enrolled nearly 1,200
4:53
patients into the program.
4:56
And the best news of all is we
4:57
have zero deaths by suicide in our patient
5:00
population in this space. So,
5:02
that's how it came about, a random article
5:04
being read,
5:05
that was used in the adult space.
5:08
Wow. That's absolutely amazing. Thank you so much
5:10
for sharing that. And you're now five years
5:12
into the program,
5:14
and, obviously, it's going really well. But what
5:16
outcomes or trends have surprised you the most,
5:19
especially in terms of patient response and impact?
5:22
Oh my goodness.
5:24
You know, our biggest hope as we as
5:26
we went into this is that,
5:29
we really wanted to reduce
5:31
our kids that were returning to us, for
5:34
repeat suicide ideation or suicidal behavior.
5:37
We also,
5:39
thought that it might give us a chance
5:41
to decrease the number of kids who died
5:44
by suicide.
5:45
We thought it would help normalize mental health
5:48
and needing to come in for support with
5:50
our pediatric health care team, but also we
5:53
thought there was potential for it to impact
5:55
our community in a positive way. And
5:59
just showing a token
6:00
of support
6:02
for these individuals. I wanna be really clear
6:04
that we never intended to replace the needed
6:07
steps
6:07
for kids after they come in for
6:10
suicidal ideation or behaviors.
6:12
We always needed to encourage them on to
6:15
go into inpatient care or to connect with
6:18
an outpatient
6:19
or intensive outpatient team.
6:22
These were really, like, we met you, we
6:24
care about you, and we're gonna continue to
6:26
cheer you on in your journey. So the
6:28
cards are written really carefully,
6:31
so that they speak to that component.
6:34
But really, magic started to happen, and it
6:37
started happening right away when the kids started
6:39
writing back to us. And I have some
6:41
cards I could read you some quotes from.
6:43
We had no idea that the kids, you
6:46
know, unprovoked, would choose to write. We've had
6:48
kids that have called, like, our our Children's
6:51
Nebraska agency line and say, hey. We're trying
6:54
to track down a social worker,
6:56
you know, and we don't we only remember
6:57
her frictioning with this. And they literally, like,
6:59
ping ponged through our system and are leaving
7:01
messages for those social workers.
7:03
We had no idea that we would hear
7:06
from their families,
7:07
that families were writing us and sending us
7:09
pictures of their
7:11
child. We got one picture where it was
7:14
the child on their on their bed with
7:16
their comfort
7:18
cat,
7:19
and all of the handwritten note cards. We
7:21
send six in that year.
7:23
We're all hanging
7:25
by the side of her bed, and the
7:27
mom was saying, this is the most amazing
7:29
thing. They're concrete. They're tangible. She reads them
7:32
over and over,
7:33
and I just wanted you to see this
7:35
picture of my happier and healthier child than
7:37
when you first met her.
7:39
We also then
7:41
really didn't know that we would begin to
7:43
see our social workers that were doing this
7:46
work no longer felt like it was a
7:48
churn and burn or a one and done
7:50
environment. They actually felt
7:52
that empowerment
7:54
to continue to support the patients,
7:56
in this really profound way. So the retention
7:59
rate improved for us with our emergency department
8:02
social workers.
8:03
I think since we started, we've lost only
8:05
one or two to moving out of state
8:07
or, different positions in our organization, and so
8:10
it's really stabilized that team.
8:13
And then as we began to share
8:15
successes after we've run the program for one
8:17
year,
8:18
it we heard from our division chief,
8:22
of our emergency department. He said, hey. None
8:24
of my peers are hearing any you know,
8:26
they're not doing anything like this. We need
8:28
to start telling people about the results.
8:30
And so we've done a bit of that.
8:32
We created a replication kit, and we've been
8:34
able,
8:35
to share that,
8:37
with over 70 different,
8:38
health care systems so far.
8:41
So that's been been really exciting.
8:44
Yeah. Yeah. As of that definitely sounds exciting.
8:46
And you answered,
8:48
my next question a little bit, but, obviously,
8:50
the program has expanded significantly with over a
8:53
thousand patients, enrolled,
8:55
and replication kids share with hospitals and schools
8:58
nationwide. Can you explain what the adoption process
9:01
looks like? And you say you share you
9:02
have,
9:04
over 70 institutions that have adopted the model?
9:07
We've shared with over 70 institutions, Mariah,
9:11
and we're really pleased to do that. We're
9:13
happy. We've presented on this program to conferences,
9:17
to larger groups, but we also get thrilled
9:19
to meet with,
9:21
health care institutions
9:22
one on one and really talk through
9:25
how we've lifted the program here. I mean,
9:27
you've got things like
9:28
HIPAA and compliance. Right? We need to get
9:31
guardian permission to be sending these note cards.
9:34
We,
9:35
need to ensure,
9:37
that the patient expects that these cards are
9:39
coming.
9:40
And so we have a ninety per ninety
9:42
eight percent of our patients that we offer
9:44
this program to,
9:46
choose to enroll. So that's really amazing.
9:49
But I will say I don't know how
9:50
many who have chosen to adopt the handwritten
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part.
9:53
We're really grateful to Children's Nebraska that we
9:57
are able to allocate our social workers time
9:59
to writing these cards.
10:01
I know there are some other health care
10:03
institutions that are doing some really neat things
10:05
with regard to texting
10:07
and those components,
10:09
but we haven't been able to argue with
10:10
the results of zero suicide.
10:12
We also have a substantial decrease in kids
10:15
that are in the program that return to
10:17
the emergency department,
10:19
with regard to any sort of suicidal thoughts
10:22
or or gestures.
10:24
And,
10:25
actually, we begin to see more and more
10:27
of our kids,
10:29
that we are seeing if they do come
10:31
back, are able to discharge home with a
10:32
safety plan and lethal means counseling as opposed
10:35
to going into a higher level of care.
10:37
So all of those things have told us
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we've really that we aren't at this time
10:41
going to change our process, and we're gonna
10:43
stick with the hand written cards.
10:46
Got it. Got it. Thank you so much
10:47
for explaining that. And read it Renee, how
10:49
do you maintain the personal and meaningful nature
10:52
of the handwritten notes, especially as the program
10:54
scales?
10:55
Can you share any memorable stories or feedback
10:57
that really
11:04
importance of using innovation and text is great,
11:07
and those things are wonderful tools. And I
11:10
think what we've realized through this program,
11:12
when you send that card and that child
11:14
was able to connect with the person that
11:16
they sat with during their most difficult moment,
11:18
they're able to recognize that
11:21
this connection
11:22
is a sign of hope and healing, and
11:24
they get these multiple reminders of that courage
11:27
it took to reach out, the ability to
11:29
trust their own inner wisdom, and work with
11:32
the the the person that's shared their story.
11:34
So I think those cards,
11:37
themselves are really a testament to the importance
11:39
of connection and that however we heal is
11:41
usually through connection with our caring team. And
11:45
I think that the
11:47
I'll have Sabrina read a card to you
11:49
of of what is said because I think
11:51
that just is is a one card from
11:53
a child touches hundreds of caregivers because we
11:56
do share the exciting words and not sharing
11:59
the identity of the child, but just the
12:01
healing that happens. And that, like Sabrina says,
12:04
is so healing for the our team to
12:06
remember that this treatment actually works. People do
12:09
heal from mental health conditions, and they do
12:12
really respond to powerful visits,
12:15
and it can be trajectory changing. So, Wendy,
12:17
you wanna go ahead and read one for
12:18
us? Yes. Yes. I'm happy to.
12:21
So, Mariah, here's a card we got back
12:24
from one of our patients, and she writes,
12:26
thank you so much for sending that letter.
12:29
I can't even begin to tell you how
12:31
much it meant to me. I got the
12:32
letter the day of my birthday and started
12:35
sobbing in the car. I'm glad I know
12:37
I have someone rooting for me. It was
12:39
so kind of you to reach out.
12:42
I'll take a moment to read another one
12:45
that I think is really impactful.
12:47
This is someone,
12:48
who wrote back after all six cards had
12:51
been sent for that first year. And she
12:53
says, I have always meant to write back
12:55
to you.
12:56
The cards mean so much to me. Each
12:58
one is hanging up in my room. I
13:00
wanted to let you know how much of
13:02
an impact the cards have and to know
13:04
someone I met once cares so deeply for
13:07
me. I'm doing the best I have been
13:09
since a year ago. I never imagined this
13:11
much happiness was waiting for me. There have
13:14
been hard times, but I have been able
13:16
to overcome them and become better in the
13:18
end. I can never thank you enough for
13:20
all you have done in my healing journey.
13:22
And, again, that's just a reminder that that
13:24
social marker met this patient once and six
13:27
handwritten note cards. I mean, again, just a
13:30
bit of magic.
13:32
Yeah. Absolutely. Thank you so much for sharing
13:35
those. And looking ahead, how do you envision
13:37
caring contacts evolving with Children's Nebraska? Are there
13:41
any plans at all to expand beyond behavioral
13:44
health into,
13:45
other areas of care where connection might also
13:48
improve outcomes?
13:50
Yes. And I'll I'll answer the being that
13:52
somebody you weigh in. But I think, ultimately,
13:54
it's very important to say that, you know,
13:57
interventions for kids experiencing mental health conditions happen
14:00
across our continuum.
14:02
We are training within Jones Nebraska. We have
14:04
a program called COPE, which is children's outreach
14:07
and provider education. And we train pediatricians to
14:10
treat mild to moderate conditions within,
14:13
primary care. And I think there's opportunities to
14:15
expand in those types of settings to bring
14:18
to outreach to other hospitals and to continue
14:20
to talk about the importance of that personalized,
14:24
deep trauma informed connection that allows for that
14:27
sense of hope, which we know is really
14:29
the key to healing. So I think we
14:31
plan to you know, Sabrina's
14:33
excellent at being able to support and to
14:35
continue to provide that implementation. And we are
14:38
gonna be using it as we expand our
14:39
services.
14:40
We have used it in our behavioral health
14:42
urgent care,
14:44
out in Kearney, Nebraska and have found that
14:46
the kids absolutely love it out there as
14:48
well. And so it's it's just a very
14:50
it's a tool that we'll continue to support
14:52
and offer to others as well as inside
14:54
of our, inside of our programs, that are
14:57
not just behavioral health programs or behavioral visits.
15:00
They're,
15:00
treating behavioral health in other parts of the
15:02
continuum.
15:04
Yeah. Agree with that, Renee.
15:06
We've really been on a robust
15:08
journey with zero suicide, and caring contacts falls
15:12
under the transition arm of that.
15:14
But what it's also taught us is that
15:17
ability to have a conversation with the family
15:19
while they're with us in crisis
15:21
and saying, hey, we're gonna continue to support
15:23
you, and this is what it'll look like.
15:25
And we've added some other tools to that.
15:27
We've really created a robust lethal means counseling
15:30
program. We're not only we providing the concrete
15:33
objects like lock boxes and gun locks and
15:36
those sorts of things, but we also teach
15:38
them how to do a home sweep. We
15:39
send them home with those materials so they
15:41
know how to make their home safer for
15:43
their child to return.
15:45
We have adapted
15:47
the safety plan and are using it in
15:49
really unique ways across our entire continuum.
15:52
We do universal screening for depression and suicide
15:55
across our Children's Nebraska,
15:57
programs on units and clinics, which helps us
16:01
identify kids, who are at risk.
16:04
And just over last year, we identified
16:07
well over 100 kids who actively had a
16:10
suicidal plan that we're here for some other
16:12
reason
16:13
besides mental health care. And I think those
16:16
are the things that keep us motivated
16:18
moving forward just like these really amazing responses
16:21
we get from our patients in the caring
16:23
contact program.
16:25
Wonderful. Thank you so much for explaining that.
16:27
And, Sabrina, Renee, before I let you go,
16:29
the last thing I wanted to ask is
16:30
beyond caring context,
16:32
how is Children's Nebraska leading excellence in pediatric
16:35
behavioral health?
16:37
What's on the horizon for bringing hope to
16:39
children and families right now?
16:41
That's a great question. I love answering it.
16:43
It's such an exciting time to be part
16:45
of Children's Nebraska. In January,
16:48
we will be opening a behavioral health and
16:50
wellness center that's part of our hospital system
16:53
that provides a full continuum of care of
16:55
behavioral health services.
16:57
And this building,
16:59
as being part of our health care system
17:00
is unique in that it is also no
17:02
wrong door. So when, kids have a behavioral
17:05
health crisis, they can walk in our front
17:06
door and they can receive behavioral health urgent
17:08
care so they can meet with a therapist
17:10
and work on, you know, a crisis that
17:13
is occurring. But they can go back home
17:14
and see be with their family if they're
17:16
stable and can return back home. But we
17:18
also have crisis stabilization
17:20
that is, twenty three hours and fifty nine
17:22
minutes. Kids can come in and stay for
17:24
a while to provide more stabilization,
17:26
be able to see a psychiatric nurse practitioner,
17:29
psychiatrist,
17:30
get therapy as peer support, and be able
17:33
to receive those services that also can hopefully
17:35
stabilize,
17:36
them back to go home. But if need
17:38
be, they can also be,
17:40
admitted to an inpatient
17:42
psychiatric
17:43
unit that will help to offer that higher
17:46
level of care for for acute services.
17:48
We also will have a day treatment program
17:51
that provides mental health care,
17:54
as partial hospitalization.
17:56
And then we have our eating disorder program
17:58
that will also be expanding. It's a partial
18:00
hospitalization we have,
18:02
but we'll be expanding. So we have 10
18:04
patients that can be in that program. So
18:06
just a really large continuum of care, behavioral
18:09
health service, as well as we'll have primary
18:11
care located in our wellness center too. And
18:13
the goal is to really help, destigmatize
18:16
care, recognizing that please reach out early.
18:19
Please,
18:20
come in the door. We'll help you navigate
18:22
the system and really create that seamless transition
18:25
depending on what the child needs that families
18:27
don't have to figure out where to go.
18:28
We have excellent services right now, but it's
18:30
just gonna be so exciting to offer the
18:32
this, full continuum in January.
18:36
Wonderful. Wonderful. Thank you both so much for
18:38
those final thoughts. It's definitely been a very
18:41
informative discussion. So, again, I wanna thank you
18:43
so much for coming on Becker's Healthcare and
18:44
explaining that. And I look forward to connecting
18:47
again with you both soon.
18:49
Thank you so much. So much, Brian.