February 14, 2018

Mobile child crisis team reduced hospitalizations, increased family communications

Photo by David Dalton.

The results of a year-long study conducted by the Wayne State University School of Medicine and Wayne State University Physician Group published this month in an Oxford Academic Journal reveals how a multidisciplinary approach to screening children having mental health crises made it is possible to deliver quality, cost-effective care and prevent children from being hospitalized unnecessarily.

The study utilized a mobile crisis team, or MCT, at 18 hospitals in Michigan, with 74 percent of the cases seen at Children's Hospital of Michigan at the Detroit Medical Center. The published study looked closely at the second year of a two-year program implementation, collected for a quality improvement project.

The MCT social workers were tasked to rapidly assess the family and child, intervene briefly if necessary to obtain additional information, summarize the information for the psychiatrist -- who used telemedicine -- and either answer directly or help families answer questions posed by the psychiatrist.

In "Social Workers and Mobile Child Crisis Screening," published in the February issue of Health and Social Work, a journal of the National Association of Social Workers Press, Professor of Psychiatry and Behavioral Neurosciences Cynthia Arfken, Ph.D., writes that, "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."

Dr. Arfken conducted and interpreted the analysis, and wrote the study manuscript.

Cumulative effects of poverty, stress and trauma can lead to a behavioral health crisis, especially in children living below the poverty line, the study suggests. In the Detroit area, those under 18 years old who come to the emergency department with behavioral health problems such as aggression or self-mutilation are typically screened by hospital-based social workers or psychiatrists. Traditionally, children are recommended for psychiatric hospitalization if they are a danger to themselves or others.

In year two, social workers made 452 trips to emergency departments to see 336 children, with one child seen seven times during the year. More than 57 percent of the children were female, nearly 69 percent were African-American and 60 percent lived in Detroit. Additionally, 61.5 percent were age 14 or older. Depression and substance abuse were the most common diagnoses, at 69.5 and 53.1 percent, respectively.

Public funding of mental health services in Wayne County was delivered through five Managers of Comprehensive Provider Networks, or MCPNs.

"The cooperation of physicians, nurses and social workers greatly helped facilitate the program," Dr. Arfken said.

Program funding ended last year, but there is interest from outside organizations to restart it.

"This was an interdisciplinary team comprised of social workers, nurses, peer support specialists, and psychiatrists," said WSUPG Psychiatry and Behavioral Neurosciences social worker Audrey Gilliatt, the study's lead author. Kelly Powell, L.M.S.W.; Albert Pizzuti, R.N.; and Gilliatt originally piloted the program under the direction of Alireza Amirsadri, M.D. They developed the forms, received initial training and then continued to receive training with regular case conferences. As the program expanded, other social workers, a professional counselor and nurse practitioners were added.

Before the initiation of the mobile crisis and hybrid tele-Psychiatry program, the hospitalization rate was 100 percent. "As described in year one of this program, inpatient hospitalization decreased to 42 percent. In year two, inpatient hospitalization decreased to 29 percent," said Department of Psychiatry and Behavioral Neurosciences Chair and Professor David Rosenberg, M.D.

After the psychiatrists arrived at a disposition, the MCT social worker communicated the information to the emergency department staff and helped the child and family understand the decision.

"Most importantly, the MCT made a difference in the lives of these children and their families. We provided both individual and family therapy in the emergency department and were able to identify some of the reasons behind the admission to the emergency department, often getting families to talk to one another for the first time about what was going on. Families reported they felt listened to and respected. It was gratifying to see some of these families open up and feel safe enough to talk about things that were difficult, and the talking reduced the crisis," Gilliatt said. "We gave our cell phone numbers to the child and the family and encouraged them to call with emergencies. Families said they appreciated being given this individual attention and felt reassured they could reach someone if needed. Our experience was that they called only when necessary. We also made at least three follow-up phone calls to the families to provide support and make sure they could access outpatient services."

When enacted, the MCT made a difference in many ways, Gilliatt said. "To the system, by reducing time the children spent in the emergency department, reducing inpatient admission for those children that did not need to be hospitalized; also linking families to follow-up care to reduce return visits to the emergency department. This represented a big cost saving. We were told by hospital staff that they appreciated the MCT coming in quickly and formulating discharge plans that were safe and effective."

Except for a social worker hired to cover a third shift, the program relied on social workers to volunteer for extra service assignments on days they chose to be on call.

The project differed from a similar intervention introduced in 2014 that demonstrated a 94 percent reduction in inpatient hospitalization when adults presented at emergency departments in crisis, saving Michigan State Medicaid $7.6 million in a single year, Dr. Rosenberg added. In this intervention, the child and their family stay at the emergency department. The emphasis is less on immediate use of medication and more on reassuring families, reducing conflicts and facilitating communication between the family members, so everyone hears the child, he said.

"Our experience with this program underscores the need to support families and not just individual patients in time of need. Our ongoing training through case conference and less-formal case discussions explore ways to implement high-quality team care through respectful use of scarce resources," Dr. Arfken added. "In this example, we lowered costly hospitalizations and diverted the children to more appropriate care. However, we did not eliminate hospitalizations. They remain a vital part of the behavioral health care continuum."