Health systems are responding to fragmented behavioral healthcare delivery in different ways: expanding telepsychiatry in rural states, building pediatric health hubs that integrate mental and physical health on one campus, launching behavioral health urgent cares, and investing in navigators and data infrastructure to keep patients connected after discharge.
In West Virginia, the access challenge is especially stark.
Keri Law, MD, a child and adolescent psychiatrist and vice chair of clinical services at WVU Medicine in Morgantown, W.Va., told Becker’s that 50 of 55 counties are federally designated mental health professional shortage areas. As a result, some families must travel two to four hours for specialty behavioral healthcare — if it is available at all.
Over the last three years, virtual care has become a critical strategy for improving access.
“In terms of just our volumes, the number of total patient visits that we’re seeing virtually in our clinic, within the department of behavioral medicine and psychiatry, are still lingering a little over 50%,” she said. “And that’s with having about 100,000 patients per year, and with kids they’re a little bit less, but still at around a third of our children are seen virtually.”
Dr. Law said virtual visits have helped improve access, shorten time to first appointment, and strengthen continuity of care, particularly for pediatric patients and those in remote areas. No-show rates are often lower for virtual visits, especially in rural populations, where transportation and weather can be major barriers, she said.
Building shared data networks
At the national level, children’s hospitals are also collaborating to address fragmentation through shared data and infrastructure.
A behavioral health leadership collaborative within the Children’s Hospital Association has joined forces with a youth suicide prevention initiative to form a network of 30 hospitals focused on the advancement of pediatric behavioral health through data-sharing and evidence-based models, Stacy Drury, MD, PhD, psychiatrist-in-chief at Boston Children’s, told Becker’s.
Fragmented data is a common challenge in behavioral health. By connecting systems and standardizing processes, hospitals can avoid building programs in silos.
For example Columbus, Ohio-based Nationwide Children’s operates its own behavioral health transport to more efficiently transfer children from the emergency department to inpatient care.
“[Nationwide Children’s] had all of the policies and procedures already in place,” Dr. Drury said. “They knew how to make the car, and they built it again at Cincinnati Children’s, so now we have one and there’s another one on the north shore in Boston.’”
EMR integration to bridge physical and mental healthcare
At Cincinnati Children’s, leaders are also working to decrease barriers between physical and mental healthcare through data integration, Laurel Leslie, MD, director of the hospital’s mental and behavioral health institute, told Becker’s.
“We’ve found a way for outpatient mental health providers that are not in [Cincinnati] Children’s to be able to link into our EMR, and then they can track if kids have come into the emergency department, if they’ve been hospitalized,” she said. “We can also see if they have openings available.”
In addition to improving coordination through data, some systems are investing in physical integration.
Boston Children’s Hospital is developing a $640 million pediatric psychiatric hospital on Franciscan Children’s campus aimed at integrating mental health across pediatric medicine, Stacy Drury, MD, PhD, psychiatrist-in-chief, told Becker’s.
The project will include 116 inpatient beds and a day hospital with 24 slots for partial hospitalization and intensive outpatient programs, as well as a 14-bedroom, community-based acute treatment program. The building will house a dental suite, a surgical suite with four operating rooms and 10 preparatory and post-recovery slots, a pharmacy and an outpatient rehabilitation space.
Patients and their families are able to shift between partial-hospitalization programs and outpatient services or connect with a higher level of care, she said.
“To have that capacity in the same building is huge. Families don’t have to choose between getting their dental care and getting their mental healthcare,” Dr. Drury said. “I think being very intentional about the medical complexity kids with neurodevelopmental disorders really need to be within the same place.”
Providing navigators to support patients after discharge
Health systems are also addressing fragmentation in the transition from acute care to the community.
Behavioral health and substance use navigators connect patients to aftercare services following discharge from the emergency department — a point at which many patients disengage from care, Itai Danovitch, MD, chair of the department of psychiatry and behavioral neurosciences at Los Angeles-based Cedars-Sinai Medical Center, told Becker’s.
Navigators help link patients to the resources they need to remain connected to substance use disorder services and their communities. They do not provide psychotherapy. Instead, they serve as nonclinical, peer-based supporters focused on engagement and trust building.
“It takes time to engage a patient who’s been traumatized, or feels stigmatized or embarrassed and ashamed of some of their behaviors,” Dr. Danovitch said. “These are roles that can help with some of the soft skills that are so important to engaging individuals who have had negative experiences with hospitals in the past.”
Strengthening the health system workforce pipeline
Fragmentation also exists within health system workforces.
New York City-based NYC Health + Hospitals, the largest provider of behavioral health services in the city, has focused on closing gaps in its behavioral health workforce through a strategic recruitment and retainment plan. With 11 acute care facilities and more than 30 community health centers, fragmentation can happen at both the departmental and system levels.
When human resources, finance and program leadership are not aligned, initiatives can stall and responsibilities can fall between departments, Omar Fattal, MD, system chief of behavioral health, told Becker’s. Fragmentation can also emerge between individual facilities and system leadership.
To address this, the system brought leaders together around a shared strategic plan, aligning objectives and preparing departments for upcoming changes.
“What we’ve done is really centralized the scaffolding, support and structure, but not the people, in the sense that we definitely standardized data,” Dr. Fattal said. “You cannot do this work without data. You cannot fly this plane completely blind. And you really need to know how many vacancies you have. For every program that we have, you have to keep track of, ‘Is it working? Is it not working?’”
The system has since adopted a data infrastructure that tracks programs, vacancies and open positions to better support retention and workforce planning.
Another strategy to reduce fragmentation is diverting appropriate patients away from the emergency department.
St. Louis-based SSM Health has adopted a behavioral health urgent care separate from the emergency department. The facility is staffed by psychiatric nurse practitioners, nurses and social workers, and provides care for patients who have run out of medication or could not secure a timely psychiatrist appointment, Becky Dvorak, MSN, RN, regional vice president of behavioral health, told Becker’s.
“Getting into a psychiatrist could take months,” she said. “This helps meet the need early on instead of waiting four months and turning it into a crisis that ends up in the hospital.”
The system is working to ensure EMS providers are comfortable transporting patients directly to the urgent care rather than the emergency department. Through county grants, EMS providers can be reimbursed for transporting certain patients to urgent care, helping support the shift in care pathways.
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