Putting Kids First: Investing in Pediatric Mental Health Care

October 21, 2022

Transcript

Dr. Angela Kade Goepferd:  This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. It is no secret that we are facing a mental health crisis among our pediatric patients. Kids and teenagers have higher rates of depression and anxiety than ever before, and suicide has now become the second leading cause of death for adolescents. More and more of our patients and families are seeking mental health care support and services, and we have an unfortunate shortage of pediatric and adolescent mental health specialists to fill that need. This has resulted in kids showing up in our clinics and emergency departments in crisis, sometimes spending days to up to weeks sitting in a hospital awaiting specialized inpatient mental health care.

There appears to be no easy fix on the horizon for this issue, but here to talk to us today about the landscape of pediatric and adolescent mental health care and some steps that Children’s Minnesota is taking to help with those gaps in care is Jamie Winter, RN, MBA, Director of Inpatient Mental Health Services and the Emergency Department here at Children’s Minnesota. Jamie is also winner of a 2022 Healthcare Heroes Award from the Minneapolis St. Paul Business Journal for her leadership and strategic planning and advancing intensive mental health services at Children’s Minnesota to meet our community-wide pediatric mental health needs. Jamie was instrumental in opening our first partial hospitalization program in Lakeville in June of 2021, and is also leading the opening of a 22 bed inpatient unit at our St. Paul campus this fall. Jamie, thanks for joining us today.

Jamie Winter: Yeah, thank you so much for having me.

Dr. Angela Kade Goepferd: I should have mentioned, as I was telling everyone all the great work you’ve done in mental health and how much of a hero you are, that you’re also a mom to two sets of twin girls.

Jamie Winter: Yes, I am. It’s a fun fact about me. I have two sets of identical twins and so not planned, but very exciting.

Dr. Angela Kade Goepferd: You should get a Healthcare Hero Award just for that.

Jamie Winter: Mom award. Yes.

Dr. Angela Kade Goepferd: Yeah. That’s something you and I have in common, having twins, but I’m thankful to just have one set. So let’s get into talking a little bit about your role on the operations side of the mental healthcare team. Many of our guests on the show have mostly been clinicians and other healthcare team members. We haven’t often had a chance to talk to our partners who do operations, who are obviously a critical part of helping us meet our mission to put kids first. So how did you get interested in kind of healthcare operations or doing that kind of work?

Jamie Winter: Yeah, so my background is as a nurse. So I worked clinically at the bedside for a number of years and really wanted to start thinking about how to implement system change, and so moved in the direction of leadership and operations leadership to really try to think about how it could impact the most kids and really provide the best care to the largest number of kids possible. And so moved into the direction of leadership, started in nursing leadership and then expanded from there. And I’ve really just been really grateful to think about those system changes and how we put in place care delivery strategies to impact the largest number of kids.

Dr. Angela Kade Goepferd: And have you always been in pediatrics or how did you get started there?

Jamie Winter: I haven’t. I actually started in the emergency department, and so worked in a large hospital locally, seeing full age range of people, so kids, adults and geriatrics. And then once I had kids of my own, really found that I was drawn to working with kids and really liked that dynamic of thinking about family centered care and partnering with parents who are navigating through a similar life stage that I was. And so really moved into pediatrics at that point and haven’t looked back.

Dr. Angela Kade Goepferd: And is that when you came to Children’s, was that your first foray into pediatrics?

Jamie Winter: It was, yep. So actually I had just had my second set of twins here at Children’s and got to experience firsthand the wonderful care that we provide. And so we spent 20 days in the special care nursery here at Children’s with my second set of twins and really just loved kind of everything that Children’s was, our mission, vision, the bedside nurses that we had, the providers, and so came here and have loved it.

Dr. Angela Kade Goepferd: So I first met you when you joined as manager of our primary care clinic, which you did a phenomenal job of by the way. But then you sort of moved over to help with mental health services. So what drew you to the mental health side of care?

Jamie Winter: So mental health is actually more familiar to my background. So I worked clinically as a nurse in mental health and that was where most of my leadership experience had been prior to coming to Children’s. Primary care was actually a step outside of my comfort zone. It wasn’t something I had done before. And so in that role got a chance to do both primary care, adolescent medicine, and then our integrated behavioral health team as we kind of spread through our primary care clinics here at Children’s. And so for me, it was really a natural step to step back in and take a bigger role in mental health because that was what I really knew from my clinical nursing experience.

Dr. Angela Kade Goepferd: I couldn’t tell that you were out of your element in primary care. You did a great job. For those of us who are taking care of kids, whether it’s in primary care, in the emergency department, in the hospital, we see all the time the challenges that we’re facing, kind of helping kids with their mental health. There’s not enough appointments, there’s not culturally specific resources, there’s not this spectrum of services to meet kids who are at varying levels, whether it’s outpatient or inpatient or partial hospitalization. So I see it from where I sit as a clinician. But from your side, what are the biggest challenges on the operational side of the care we provide, trying to advocate for more mental health services?

Jamie Winter: Probably not surprising and not necessarily unique to mental health, I think some of the operational challenges that we face are really related to staffing, to workforce, so just really understanding how we can attract and build that pipeline for recruitment, for mental health clinicians to come to Children’s and to be able to provide these amazing services for kids who need them so desperately. The other thing I would say is really thinking about how we pull in that financial story. So I know that that’s not always the piece that we lead with, but it is important as we think about building that financially sustainable healthcare business is really how do we do so in a way that will make financial sense as well. And so really balancing that story of the care that we need to provide and doing the right thing for patients and families, but also building in the piece about how we do it in a way that is financially responsible and sustainable. And so it’s often balancing that and pulling on kind of my clinician [inaudible 00:06:45] partners to help tell that story from both lens.

Dr. Angela Kade Goepferd: When it comes to the financial side of mental health care, I don’t really know much about that as someone who’s kind of in the exam room with the patients. What I imagine is that it’s not highly reimbursed care.

Jamie Winter: It’s not.

Dr. Angela Kade Goepferd: And so are hospitals who are trying to provide services off and running at a deficit to do that?

Jamie Winter: Mental health services universally typically run at a deficit in most hospitals. Certainly on the inpatient side, you can bring in some additional revenue to hopefully break even. But really mental health services are not a financially lucrative service, but are in that compliment of services that we need to provide when we think about whole child care. And so we’ve been really fortunate here at Children’s to have really great support from our executive leadership team to prioritize mental health services, knowing how important they are to the kids and families we serve, and how central they are to our mission and vision, to move them forward regardless of the fact that we often lose money for every visit that we do.

Dr. Angela Kade Goepferd: And I would imagine in that arena that any kind of philanthropic support or donors who have made investments to help us get those services off the ground have been really important.

Jamie Winter: So important. Yeah, we rely heavily and as we’ve opened our inpatient unit, it’s been really important for us to have that support as we think about wanting to grow and expand our services. Again, just really thinking about how we meet the demand, which has really risen over the last couple of years, and do so in a way that meets patients and families where they’re at. And so I think it’s really important for us to continue to have partnership with the foundation and receive those philanthropic support in order to be able to continue to grow and expand our services.

Dr. Angela Kade Goepferd: For us at Children’s Minnesota, equity is a huge part of our mission and the care that we provide. And one thing that I’ve seen on the clinical side is that it’s often really hard for us to find culturally informed services and care for patients who are not white or who don’t have great insurance. How are we addressing that issue, or what do you think about on the operation side as we seek to expand services and make sure that they’re accessible for all of our families?

Jamie Winter: Yeah, one of the things that immediately comes to mind is really thinking about where we put our services. Over the last two years, we’ve seen a great expansion to telehealth, but that’s not always accessible to all patients and families, and it might not be the way that they want to receive care. But it’s been highly adopted in mental health, which is certainly great. And I think that there’s opportunities for us to continue to think about how we go to where patients and families are. And that’s some of the work that we’ve done already with our integrated behavioral health program. So really putting mental health clinicians in our primary care clinic so that patients and families don’t have those additional barriers to getting to a mental health clinician, or receiving care where they see their trusted primary care provider who can provide a recommendation of a colleague who’s right there in the office. I think that’s really helped us get to families who maybe weren’t able to access care previously.

The other piece I think is really thinking about workforce and helping to build that more diverse workforce that looks and believes in things similar to the patients and families that we serve. And I think that really helps us to build trust in the community. We certainly have seen over the past year and a half to two years that the utilization of our emergency departments for those crisis mental health services are disproportionately impacting our families of color. So they’re accessing us in the emergency department at higher rates or disproportionate to the population. And so I think it’s really important for us to continue to think about how we target our services and resources to families across our system in all locations.

Dr. Angela Kade Goepferd: In pediatrics, obviously we on the clinical side want what’s best for kids, and to get that we have to partner effectively with you and your colleagues on the operations side. How can we best partner with you, whether it’s in primary care or maybe specifically around mental health care? How can we help with some of the challenges and how can we partner?

Jamie Winter: Some of the most effective partnerships that I’ve had with my clinical [inaudible 00:10:53] have really revolved around working in tandem to be able to tell the story and to present kind of the plan or the business case for whatever it is that we’re needing to move forward with in order to provide the best care. And so I might not know clinically what is needed for the patients or what we need to do from a clinical perspective, but I can help tell the story from a financial and an operational perspective. And so it really works best when those two perspectives can come together as we think about advancing strategies or moving forward with new ideas, it’s often our executive team that wants kind of both pictures, they want to know clinically what we’re doing, but also operationally and financially how that will impact us as a business.

Dr. Angela Kade Goepferd: Sure. And it sounds like there’s maybe some room for us, and this is me coming from a medical education background to do some upfront work in terms of our workforce pipeline and really getting folks interested in providing mental health services, and particularly maybe doing some mentorship or some early career exposure for folks of color who are interested in providing services.

Jamie Winter: Absolutely. I think that’s so important. We’ve done some work to advance just our opportunities for people to come to Children’s for internships or fellowships across our mental health services departments. And that work has really happened over the last year, but I would say really accessing early learners sooner. So thinking about how we are getting to kids when they’re in high school or in their undergraduate to really kind of help identify and steer them towards career and mental health. I think that as we want to continue to build that sustainable pipeline for having clinicians who can deliver the services that kids so desperately need, it’s important for us to think about how we’re helping in that process and giving them the exposure to know that mental health is a field that they want to go into.

Dr. Angela Kade Goepferd: I’ve known you for a while, and I don’t want to put you on the spot, but I do trust your perspective and it’s a unique perspective, and I trust from our experience working together that you’ll answer this honestly. So I’m sure I don’t have any but when you’re working with doctors or other clinicians who are trying to partner with operations, what are the sort of blind spots that we have or common missteps that you see on the clinical side where it just gets in the way of us being able to partner effectively?

Jamie Winter: I would actually say that most clinicians that I work with have a really good awareness of that, but really thinking at the detail level of how much things cost, and when we want to add something or change something, how that impacts our financial bottom line is often something that maybe it’s not an unawareness, but it’s not the first thing that clinicians often think about. Because they’re really focused on what impact this will have to my patient and their family, how will this impact their access to services? And they’re not always thinking about that business side. What processes do we need to put in place? Or what staffing will we need that might be different than what we have now? And what does the finances of that look like? And so I would say that’s the only thing that really comes to mind.

But in general, I would say most clinicians have really gained a good awareness just from being in this healthcare environment that we’re in now and responding to the financial pressures that we’ve experienced over the past couple of years. I would say most have a really good awareness and are really great partners and are open to having those discussions and thinking about it. It’s just not everybody’s favorite topic.

Dr. Angela Kade Goepferd: To be transparent, we don’t really get that education on the business of health care, or rather, I think the idea of introducing that at the medical school level or in advanced practice training programs is relatively new. So for those of us who’ve been in practice for a decade or more, it wasn’t something that we ever got taught, but something certainly that we have to have some savviness with to be effective on healthcare teams.

Jamie Winter: Yeah, absolutely. And I completely resonate with that being a nurse. And we also did not get that in nursing school. And it’s something that going back and getting my MBA, I was able to develop. But I certainly think that there’s opportunities, and I have heard of programs moving in that direction more to talk more about the financial side of healthcare, but I think it’s something that we all continue to learn and to grow together.

Dr. Angela Kade Goepferd: As I’ve moved kind of away from direct clinical medicine and into different leadership roles, whether it’s in medical education or in the gender health program, one of the biggest disconnects that I’ve seen is with time and how much time it takes for change. Often we want to put in the order and then we want to have the change happen immediately, and hiring, and credentialing, and onboarding staff, and getting operational approval and all of that, even if there’s an agreement around the change that needs to happen, it often takes much longer than we initially realize on the clinical side.

Jamie Winter: Yeah, absolutely. I would say there’s always those hoops to jump through. The other thing I think that resonates with me when we talk about this is really that approach to continuous improvement. And we’ve done a lot here at Children’s to really think about how we approach from a lean thinking perspective, problem solving and doing that in real time. And so I think it’s something that our clinicians are exposed to and they’re getting lots of practice doing. And so I think it’s just kind of building that culture and creating those norms around how we think about process improvement and reducing waste in our environments.

Dr. Angela Kade Goepferd: Let’s go back to the mental health services and the expansion that we’re undertaking here at Children’s. So let’s talk first about partial hospitalization. Can you describe what’s available in the partial hospitalization program and what that looks like for kids and families?

Jamie Winter: About two years ago, we started to think about our continuum of mental health service offerings. And a gap for us was really those more acute outpatient services. So when a kid is receiving therapy or outpatient medication management through one of our mental health services clinics, but a weekly or biweekly visit is just really not cutting it to maintain their stability. Oftentimes the next step up is a mental health day treatment program, like a partial hospitalization program or PHP. And so similar to being in school, kids come to a PHP for most of the day, so they’ll come at 8 or 8:30 and they’ll be with us until into the afternoon, they’ll eat lunch, they receive school services while at PHP. And then intermixed with that is really hours of intensive mental health programming.

So often in the form of groups. So they do group therapy, psychoeducation, they often do groups around things like resiliency, wellness, sleep hygiene, things that also impact your mental health. And then there’s focused individual services that are offered during partial hospitalization as well. So meeting with a psychiatrist for medication management if appropriate, individual therapy, family therapy. So really thinking about from a Monday through Friday program. So they come to us Monday through Friday and are able to go home in the evening and on the weekends, how we can best meet their needs when they need those more intensive services.

Dr. Angela Kade Goepferd: And how long would a child typically be in a PHP program?

Jamie Winter: Can certainly vary based on need, but I would say kind of average is around three weeks. Kids might come to us for less and after about two weeks as a step down from being in the hospital, and they need kind of that bridge until they’re able to reintegrate into their community, and their school and really serve as kind of a step down program. But we also have kids who stay with us for longer, and really the goal is to prevent them from going into the hospital. So they come to PHP with the goal of really staying out of the hospital and being able to step up from outpatient services.

Dr. Angela Kade Goepferd: And in terms of our children’s services that we have in Lakeville, for those people who are listening to us locally, is that something that any clinician can refer to?

Jamie Winter: Yes. So we take referrals from any clinician in our Lakeville program. The program we have in Lakeville serves adolescents, so ages 12 to 18. And we are also going to be opening a new partial hospitalization program in Roseville, and that will be in quarter 1 of 2023. It’ll be a larger program, and we’ll also serve a wider age range, so kids ages 6 all the way up to 18.

Dr. Angela Kade Goepferd: Wow, that’s great. And what’s the capacity for both of those programs?

Jamie Winter: So our program in Lakeville, we’re really learning kind of how to operate a group program in the time of COVID, which has been really interesting. Right now we serve 8 kids in Lakeville at any one time with the goal of getting up to being able to serve 16. And then Roseville will be able to have 24 kids a day in program.

Dr. Angela Kade Goepferd: And how is it in terms of being full? Is it hard to get kids in?

Jamie Winter: Yeah, so being that it’s a more acute program, we do really try to maintain the shorter wait list knowing that it’s really in lieu of going in the hospital. And so if our wait lists are months out, it’s not effective. And so I would say certainly similar to what we see in our emergency departments, there are times of year that it is much busier, so we often see a dip in the summer, and then now as we reenter into the school year, it really picks up and we see a bigger demand and wait for services.

Dr. Angela Kade Goepferd: Let’s move into the inpatient mental health services for which you were just announced as the new director. Tell me a little bit more about what that will look like and kind of timing and what services we’ll offer there.

Jamie Winter: So we’ll be opening our new inpatient mental health unit on our St. Paul Hospital Campus in November. So we’re really excited to be able to bring inpatient mental health services to Children’s. It’s not a service that we’ve previously offered, and right now rely on external hospitals when kids are in need of inpatient care. It’s a 22 bed unit. It will serve both children in adolescents, so typically kids as young as 6 all the way through kids who are 18. And really similar to our partial hospitalization program, we’ll offer a full cohort of programming throughout the day. The only difference would be that it’s a 24/7, that you would stay overnight in the hospital. We’re just really excited to be able to bring this service to the East Metro. Right now, there’s no other programs in the East Metro that serve younger kids, so kids under 12. And so I think it’s really just great that we’re able to step up and bring that service to this geography.

Dr. Angela Kade Goepferd: And then just circling back to our earlier conversation about health disparities and health equity, talk to me a little bit about what we’re doing to make sure that it’s kind of a community informed approach to the care, or for my vested input, making sure that our LGBTQ kids get inclusive care. How are we doing that?

Jamie Winter: So we’ve really tried to bring community and different communities along with us throughout the planning. So we’ve been to a number of different committees to really talk about what are the things we should be thinking about when we’re providing inpatient mental health care. We’ve also engaged with the counties, with schools and really thinking about what is it that kids that you encounter and need? And so really trying to take that community informed perspective.

The other thing I would say is throughout the design process, we’ve tried to be really mindful of creating spaces that are inclusive, and that can also be adaptable depending on what the individual needs are of the child or family. So we’ll have all individual rooms, which doesn’t sound unique because all of our medical beds are individual rooms. But in a mental health floor, it’s not uncommon to have kind of double capacity rooms. And so those individual spaces where families could potentially room in if clinically appropriate, and also be able to bring things that would be important to them as long as it was safe. And so really thinking about how we put the patient and family at the center of their care and create those individualized treatment plans to allow them to feel that we’re creating that inclusive space.

Dr. Angela Kade Goepferd: Well, thank you again, Jamie, for joining us today. It’s been really helpful and interesting to hear your side from the operational side, and just I’m really excited about the expansion of our services to better serve the mental health of kids in our community. It’s obviously something that we need, so thanks for being such a huge advocate for that care.

Jamie Winter: Yeah, thank you for having me.

Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.