BEHAVIORAL HEALTH

Several recent news articles have highlighted the mental health crisis in our state—where children and youth are boarded in emergency departments while they await appropriate treatment in inpatient facilities and/or safe living environments. One Minneapolisbased hospital system reported as many as 20 children are boarding in its hospital emergency departments or pediatric units while awaiting inpatient beds where they could receive the more specialized care they require. This hospital, which would normally experience one or two children per month brought in for mental health reasons, ended up resorting to developing a makeshift holding unit in an ambulance bay when they had taken in nearly 145 children over a nine-month period between September 2021 and May 2022. Most of these children stayed approximately 15 days while awaiting treatment, though one had boarded 97 days. In addition to costing the state a tremendous amount of money for having children and youth in inappropriate and costly settings for prolonged periods of time, there is also concern that these prolonged stays will have devastating longterm effects on young people and may impact willingness to seek treatment in the future.

In response to the boarding crisis, the Metro Health and Medical Preparedness Coalition, in partnership with AspireMN, launched a Children’s Mental Health Services Coordination pilot in August 2022. They invited key community stakeholders to attend bi-weekly video calls to monitor communitybased services for children and facilitate the sharing of information between health systems and mental health providers. In the state of Minnesota, there are over 800 beds for mental health treatment and substance use disorders for youth. Over 200 of these beds are in hospital settings, and over 600 are for longerterm residential care. Nearly 80% of the hospital beds are in the metro area, specializing in treating acute conditions or those in crisis. Interestingly, only 27% of the longer-term care beds are located in the metro area. Unfortunately, accessing the right kind of bed at the right time has proven challenging and has been a major contributor to boarding situations.

Understanding the variety of mental health treatment programs that exist and the changing criteria for admission are two of the most common problems in making a successful referral. For example, some facilities are only licensed to treat certain ages, conditions, and even genders. Others may lack capabilities of treating more complex conditions such as medical comorbidities, eating disorders, or co-occurring substance use disorders. The vast majority of youth in boarding situations are described as being aggressive, which can be a trigger for a declined admission. Understanding the nuance and reason for aggressive behaviors is important for successful placement and to avoid running into barriers. An isolated incident of aggressive behavior or aggression toward a specific person (e.g., parent or caretaker) is very different than chronic general aggression. Understanding the reason behind these behaviors is critical, and misunderstanding them can lead to exclusion from a treatment center. Lastly, most treatment centers have limitations on the acuity of cases that change based upon staffing and current patient population or milieu. This wide gap in understanding the landscape of mental health treatment settings needs to be eliminated. This is where technology and open communication can help.

Leaders within this pilot project stakeholder group have partnered with the Psychiatric Assistance Line (PAL) to develop an online Mental Health Collaboration Hub (MHCH) so hospitals and mental health providers across the state can connect 24/7 in real-time to help individuals get out of boarding situation and into safe therapeutic treatment settings. The MHCH matches cases of youth boarded in hospitals, emergency departments or any other inappropriate setting to a safe mental health treatment provider who can meet their needs. Both parties (i.e., hospitals and mental health providers) have profiles in the hub that allow collaborators to better understand their care settings and exchange key contact information. When an individual is either in a boarding situation or an anticipated boarding situation, the case is submitted in real-time to the hub. Once submitted, the case appears on a centralized dashboard for registered users to view, and the treatment centers that are a good fit and have capacity are notified. The information is de-identified and

shows only pertinent data required for admission criteria. The system also ensures consistency of semantics and what information is collected. For example, if the case is reportedly aggressive, the system will ensure the nuance of that is captured in a meaningful and objective way for assessment. A case can be reviewed and accepted by any of the treatment centers, and the hub then facilitates real-time exchange of information through messaging and secure records exchange facilitated directly between the providers.

In addition to the case submission hub, a core component of MHCH is to continue to catalyze ongoing live discussion between providers to nourish relationships and monitor trends. For example, changes in staffing patterns, licensure and even patient acuity can be discussed in advance, and often troubleshooting between partners can occur. Providers can also use this time for anonymized case review and workshops as a part of professional development. The mantra adopted by this team is “Getting to yes!”

Another incredibly valuable component to the MHCH is the automated tracking of cases on an aggregated level. While some health systems track their own data via electronic health record or manualized reporting (especially during the last two years), the cases that are most often reported in the media are the extreme outliers. They sway the narrative and can lead to a misrepresentation of the majority of boarding cases. The MHCH will track key components of every case, the barriers that exist and the eventual care pathway. For example, we will better understand the most common boarding cases themselves. We will monitor and track ages, genders, diagnosis and locations. In addition, we will better understand the precipitating events that resulted in a boarding situation and the desired treatment setting. From there, we can determine which treatment settings are in the highest demand or have the most barriers in accessing them. By grouping case profiles, we will better understand what the most successful placements have been and what to expect in the referral process. For example, a 14-year-old with a major depressive disorder and a suicide attempt may most often need an acute care hospital bed and should expect to wait three days for admission. Or a nine-year-old female with autism and aggression towards caregivers may need a group home and likely wait 45 days for placement. This data will help us better design our mental health systems and care pathways connecting children and youth to care faster and even work towards preventing the situations from occurring at all. This is data which does not exist in an aggregated way between providers today.

The work of the MHCH focuses on the following objectives: • Leverage an online portal to track and monitor cases of children and adolescents boarding in hospitals and emergency departments. • Interact across the state in real-time to facilitate prompt review of cases.

• Through ongoing data collection, identify trends and opportunities to improve access to care for children and adolescents experiencing crisis.

The MHCH exists in an online virtual environment that leverages a secure portal and regular video calls. The online portal is a tool to help facilitate information exchange, and the live facilitation of the

The Mental Health Collaboration Hub to page 204

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3The Mental Health Collaboration Hub from page 19

meetings is critical in connecting providers with the primary goal of reducing the number of children and adolescents boarding in hospitals and emergency departments. The meetings can identify optimal care pathways in real-time.

Through the use of this online portal and ongoing communication between hospitals and mental health treatment settings, Minnesota will be better able to monitor trends in boarding as well as identify opportunities for improving access to care. We will be better able to understand if there are key characteristics in children and youth who are waiting extended periods of time for care (i.e., aggression, co-occurring developmental concerns, etc.) and then use those findings to help advocate for increased availability of treatment services in the community. The work of the pilot team is ongoing, and the full online Mental Health Collaboration Hub will be launched in early 2023 and accessible to all health care providers in Minnesota.

Mental illness is real, it is common, and it is treatable. More people today are facing challenges with their mental health, yet less than half of those with a diagnosable condition will receive treatment. This disparity is much greater for those underrepresented communities where the social determinants of

health often have an amplified impact. Our mental health system has been shaky, fragmented and largely unbuilt for decades. Rates of suicide have been increasing since the early 2000’s, record numbers of individuals are boarding in hospitals and emergency rooms and a majority of parents report concern about their children’s mental health. It is well-documented that the pandemic has exacerbated these problems, introducing new levels Cases that are most often reported in the media are the extreme outliers. of angst into family systems combined with added barriers to accessing care. One of the most notable trends in the treatment setting is the increased prevalence of trauma—adding complexity and the need for longer-term— and often deep psychological healing. The study of adverse childhood events (ACEs) is robust, and the disruptions of the COVID19 pandemic exacerbated concerns about youth mental health and suicidal behavior. The most significant events are changes in economic stability and parental relationships or divorce. The rate of individuals in psychiatric crisis boarding in hospitals and emergency departments has increased sharply in recent years. Emergency departments have become the most common entry point for those in crisis, and that number has grown by nearly 40% in the last 20 years, even more for youth. The most common medical reasons for an ED visit are chest pains, The Mental Health Collaboration Hub to page 304

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