Morgan State University School of Social Work Secures Contract to Support Baltimore City Pediatric Primary Care Providers

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Morgan State School of Social Work students performing field work consultations

Program Will Provide Critical Aid to the Maryland Health Department’s Effort to Address Disparities and Better Serve the Behavioral Health Needs of  Underserved Communities

The primary goal of the project is to support pediatric primary care providers, strengthening their capacity to meet the behavioral health needs of young people in their care. To accomplish this goal, Morgan State and its M.S.W. program participants will engage in training, telephonic and telepsychiatry consultation, information gathering and dissemination, referral for specialized services available statewide and additional activities designed to support primary care providers.Morgan State University School of Social Work (SSW) has been awarded a $960,641 subcontract from the Behavioral Health Administration (BHA) of the Maryland Department of Health (MDH) to provide frontline support in assessing and treating mental health needs of Baltimore City families and youth.

Teaming with the Behavioral Health Integration Program for Pediatric Primary Care Program (BHIPP), faculty and students from Morgan’s Master of Social Work (M.S.W.) program will conduct critical field work focusing exclusively on underserved minority communities, many of which have experienced long-term trauma and great disparities in mental health treatment. The effort will establish a collaborative learning community to support behavioral integration and foster interprofessional learning opportunities for next-generation social work clinicians.

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Anna McPhatter, Ph.D., LCSW, dean of the School of Social Work at Morgan State University

“For our future clinicians who aspire to affect the communities they serve in bold, meaningful ways, programs like these offer invaluable field experience that will inevitably help bridge gaps and enhance service within our most underserved populations,” said Anna McPhatter, Ph.D., LCSW, dean of the School of Social Work at Morgan State. “As an anchor institution in Baltimore, we are proud to carry the mantle by addressing critical issues in behavioral health and creating new pathways for rehabilitation.”

The Morgan State BHA/MDH subcontract in coordination with BHIPP places a significant emphasis on urban areas and populations suffering from shortages of child psychiatry practitioners and other health-related disparities. Working collaboratively with primary care providers, Morgan M.S.W. program participants will be instrumental in early intervention, reducing long-held stigmas associated with mental illness and increasing the population’s general knowledge of mental health services.

“To utilize the expanding knowledge base of the social work profession and address the growing complexity of the population it serves, it is important that all social workers be equipped with practical field work related to their academic pursuits,” said Laurens G. Van Sluytman, Ph.D., LCSW, associate professor and assistant dean of SSW and co-principal investigator for the program.

SSW will identify and supervise students to serve as social work interns, Dr. Van Sluytman said. The interns will conduct field placements within primary care settings and establish working relationships with pediatric offices to coordinate mental health screenings and psychiatric consultations and better understand the overall goal of integrated care. Dr. Van Sluytman anticipates that, through this advance practicum, Morgan students will gain deeper insights into the implementation process, identify strengths and weaknesses within the program design and improve upon the program in future scale-up efforts.

The expanded minority health component secured by the Social Work program at Morgan through this subcontract is part of an ongoing statewide interagency initiative that has enlisted the support of advanced-year M.S.W. students from Maryland higher education institutions. The project was initially forged as a partnership with the University of Maryland School of Medicine and The Johns Hopkins University School of Medicine and was broadened to include Salisbury University, which placed interns in rural pediatric primary care practices in Western Maryland and on Maryland’s Eastern Shore. Morgan State’s involvement and its emphasis on urban/minority health further broadens the scope of the project.

Depressed Kids Do Not Have A Look – Identifying Children in Crisis

As the lead social worker in charge of the behavioral health screening protocol at Nemours/Alfred I. duPont Hospital for Children in Delaware, Jessica Williams, MSS, LCSW is responsible for educating clinicians, staff, and families about the one thing they can do to identify kids in crisis: ask them the right questions. “Kids that appear to be depressed, whatever you think that might look like, they might not actually be depressed,” she explains. “And sometimes the kid with a suicide plan has tons of friends and makes straight A’s. We can’t make assumptions based on how a child appears.” As “champion” of the behavioral health screening protocol, Williams manages and evaluates the program, working concurrently with stakeholders at the Delaware Department of Services for Children, Youth, and Their Families.

The program, which went live in November of 2017, aims to screen all patients 12 years of age and older who are admitted to the emergency room. The protocol is first triggered when a nurse receives a best practice alert (BPA) for an eligible patient in the EMR. The nurse then asks the patients to complete a behavioral health assessment on an iPad using a software program called BH-Works. The web-based survey asks patients questions to identify risk level for things like depression, trauma, substance use disorder, bullying, abuse, and suicidal ideation. Responses are automatically scored, summarized, and ready for review in the EMR, helping providers determine when a patient requires additional support. As a licensed clinical social worker, Williams is one of the team members who provides in-person clinical mental health assessments for patients who screen positive for risk.

Williams trains all staff and providers who interact with the BH-Works tool in some way. This roster includes about 150 nurses, social workers, attending physicians, fellows, residents, physician assistants, and nurse practitioners. Additionally, Williams educates ancillary staff who may not interact directly with the tool, but who need to understand the screening process. This includes child life specialists, unit clerks, flow supervisors, and nursing leadership. When Williams joined the ED team in early 2019, she was tasked with reaching out individually to each associate, confirming they knew about the protocol and understood their part in the process.

In addition to reaching out to individual staff members, Williams attends huddle meetings to answer questions, listen to feedback, and share case examples. One of the cases she talks about regularly involves a patient who was put into the fast track section of the ER for a sports injury. When the teen was screened before discharge, he was flagged for critical risk. The teen was severely depressed, experiencing current suicidal ideation, and had made a suicide plan. Hearing these types of stories helped the ER team understand the importance of the protocol. “Initially, the nurses and providers were surprised by those patient stories,” she recalls. “Surprised at first that the protocol was working, and then surprised there were so many kids at risk.”

Williams wanted to help her associates through the inevitable growing pains of a new workflow, so she began troubleshooting issues with the help of an interdisciplinary team, working through a process she coined “collaborative implementation.” Her team actively involved providers and fellow associates as they worked to address kinks in the technology, workflows, and communication plan. “Sure, they know that they have to do this for their job,” she states. “But we’re asking them to do something that isn’t always the easiest or most comfortable thing, so it helps to bring them into the process.”

Based on those suggestions, the team created algorithms to guide nurses and providers through common scenarios, posting them in high-traffic areas. Williams is careful to point out that these algorithms are not hard and fast rules. She explains, “With behavioral health, we can’t always say, ‘Do a,b, and c’ every time a patient screens positive for severe depression. Sometimes that patient is on medication and working with a therapist, and the doctor doesn’t necessarily need to call down a social worker immediately.”

Although the protocol aims to screen all eligible patients, many variables can stop or slow the process. To provide an appropriate course of action in all situations, the team worked with the hospital’s Epic analyst to add buttons to categorize a nurse’s response to the BPA. Armed with that information, Williams was able to audit individual patient charts to understand issues on a case-by-case basis. She identified six common problems and worked with emergency department management to address them. For example, in order to remind providers to review the results, the team’s Epic analyst incorporated the screening report into the discharge process, a time that fit better into some of their workflows.

These collaborative efforts helped to quickly increase the number of patients being screened in the emergency room. The month before the team started their collaborative implementation plan, only 20 patients had been screened using BH-Works. After their first month of strategic efforts, that monthly screening number increased to 180. By the third month, the numbers had jumped to 507. Currently, the team consistently screens between 32-49% of clinically appropriate cases monthly, which is an above average number compared to other emergency departments with similar protocols. The department plans to improve the screening process through 2020, with a goal of screening 100% of clinically appropriate patients.

By the end of 2019, over 3,000 patients had been screened in the emergency room. Out of those patients, twenty-three percent (715 kids) reported symptoms of moderate to severe depression, twenty percent (609 kids) reported significant trauma, fifteen percent (479 kids) reported a history of suicide ideation, and 117 kids were actually contemplating suicide at the time of screening.

Williams is now educating other departments about the program, seeing potential for behavioral health screening throughout the Nemours Health System. She also urges providers across the country to consider implementing similar protocols. “Kids are literal beings,” she explains. “I can’t tell you how many times I’ve asked a kid why they hadn’t shared their feelings with someone before taking this screen, and they tell me it’s because no one had ever asked them. That’s why we have to do things like this. Because there’s no other way to know other than to ask.”

National Survey Reveals the Scope of Behavioral Health Across the Nation

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) latest National Survey on Drug Use and Health (NSDUH) report provides the latest estimates on substance use and mental health in the nation, including the misuse of opioids across the nation. Opioids include heroin use and pain reliever misuse. In 2016, there were 11.8 million people aged 12 or older who misused opioids in the past year and the majority of that use is pain reliever misuse rather than heroin use—there were 11.5 million pain reliever misusers and 948,000 heroin users.

“Gathering, analyzing, and sharing data is one of the key roles the federal government can play in addressing two of the Department of Health and Human Services’ top clinical priorities: serious mental illness and the opioid crisis,” said HHS Secretary Tom Price, M.D. “This year’s survey underscores the challenges we face on both fronts and why the Trump Administration is committed to empowering those on the frontlines of the battle against substance abuse and mental illness.”

Nationally, nearly a quarter (21.1percent) of persons 12 years or older with an opioid use disorder received treatment for their illicit drug use at a specialty facility in the past year. Receipt of treatment for illicit drug use at a specialty facility was higher among people with a heroin use disorder (37.5 percent) than among those with a prescription pain reliever use disorder (17.5 percent).

The report also reveals that in 2016 while adolescents have stable levels of the initiation of marijuana, adults aged 18 to 25 have higher rates of initiation compared to 2002-2008, but the rates have been stable since 2008. In contrast, adults aged 26 and older have higher rates of marijuana initiation than prior years. In 2016, an estimated 21.0 million people aged 12 or older needed substance use treatment and of these 21.0 million people, about 2.2 million people received substance use treatment at a specialty facility in the past year.

Rates of serious mental illness among age groups 26 and older have remained constant since 2008. However, the prevalence of serious mental illness, depression and suicidal thoughts has increased among young adults over recent years. Among adults aged 18 or older who had serious mental illness (SMI) in the past year, the percentage receiving treatment for mental health services in 2016 (64.8 percent) was similar to the estimates in all previous years.

“Although progress has been made in some areas, especially among young people, there are many challenges we need to meet in addressing the behavioral health issues facing our nation,” said Dr. Elinore McCance-Katz, Assistant Secretary for Mental Health and Substance Use. “Fortunately there is effective action being taken by the Administration and U.S. Department of Health and Human Services with initiatives to reduce prescription opioid and heroin related overdose, death, and dependence as well as many evidence-based early intervention programs to increase access to treatment and recovery for people with serious mental illness. We need to do everything possible to assure that those in need of treatment and recovery services can access them and we look forward to continuing work with federal and state partners on this goal.”

“Addiction does not have to be a death sentence – recovery is possible for most people when the right services and supports in place, including treatment, housing, employment, and peer recovery support,” said Richard Baum, Acting Director Office of National Drug Control Policy. “The truth is that there’s no one path to recovery because everyone is different. And frankly, it doesn’t matter how someone gets to recovery.  It just matters that they have every tool available to them, including peer recovery support and evidence-based treatment options like medication-assisted treatment for opioid addiction.”

NSDUH is a scientific annual survey of approximately 67,500 people throughout the country, aged 12 and older.  NSDUH is a primary source of information on the scope and nature of many substance use and mental health issues affecting the nation.

SAMHSA is issuing its 2016 NSDUH report on key substance use and mental health indicators as part of the 28th annual observance of National Recovery Month which began on September 1st. Recovery Month expands public awareness that behavioral health is essential to health, prevention works, treatment for substance use and mental disorders is effective, and people can and do recover from these disorders.

Telemental Health: Improving Access to Veterans’ Mental Healthcare

By Brian Neese

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Photo Credit: Dublin VA

Military members comprise less than 1 percent of the U.S. population, yet veterans represent 20 percent of suicides nationally, according to the National Alliance on Mental Illness. Each day, about 22 veterans die from suicide.

An issue affecting mental healthcare for veterans is accessibility. In the spring of 2014, the U.S. Department of Veterans Affairs (VA) wait time scandal emerged when allegations surfaced of veterans dying while waiting for care at the Phoenix VA Health Care System, according to Military Times. Wait time issues and manipulated appointment scheduling highlighted a nationwide problem and resulted in several top officials resigning or retiring.

Months later, Congress passed a $15 billion bill allowing more veterans to seek care in the private sector through the VA Choice program. Meanwhile, the VA continued focusing efforts on telemental health, or the use of telecommunications technology to provide behavioral health services, to try to improve veterans’ access to mental health services, National Psychologist reports.

Accessibility

Nearly one in four active duty military members show signs of a mental health condition, based on a study in JAMA Psychiatry. With 44 percent of veterans returning home from Iraq and Afghanistan to rural zip codes, accessibility becomes an important topic for veterans’ mental healthcare. This is a natural strength of telemental health services, which can include clinical assessment, individual and group therapy, educational intervention, cognitive testing and general psychiatric treatment.

The first telemental health program funded by the VA’s Office of Rural Health is at the Portland VA Center in Oregon. Through telemental health sessions, veterans saved 826,290 miles driven and $161,126 worth of gasoline in 2013, program director Mark Ward said. Some veterans who live far from Portland and lack high-speed internet are given electronic tablets and notebooks for videoconferencing.

Telemental health can increase veterans’ access to services and eliminate travel. Another benefit is that telemental health can help veterans overcome the perceived stigma sometimes associated with seeking mental health treatment. Veterans who might feel embarrassed or ashamed to get help in person can receive care in their home.

The VA delivered a total of more than 650,000 telemental health sessions nationally from the program’s inception in 2004 through 2014. The VA anticipated delivering 300,000 telemental health visits for 115,000 veterans in 2014, an increase from more than 200,000 telemental health visits for 80,000 veterans the previous year. Additionally, the VA has created free smartphone apps that veterans can use to help with post-traumatic stress disorder (PTSD), such as the PTSD Coach application developed by the VA and the Department of Defense.

Telemental health has made progress in improving accessibility for veterans’ healthcare, and it will be needed to make further ground. The Government Accountability Office found that 18 months after the wait time scandal, the VA still struggled with wait times and patients’ schedules.

Effectiveness

The first large-scale assessment of telemental health services was published in Psychiatric Services. This study assessed clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services of the VA between 2006 and 2010. During this time, psychiatric admissions of telemental health patients decreased by an average of about 24 percent, and patients’ hospitalization lengths decreased by an average of nearly 27 percent.

A survey of veterans found high levels of satisfaction and perceived safety with home-based telemental health provided by the VA pilot program in Portland, according to the International Journal of Psychiatry in Medicine. Findings support the feasibility and safety of using technology in the home for the delivery of mental health services. Additionally, results suggest fewer no-show appointments in home-based telemental health compared to clinic-based telemental health.

Currently, telemental health is regarded as appropriate for general clinical use. Yet, the VA cautions that more needs to be known about using telemental health services for conditions such as PTSD, which Jama Psychiatry says is 15 times higher for those in the military than civilians. “While preliminary research has clearly established that a variety of telemental health modalities are feasible, reliable, and satisfactory for general clinical assessments and care, less is known about the clinical application and general effectiveness of telemental health modalities employed in the assessment or treatment of PTSD,” the VA says.

The Need for Behavioral Health Professionals

Approaches such as telemental health can support better access to behavioral healthcare and are expected to grow as a result. Yet, more professionals are needed for rising populations of veterans, children and others in need of services.

The online B.A. in Behavioral Health from Alvernia University enables students to meet this need. Some graduates enter fields such as addiction counseling, long-term care and child welfare, while others enter graduate studies. The program takes place in a convenient online format to accommodate students’ work and personal schedules.

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