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.”

Engaging Vulnerable Populations Where Its Needed Most With VotER

As a result of the COVID-19 crisis, inequities within our healthcare system are on full display, and it further exposes how our most vulnerable are treated when seeking care. The disparities around who gets tested, access to testing, and whether they can even be seen by a health care provider are even more apparent during this crisis. Politicians, celebrities, and athletes are reporting access to testing while this is not the lived experienced of everyday Americans.

Even with the advancement of technology and an encouraged reliance on telehealth, these inequities in our health care system are the reflection of a country with barriers to civic engagement for its most vulnerable. We live in a country where 51 million potential voting-age adults are not registered to vote.

Disproportionately, those who are not registered to vote fall into one of three categories – the young, the poor, and those of color. For example, 36 percent of eligible African Americans and 48 percent of Hispanics were not registered to vote in the 2014 presidential election. And rates among young citizens are not much better; just 50% of millennials voted in the 2016 election, compared to 69% of Baby Boomers and 63% of Generation X.

It turns out that the same demographic groups that are not registered to vote also disproportionately utilize ERs at higher rates across the country for non-emergency care because they lack access to primary care. In other words, patients who are young, people of color, and have low income are frequently coming to the emergency room for non-life threatening conditions. 

Consider, the annual visit rate was 45.1 ED visits per 100 persons for the average patient in America. But when stratified among patients of color the visit rate was almost two times higher at 85 visits per 100. I’m an ER doctor and I see this phenomenon nearly every shift, but how do we empower our most vulnerable in order to create change?

Why not use the opportunity to register them to vote in the ER and in other health care settings where marginalized communities get their health care?

VotER Gets Patients Registered to Vote While They Wait

VotER is a new civic engagement organization that registers patients to vote in health care settings as described here in the Boston Globe. VotER was launched through a collaboration between Massachusetts General Hospital, TurboVote, and ideas42 and we build platforms that offer non-emergency patients a chance to register to vote in 90 seconds or less using a combination of iPad kiosks and behaviorally informed posters, stickers, and discharge paperwork while non-emergency patients wait in ERs and community health centers.

Our early pilots have resulted in significant demand from over 50 hospitals across the country in two months – and we are confident this model will lead to large increases in voter registration rates when paired with effective integration with engaged and social justice oriented staff like social workers in chosen health care settings. 

How We Work

iPad Based

VotER uses ipads contained in freestanding kiosks in areas where low acuity patients wait in the ED. The ipads are programmed to only allow voter registration. Above the ipads are large signs that invite voter registration. 

Patient Phone Based

We deploy posters in the ED that have a text to register feature which allows patients to text a ‘short code’ to a specific number which lets them register using their phone or use a QR code to initiate the same process.

Second, we have developed patient handouts that have embedded QR codes and URL links that connect patients to the same Turbovote voter registration platform. 

Social workers as innovators in civic engagement

Studies demonstrate that social workers participate in political activities more than other professions and vote at higher rates than the general population. Indeed the institution of The Human Service Employees Voter Registration and Education Campaign (Human SERVE) and the successful National Social Work Voter Mobilization Campaign (Voting is Social Work) demonstrate that the social work profession has always known that voter registration and voting support a robust democracy, a just society, and an equitable health care system.

Moreover, social workers have a long track record of success doing voter registration at rates higher than other traditional voter registration groups. During the 1984 election, for example, just 1% of those working with Human SERVE voter registration campaign registered 275,000 people nationally

At VotER, we know that for decades social work has been out in front doing the hard work of voter registration in health care settings — and the tide is now turning. Hospitals are now becoming engaged participants, and VotER is letting them do this in a way they’ve never been able to before.

We value the legacy of activism and empowerment among the field of social work and know that VotER needs input from social workers to blend our novel approach with on the ground tactics and real-world applications inspired by you. We also know that while VotER’s early pilots have resulted in demand and excitement from hospitals across the country, we need the input and insight of the field of social work to truly scale this effectively. 

We know that without participation from those most hurt by the healthcare system, politicians will continue to turn a blind eye to the needs of disenfranchised patients. Do you have ideas on how to partner effectively? Do you have suggestions on how social workers can use part, or all, of the VotER platform in the 2020 election and beyond? We’d love to hear your thoughts and suggestions here.

Call to Action and How You Can Help

We need your help and ingenuity to address this challenge — specifically, to explore how healthcare workers and spaces can support patients with voter registration via VotER. If you are interested in partnering with us, fill out this form to connect with us

Exit mobile version