While the emergency department waits for days on end, Massachusetts is turning to home care for children’s mental health
It was around 2 am on October 24th when a mother named Carmen realized her 12-year-old daughter was in danger and needed help. Haley wasn’t in her room – or anywhere in the house. Carmen used an app on her phone to locate Hailey. She was moving along a main street in their central Massachusetts community. Carmen’s mind raced toward frightening possibilities.
“She didn’t know what danger she was taking there,” said Carmen, in a voice choked with tears. “Walking in the middle of the night, anything can happen. I wanted to see her again.”
Carmen Haley was picked up, unharmed. But in those early morning hours, Carmen learns of potentially more dangerous behavior – provocative photos sent by the 12-year-old and plans to meet with an older boy. Carmen also recalled the time Haley was bullied a few years ago and told Carmen she wanted to die, which is why WBUR only identifies Haley and her mom by their first names.
Fearing her daughter would hurt herself, Carmen drove Haley to the UMass Memorial Emergency Room, the only place she knew to look for help in the middle of the night.
That’s why we went to the hospital because she also thought to kill herself. Carmen said.
Haley ends up on a stretcher, in the hallway, with other guys. Carmen has had to come home sometimes to take care of Haley’s siblings.
“Leaving [her] There for days, and seeing all these kids, it was terrifying for me,” Carmen said.
Haley too.
“I didn’t know if they were going to send me home or put me in a really strange place,” she said. “It was, like, really nerve-wracking.”
That week, Hayley was one of the 115 children and adolescents Who came to a hospital emergency room in a mental health crisis and got stuck there. Many have waited days or weeks for an adolescent psychiatry unit to open. The problem was, known as boarding increasing for more than a decade. Some hospitals have reported record high numbers during the pandemic.
To speed up the transition to mental health care and reduce stress on emergencies, Massachusetts is trying something new. The state contracted four agencies to provide intensive home counseling as an alternative to psychiatric hospitalization. The approach is called Transform the emergency department.
To find out what’s best for each child, the hospital begins with a psychological evaluation. Haley got one on her second day at UMass ER. DeAnna Pedro, the pediatrics-psychiatry liaison at UMass, reviewed Haley’s report and considered recommending time on the psychiatry unit.
“She was doing a lot of high-risk things,” Pedro said. “So there was a lot of thinking about, are we going to need to go to something as extreme as psychological acceptance, to keep it at bay.”
But Pedro and Haley’s parents are worried about this option. It would be a sea change for a 12-year-old whose only experience with mental health care was her school counselor.
“Put her in an inpatient psychiatric unit with children who have likely been through a lot of other things,” Pedro said, then paused. “Parents are concerned, appropriately.”
So Pedro contacted Youth Villages, one of the youth transfer agencies Massachusetts has hired during the pandemic. The state pays the cost: $8,522 on average for the usual course of care. In youth villages, this takes three counseling sessions of 45-60 minutes per week for three months.
The savings are significant. One study She calculated the cost for homestay at $219 an hour or $5,256 for just one day. This does not include expenses associated with care in a psychiatric unit.
The Haley family met with the Youth Villages Supervisor at UMass ER. The first home visit the next day included a safety survey.
“We look under rugs, we look behind picture frames, we look in plant dirt,” said Laura Polizotti, the counsel assigned to Haley’s case. “We made children hide things in the dirt of a plant.”
Haley had to give up her phone. So the sweep included making sure she didn’t have an old one stashed away. Youth Villages provided window and door alarms that Haley’s parents could activate at night. The program also provides lock boxes, if needed, for medications or sharp items the family wants to keep out of reach. Counseling for Haley and her parents began immediately.
The main goal was to understand why Haley would sneak around at night and take sexually inappropriate photos. During a counseling session one December afternoon, Polizotti focused Haley’s anger at her and her mother.
“Have you ever taken an emotional thermometer before?” Polizzotti asked, placing a large picture on the table in a private room in the local library. The picture had blank lines for five emotions, from cold to hot.
“It can help you see where your feelings are,” Polizzotti explained. “Then we will come up with coping skills for each level.”
In the space next to the bottom of the thermometer, Hayley wrote, “COOL.” At the top—in the red area—I wrote, “angry.”
“Exasperated,” Polizzotti said, “that’s a good word.” “So when you’re angry, how do you think you feel physically, what do you notice?”
Her palms are sweating, she stops talking, and makes a “weird face,” Haley told Polizotti. Haley cut her nose and frowned to appear. Polizotti laughed.
As the rehearsal began, Polizoti asked Haley to think of ways to calm herself before the annoyance turned to anger. Hayley suggested spending time alone, watching TV, playing with her siblings, or jumping on the family trampoline.
“That’s good, the trampoline,” said Polizzotti. “Can we come up with another one?”
“I can talk to my mom,” Hayley said out loud as if to ask a question.
“Awesome,” said Polizzotti.
Hayley often gets into the red during fights with her mother. It may start because Haley left dirty dishes or didn’t clean her room. From Haley’s point of view, her mother is impatient.
“Sometimes I wish my mom would just ask me [to do chores] Hayley said “instead of yelling at me.
Polizoti pulled out another diagram to help Haley see the connection between thoughts, feelings, and behavior, which is known in therapy as the cognitive triangle. Understanding these connections can help Haley act differently when she and her mom are fighting.
Haley gets angry when her mother screams. She tells Polizotti that this makes her even more disrespectful.
“And the behavior is that you are sneaking?” Polizzotti asked. Haley nodded, yes.
Polizoti leads the sessions with Haley and Carmen together as well, often around the kitchen table or in the living room. Polizoti proposed a technique called Collaborative problem solving To resolve cleaning disputes. The first step is to show empathy. This is hard for Carmen. She loves a clean house. And Carmen didn’t have a problem with too many clothes or toys when she was Hayley’s age.
“I try to give my children the best,” said Carmen, emotion rising in her voice. “I didn’t grow up in a house like this.”
Hayley suggested another wardrobe for her room. Carmen suggested letting go of the clothes Haley doesn’t wear often. As the hour wound down, it was clear that cleaning would be a topic for future sessions. But overall, Carmen said counseling helps Hailey. She started vaping, but never left the house at night.
“It’s been good, honestly, since you guys have been here,” Carmen told Polizzotti.
The Emergency Department Youth Referral Program has grown rapidly from a trial in March 2021 to 37 hospitals participating today. The state Department of Mental Health says that as of early December, 470 young people ages 4 to 18 worked with one of the four agencies. The vast majority, 83%, did not return to the emergency room due to mental health concerns. In all, 91% of young people met their treatment goals or were referred for additional treatment services.
Advocates for parents of children with mental health problems say the main complaint they hear is that hospitals don’t offer home care programs fast enough and that when they do, there is often a wait.
“We’d like to have more opportunities to have these transfers with more families,” said Miri Viano, associate director of the Professional Parents Association. “We’ve seen in the data and heard from families that this was a great program to get kids in the next place to recover faster.”
There are families who are reluctant to attempt a conversion if their child is taking, or may need to start taking, psychiatric medications. Youth Villages does not have prescribers among the staff. Children who need medication see a psychiatrist or primary care physician outside of the program.
Diversion programs appear to offer some relief to overburdened hospitals and staff. a Report From the Massachusetts Health and Hospital Associations, it shows the number of inpatients has decreased as more hospitals begin to refer families to one of the home options. Demand for mental health care varies by season, but the Department of Mental Health says the numbers are hopeful.
“I think it would be worse without these programs,” Simmons Yeomans, senior director for health care policy at the Department of Health, told me. “They are helping hospitals manage capacity” and helping children out of chaotic emergency rooms.
It is not clear what percentage of children and adolescents who go to a hospital emergency room for mental health care can be treated at home rather than in a psychiatric unit. Home is not always a safe place for the patient. But Matthew Stone, director of Youth Villages in Massachusetts and New Hampshire, says that in other situations home care can be the best option.
“Many of the mental health challenges these children face are driven by factors in their natural environment: their school, their neighborhood, their peer system,” Stone said. “It is our view that you can’t really work on addressing these factors with a child in situ.”
Doctors in psychiatric units work on family and social issues, and sometimes bring family members to the hospital for sessions. There is no data yet to compare results.
The state of Massachusetts is unusual in using diversion as a way to mitigate the ups and downs of child and adolescent mental health. There is some disagreement as to whether conversion is a short-term or long-term solution.
“It was effective,” said former Health and Human Services Secretary Marilou Sudders, who now serves as an advisor to the Healy administration. But Seders calls the diversion “a temporary gap in response to what emergency departments are experiencing immediately.”
Sidrs argues that the need for diversion will disappear as the state launches a multi-year plan to improve mental health care. the A roadmap for behavioral health reform file includes Statewide Helplinemore Community mental health centers and more compelling alternatives to mental health. Advocates are watching whether these services help patients treat mental health problems early, before they escalate into the need for an emergency room visit.
But for now, Carmen and the other parents dealing with their first mental health crisis will likely be headed to the ER. Carmen hopes they will. She doesn’t like having people “in her work,” but this is an experience Carmen said she wanted to share.
“A lot of parents don’t know what their kids are going through because they don’t want to accept the fact that your kids need help,” she said. “That’s why I’m doing this, you came to my house. Hopefully this will help another family.”