The COVID-19 pandemic has put great strain on the entire healthcare ecosystem, and one of the most pressing challenges early on for patient care organization leaders was navigating the new landscape of shifting a large number of in-person visits to telehealth.
While the pandemic has of course impacted many healthcare settings, hospitals have experienced a disproportionate burden; the American Hospital Association estimates that from March 1 to June 30, 2020, hospitals experienced a financial impact of $202.6 billion in losses, or an average of $50.7 billion per month. Part of this group experiencing great financial distress has been children’s hospitals, of which there are more than 250 in the U.S. In a May 2020 letter to the then-Secretary of the U.S. Department of Health and Human Services (HHS), Alex Azar, leaders from more than 75 children's hospitals explained that they have sustained more than a 40 percent decline in revenues and were incurring approximately $2 billion in losses per month.
At the North Texas-based Children’s Health, one of the largest pediatric healthcare systems in the U.S., care is delivered to nearly 75,000 patient visits annually. However, like it did at most organizations across the country, the typical patient experience at Children’s Health began to rapidly shift as COVID-19 became more prevalent in the Dallas metro area. Suddenly, patients were hesitant to attend their in-person appointments, schedule new appointments or receive care altogether in fear of contracting the virus.
Approximately 15 percent of pediatric patients in the country are categorized as children with special healthcare needs, and roughly 23 percent of U.S. households have more than one child with such needs, as referenced in a December 2020 health policy brief in the Journal of Pediatric Health Care.
Specifically at Children’s Health, the organization’s behavioral health team—which offers its patient population various behavioral services, treatments and therapy—recognized that their essential work would even more vital during this unprecedented time, which propelled team members to pivot their existing strategies and operations to provide comfort and safety to both patients and their families.
When the behavioral health team evaluated its patient populations at the onset of the pandemic, three key groups came to the forefront: general patients with various conditions; patients in recovery from substance abuse; and those with developmental disabilities. With this key audience information, the behavioral health team set out to create strong alternatives to traditional in-person care, and the efforts put forth by the health system’s comprehensive integrated behavioral health team and virtual health program resulted in being named a co-third-place winner in Healthcare Innovation’s 2021 Innovator Awards program.
School-based behavioral health moves to the home
As part of the general patients with various conditions cohort, Children’s Health school-based tele-behavioral health program connects students throughout 178 North Texas schools with licensed behavioral health specialists virtually, addressing common behavioral health issues, including depression, anxiety, self-esteem and coping skills. Typically in this program, the school will identify a student with a potential behavioral health need, and then if deemed necessary, will make a referral to the Children’s Health program. If that handoff occurs, a licensed clinician at the health system will outreach the family, conduct a behavioral health assessment, provide supportive telephonic case management, and when clinically appropriate, will offer behavioral health telehealth therapy sessions in the school setting in which the student is in the school and the clinician elsewhere.
However, as children were required to learn from home as a result of COVID-19, the team at Children’s Health wanted to ensure this service continued to be available to students as they faced new challenges that could negatively impact their mental health, organization officials said. As such, the team pivoted this program to host videoconference psychosocial assessments from home using a tablet device.
“One of the things that changed for us in our school-based program was that prior to the pandemic, students would be on campus and would come to the office when it was time for their virtual session. So there was sort of almost a captive audience there,” explains Jason Isham, director, integrated behavioral health, Children’s Health. Isham reports that virtual learning presented a challenge as students were at home and parents may have been otherwise occupied working on their own work, or with a younger sibling on educational needs.
“We found that when we were doing services while students were at home, they would miss sessions much more frequently than they would prior to the pandemic when they were in school and could have a counselor remind them,” he acknowledges. Nonetheless, with a few adjustments made by the Children’s Health team to fill these gaps, eventually they were able to maintain their pre-pandemic visit volumes by providing services to students at home instead of at school, Isham says.
Virtual teen recovery program proves successful
For patients in recovery from substance abuse, the behavioral health team wanted to ensure essential care continued for patients participating in Children’s Health teen recovery program, which aims to help children and teens struggling with substance abuse. In an effort to prevent relapsing amidst the pandemic, the behavioral health team immediately pivoted its clinic to be 100 percent virtual, including group therapy sessions.
Additionally, the team purchased drug testing kits, which they then mailed to patient homes for the parents to administer. This allowed the team to continue monitoring patient progress similarly to how they did prior to the pandemic. These initiatives and innovations in care resulted in 57 percent of patients successfully completing the program in 2020, Children’s Health leaders report.
The teen recovery program already had virtual visits as part of its structure before the pandemic, so switching to fully virtual wasn’t a major infrastructure challenge, notes Sue Schell, vice president and clinical director, behavioral health, Children’s Health. She notes that 57 percent of patients successfully completing the program last year “is a good number, given the disease of addiction.”
Schell adds, “What we’re seeing now, and what everyone is seeing across the country, is that youth mental health issues are the next wave of the pandemic, and the emergency departments are overrun with children and adolescents in crisis with behavioral health issues. And certainly substance use is a part of that, with [people] turning to substance to deal with their depression and anxiety because it can make them feel better temporarily. But of course, it leads to more significant longer-term issues.”
Stacie Goran is the manager of the teen recovery program and in one statement from an individual in the program that was shared with Children’s Health, and then with Healthcare Innovation, the patient noted he or she was still seeing Stacie throughout the quarantine period, and that virtual appointments helped during this time since isolation and boredom could lead to poor decision making. The patient further stated, “But with Stacie being only one text or call away from an appointment, I was always on a plan with her to get the reassurance I needed.”
Modifying protocols for those with developmental disabilities
Lastly, the behavioral health team needed to pivot protocols for the Center for Autism and Developmental Disabilities (CADD) and Applied Behavior Analysis Program (ABA). While CADD patients were a priority, the team also recognized that patients within the ABA program likely suffered the most with the pandemic, as the ABA program serves young children who are unable to mask. Schell adds that children with autism indeed have difficulty communicating and a lot of sensory issues, so there is a need to stay very connected with them.
The CADD program team modified the protocols for necessary psychological testing, allowing them to treat patients virtually at home, officials explained. For several months, the team was also able to complete all but the portion of the evaluation that required a clinic visit during the mandatory quarantine. While many parents opted to postpone treatment throughout 2020, the team continued parent training sessions virtually and used this time to create new training materials for families, including a newsletter. These materials are now incorporated into all services as easily accessible parent resource tools, Children’s Health leaders note.
Raequael Anderson, manager, ABA, Children’s Health, acknowledges there was definitely concern over the impact the pandemic could have on these two programs’ patients, as it “put our families in a position to not only be parents and caregivers and providers, but now become teachers, educators and therapists, which in turn actually changed our jobs. We had to be stretched into being more flexible and trying to gather [information] from different areas to support the families,” she says.
In some cases, Anderson and her team did see that there was some regression with skill acquisition and skill maintenance. “That's actually something that we typically see within the autism population, even without something like a pandemic being impactful, just because of the nature of the condition and being a neurodevelopmental delay,” Anderson explains. So with all of those environmental changes, Anderson said her team “had to get creative in how we educated our parents and families.” That shift involved trying to maintain as much of the previous skills that they had learned as opposed to teaching them new skills.
In the end, the behavioral health team at Children’s Health impressively completed more patient visits in each of these programs in 2020 than in 2019. “This is indicative of both the increased need for behavioral health services during this time, as well as the team’s ability to pivot and create virtual program innovations quickly and efficiently,” the health system’s leaders contend.
