Catching up to the Crisis: Opportunities for Pediatric Hospitals to Improve Children’s Access to Mental Health Services

Because of longstanding shortages of pediatric mental health clinicians¹ and inpatient psychiatric hospital beds, many children have unmet mental health needs. Some of these children seek safety-net care in children’s hospitals and emergency departments (EDs) for mental health crises, such as suicidal thoughts or aggressive behaviors.² Although acute-care medical hospitals may not have been designed for mental health crisis care, acute-care hospital teams are developing experience in mental health crisis management.³ As a result, ED and hospital clinicians have unique knowledge of which factors contribute to children’s mental health concerns and which services are needed to prevent mental health crises. When hospital clinicians take advantage of their experiences in caring for children who are experiencing mental health crises, they can develop innovative approaches to improve children’s access to mental health services.

In this month’s issue of Hospital Pediatrics, Clark et al⁴ describe how an instrument developed for ED mental health evaluation and referral was implemented in a prehospital, telephonic, mental health intake system in Nova Scotia, Canada. The home, education, activities and peers, drugs and alcohol, suicidality, emotions and behaviors, and discharge resources (HEADS-ED) tool (available at www.heads-ed.com) is a mental health screening, triage, and referral tool that was originally developed to be used to guide ED decision-making for patients with mental health concerns.⁵ In the current study, Clark et al⁴ describe how the HEADS-ED performed as an intake tool for patients who contacted a telephonic intake system seeking mental health services. In the context of a publicly funded, Canadian provincial health care system, the tool supported effective care recommendations; of the ∼700 patients who were evaluated via telephone with the HEADS-ED tool, 86% were referred to a definitive treatment path at the time of their initial referral. Patient engagement in care was excellent; <10% of patients cancelled or did not show up for their initial appointments. Finally, interrater agreement was high, which suggests that the instrument can be used to ensure that different clinicians make consistent decisions.

Employing the HEADS-ED tool in prehospital care is an innovative response to the current mental health epidemic. Implementing a standardized assessment tool that was developed for emergency care within a telephonic intake system enabled providers in this health care system to provide access to the right services to patients with subacute symptoms at the first point of contact with the mental health system. Efficient connection to appropriate mental health services can build families’ trust, promote patients’ engagement in care, and reduce the risk of patients developing mental health crises. Although the authors of the current study did not evaluate subsequent acute care use, efficient prehospital connection to mental health services might prevent subsequent ED visits for mental health crises.

Findings from the current study suggest that the HEADS-ED tool helped ensure quality and consistency in triage and referral decisions. Knowing that the telephonic assessment adheres to the same standards as an in-person ED assessment might help families and community clinicians feel comfortable in relying on a telephonic assessment rather than an in-person assessment in the ED. If this were the case, an effective prehospital intake and referral system might help prevent families from visiting the ED for mental health care coordination.

One feature that enables the HEADS-ED tool to function well in both ED and prehospital settings is the inclusion of pragmatic screening for patient concerns in multiple domains. Unlike screening instruments that are designed with only 1 focus, such as a specific diagnosis (eg, depression), behavior (eg, substance use), or risk of crisis (eg, suicide risk), the broad screening domains of the HEADS-ED tool are aligned with widely accepted priorities in pediatric psychosocial screening and health maintenance, which are as follows: home, education, emotions, activities and peers, drugs and alcohol, and suicidal thoughts and behaviors. To facilitate referral recommendations, the HEADS-ED tool augments screening with an assessment of discharge resources. By including assessments of both clinical needs and current services, the HEADS-ED tool maximizes the efficiency of the clinical interaction. This comprehensive yet practical screening approach lends the tool face validity, which likely facilitates communication with families about recommendations supported by the tool.

The current study revealed that the HEADS-ED supported effective referral for patients seeking access to publicly funded mental health services within a Canadian provincial health care system. In the United States, the diversity of models for coordinating access to and payment for mental health services greatly complicates the process of making referral recommendations. Children and families in the United States might seek to access mental health care by referral from a general clinician, a medical insurance plan, a mental health–insurance plan (ie, a behavioral health “carve out”), school, or county-funded mental health services. Each of these access points likely includes a different range of options for mental health services. The coordination of services might be improved if different referring and coordinating bodies used a similar approach to triage and referral. A tool like the HEADS-ED could be used to provide a means for achieving consistency.

One potentially concerning feature of using the HEADS-ED tool for prehospital triage was that members of the clinical staff were hesitant to assign higher symptom severity if the appointment wait time was longer than that recommended for a patient with higher-severity symptoms. Careful attention to staff training and clear guidelines or protocols for managing longer-than-recommended wait times might help mitigate this problem. Future research closely examining treatment engagement and outcomes in patients who wait longer for an appointment than is recommended for their level of symptom severity could help determine if the instrument’s symptom-severity scale supports clinically appropriate recommendations and provides evidence in support of building additional capacity for urgent mental health services.

Because emergency and hospital mental health care is less efficient and less effective than outpatient management,⁶ a prehospital triage and referral system can be used to reduce costly hospital resource use and potentially enable more children to receive effective services. The use of the HEADS-ED tool in a prehospital, telephonic, mental health intake system is 1 example of how insights that are gained in hospital practice can be translated to prehospital care and used to improve the timeliness and efficiency of children’s access to mental health services.

• Copyright © 2019 by the American Academy of Pediatrics