Corinn Cross, MD (Host): Welcome to Peds Cast, a podcast brought to you by Children's of Alabama. I'm your host, Dr. Cori Cross. Childhood and adolescence can be a challenging time, especially when children have problems with mood, paying attention, or if they face difficulties at home or school. If problems are not treated, children can develop low self esteem, perform poorly in school, have trouble with relationships, or struggle to reach their potential. Children's of Alabama offers comprehensive behavioral health care that addresses the specific needs of each patient. Today, we are joined by Brandy Reeve. She is the Senior Executive Leader of Behavioral Health Services at Children's of Alabama. She will be discussing the breadth of services the hospital offers and how they are helping children cope with difficult times, especially as the mental health crisis progresses. Thank you for being here with us today to discuss such an important topic.

Brandy Reeve, MSN, RN, CPN, CENP: Thank you for having me. Good morning.

Host: There is a mental health crisis in the country right now, which is affecting many of America's youth. Tell me about your role at Children's of Alabama and what it's been like for you and your team trying to address the mental health needs of the young people in the community.

Brandy Reeve, MSN, RN, CPN, CENP: Yes, that's certainly true. We have seen quite an influx and rise in needs of our children that are experiencing mental health concerns, really since the pandemic, we've certainly seen an increase. That's what our data shows. My role here is to oversee the operations that we offer through Children's of Alabama, within the behavioral health space.

And so we offer many different programs and day to day I oversee those operations and truly from what you mentioned, our goal here is to try to be creative and look at the way that we're offering services from a different lens to see if there's an opportunity to increase access for patients.

At the end of the day, it's all about our ability to meet as many patient needs as possible. And when those needs rose as quickly as they did, following the pandemic; it is quite overwhelming and so it's been certainly a challenge that we are looking at very differently than we would have prior to the pandemic, in ways of being able to increase that access through unique forums so that we can meet as many patient needs as possible.

Host: And that makes sense because you're right, you have to meet the patients where they're at. Tell me a little bit about Children's of Alabama and how, like you said, it offers a variety of services to address patients needs. Can we talk a little bit about some of those, starting with maybe the inpatient and the outpatient services? Can you tell me a little bit about the care you offer in these services and how you decide which one's more appropriate for a patient?

Brandy Reeve, MSN, RN, CPN, CENP: Yes. So, our inpatient, you can think of it a little bit like based on the patient's severity of need. So if they are in a mental health crisis, they may require something like an inpatient stay. We have a 44 bed inpatient unit currently, and we treat patients there. It's is a lot of medication management by our psychiatrists and our nurse practitioners that are the providers within those spaces.

And then we do a fair amount of group therapy and they're followed by our mental health therapists within those spaces. And those are an acute admission where we're really trying to get them what they need in order to get them discharged back out into their community to maintain that sense of normalcy for them within their environment as quickly as we can.

And then that, when they are discharged out, they're often followed in an outpatient space. And so we offer both psychiatry and psychology services within our outpatient spaces. We have two locations. And so, there the patient may be followed for medication management on the psychiatry side, and then for psychology may be followed for therapy sessions on an outpatient basis.

Those therapy sessions, if they're followed in outpatient, typically are, they may start at a session a week, but then we try to get those sort of spaced out to every two weeks, four weeks, and so on. And so that often follows an inpatient admission. Or we may have a patient that just has not so acute symptoms when they present and perhaps their pediatrician refers them over.

And they may go straight to outpatient and not require an inpatient stay. So it really varies based on the patient needs. But typically for those two spaces, both inpatient and outpatient, it is dependent upon the acuity of the patient.

Host: And that makes sense. Now you also have something that I'm not familiar with, called the partial hospitalization program. What does this offer patients and how does this differ from a true inpatient experience?

Brandy Reeve, MSN, RN, CPN, CENP: Yes, this is a space that we've been just so excited about. It's only been open a few years now. The partial hospitalization program would be a step down from inpatient. Perhaps a patient is ready to discharge from inpatient, but they're just not quite ready to go to only seeing someone once a week. They really need more intense therapy than that. They can step down to our partial hospitalization program that is set up and mimics more like a school day. So rather than discharging, going back to the school system, they would discharge and begin partial hospitalization within that space. And it is a day that looks like 8:30 to 2:30. And in that timeframe, they're receiving four to five hours of intense group therapy with other children that are of their same age group.

And so they learn coping mechanisms and how to deal with those everyday stressors that our adolescent population often faces. And then they leave about 2:30 every day. During that 8:30 to 2:30, they are also doing at least one full hour of school so that they don't fall too far behind.

And so we work closely with the school systems to get whatever school work that they'll need so that they can continue that as well while receiving this intense therapy.

Host: As a pediatrician, that's absolutely genius, because what we see most of the time is that you can stabilize children, but then they go back and they're sort of thrown back into their daily life, their community, whatever their triggers were, and they're trying to hold it together. And all they have is this little tether, you know, once or twice a week where they go in and see somebody for an hour. And it's really learning how to keep it in place when you change communities. That's so difficult. And this seems like just a genius way to do it. How long have you had this program?

Brandy Reeve, MSN, RN, CPN, CENP: We've been open about three years now. And just to tack on to one of the things that you said, this is the most effective treatment for our population as exactly like you said, you know, you can get really intense therapy while you're inpatient. And then when we discharge you from having structure 24 hours a day, to now only having one hour of therapy a week; that's a big difference for a child. And so, that is why I think the evidence shows that this is so successful and is such needed robust program within our state. And so we're been very fortunate to be able to offer that.

Host: And do you feel as if you have the capacity to take in as many children into this program as really are needed or is this something that you see growing in the future?

Brandy Reeve, MSN, RN, CPN, CENP: I could see it growing. I don't know that there's any area that we'll talk about that I couldn't see growing though, and we may talk about this in a moment, another program that we're just getting ready to start. But with that, you are correct. If the space is there, we for sure would have patients to fill those slots. And so that's where it's been a balancing act of, where we're allocating resources to make sure we're meeting the most patient needs as we can with the resources that we have. And so, very fortunate to have this program.

Host: And to touch on that, I think you were just alluding to your intensive outpatient program. And, I was curious how this goes along with your partial hospitalization program and basically how the two programs complement one another.

Brandy Reeve, MSN, RN, CPN, CENP: Yes, so, if you think of the PHP, which we just previously spoke about, as looking like a school day, you can think of IOP, or intensive outpatient program, as mimicking more of an afterschool care. This is where the patient may have been inpatient and they may step down to partial hospitalization and then may step down to IOP.

We have some that may come from inpatient and be fine to move straight to IOP and then we have others that may be in an outpatient space where let's say they're receiving therapy once a week or once every other week and their therapist or their psychologist is saying, gosh, they're just really struggling. I think they need something more intense. They can step up to the IOP program. And so a little more detail on what it entails is that it does mimic an afterschool care type setting. The patients arrive at 2:30 every day and then they don't leave until between 5 and 5:30. So they receive between two and three hours of intensive therapy three days a week. And so their program runs three days a week. So as you can see, better than just one hour a week on outpatient when they're in a space of needing that. But if they're doing well enough to not have to miss school and be in the PHP space, it does allow for them to enter back into the school system, but then still get that very structured therapy three days a week where they're with other like adolescents that are going through the same thing and then they're able to really talk through their stressors and work through their coping mechanisms within that group therapy space in after school like setting.

Host: You touched a little bit about this, when you were talking about deciding whether it's an inpatient or outpatient treatment that would best suit the patient. Can you dive a little bit deeper into what the Psychiatric Intake Response Center does and sort of walk us through what that looks like?

Brandy Reeve, MSN, RN, CPN, CENP: Yes, we're so proud of that program and the team that we have there does really great work. So our Psychiatric Intake Program, they receive phone calls from the community. And the only requirement is that you be of adult age to call and they maintain a database of all types of resources throughout our state.

They have resources within every one of our counties and then therefore when someone calls in and says, hey, my grandchild is experiencing this and this, we really would like to get them in with someone, we're struggling to find somebody that will accept our insurance or that is accepting new patients.

They maintain this database to where they can immediately go to where that person is calling from look in that county or surrounding counties, identify providers that are currently actively accepting patients that also will take their insurance, provide those resources back to these families so that they can then call and get an appointment.

That has been just so well received by our community partners and that it's a free service that we offer and anyone can call and that line is manned 7 a.m. to 11 p.m. In addition to that, those same mental health therapists that are manning those phone calls, also operate within our emergency department and see patients that arrive in our emergency department in a mental health crisis, to really go ahead and begin that mental health assessment immediately upon their arrival, versus waiting for a psychiatrist to be consulted who's just one person and is trying to see many, many, many patients.

We can go ahead and begin the process of seeing those patients. So they sort of hold a dual role, both in providing resources to the community for phone calls of patients, families, and or providers that may come in, but also seeing patients that present to our emergency department as well.

Host: Yeah, it sounds like you're really doing a great job of taking a lot of the leg work out and helping families really be able to connect quickly with services they need. Tell me a little bit about Children's of Alabama's program, the Pediatric Access to Tele Mental Health Services, or the PATHS, as you call it, program.

How does this program work? When is telemedicine appropriate in the mental health setting and how has this program with telemedicine helped you reach patients that you otherwise might not have and who would have gone without services?

Brandy Reeve, MSN, RN, CPN, CENP: Yes, another sort of what I would consider our unique program. So I feel like we have traditional services, but both HERC that you mentioned and then PATHS is our abbreviation for this particular program is just something that's a little bit outside the box thinking, but has proven to be quite successful.

So this program is a partnership with the Alabama Department of Mental Health. And it is funded through a HRSA federal grant, and it began about five years ago. It's three pronged. It begins with education, and that's education of primary care providers throughout our state on mental health disease processes, mental health treatment options. And so there's the arm of education. The second arm is teleconsult. That is where we go out and as we enroll these pediatric practices or family care practices, if they see pediatric patients. We enroll them into our program and then they have access to our teleconsult line where when they are seeing a patient that may be having some type of a mental health concern or crisis, they can contact our teleconsult.

Within 24 hours, they will receive a call back from our psychiatrist to provide them with certain, recommendations based on what they're talking about. We say 24 hours just to be safe. Most of the time they're receiving a call back within the hour. And then we provide them with what they need to better care for a patient that's sitting within their practice at that very point in time that otherwise they might have said, I'm sorry you're going to have to the nearest emergency department, I don't really know how to care for this or that. And so that's been very, very helpful because it gives power back to the primary care providers and gives them the resources needed to care for the patients they're seeing anyway.

If the teleconsult portion, which is our second arm, let's say that we've tried that, but the patient just seems to be more complex than what the pediatrician is comfortable making those, treatment recommendations or offering treatment for. Then we will pull that patient back into the primary care provider's office and do a telemedicine visit.

This telemedicine visit will include their primary care provider, the patient, the family, and then on the other end would be our psychiatrist. They will then do a telemedicine like appointment where they're asking the appropriate questions, doing the appropriate assessment, and getting feedback from both the patient, the family, and then whatever the provider has to add, to where they can better walk through and help to guide treatment options at that time. So that's where it sort of dives over into our third arm, which is the telemedicine component. That is also done by one of our psychiatrists here that is on staff. And typically those are set up in advance and then they're scheduled through both the pediatrician's office, so the pediatrician is available and through our PATHS slots here at Children's so that our psychiatrist is also available. So those are sort of the three arms of that particular program, that have equipped our pediatric physicians within our state to be able to care for the more straightforward type of mental health concerns that are being seen in the community; since there is such a long wait list to be seen by a mental health provider and especially by a psychiatrist or a nurse practitioner that have prescriptive writing abilities, those wait lists can become quite lengthy and many of those patients need treatment that includes medication now. And so to avoid emergency department visits, this is another opportunity to increase that access through these services.

Host: Yeah, it sounds like you've basically made it possible for all pediatrician, family practice offices to almost have a mental health expert sort of on staff. That's pretty amazing. As we wrap up, can you give us some parting thoughts on how you see all these programs working together for the benefit of your patients and really what you see the future holding for the behavioral health services at Children's of Alabama?

And

then

Brandy Reeve, MSN, RN, CPN, CENP: Sure. Yes. So, I mentioned this a little bit earlier. We have the traditional services that we talked about, our inpatient, our outpatient, even PHP is sort of integrated as a part of our traditional services now. But with that, there's still many needs that our team, there's just not enough of us to go around to meet all of those.

So then that began our unique services approach through our PERC program, where we're able to offer those resources, back out to family members, and then PATHS, where we're equipping primary care providers to be able to provide these mental health services throughout the state, and we find that those programs all intertwine quite nicely to create some sort of a framework for which we're able to meet needs across the spectrum of acuity, which has been really great.

As far as the growth, we have a lot of things in the works. The construction is going on now for our fifth floor, which will be another 11 beds for inpatient that we will be opening in February of 25. So that'll bring our inpatient space up to 55 beds. We have recently just added some psych safe beds within our emergency department, 16 of those. And that's fully staffed by our mental health expertly educated staff, to be able to take care of those patients immediately upon arriving, with that mental health mindset.

With that, we also see our outpatient spaces perhaps growing further. And then our PATHS program is probably what I'm most excited about and that we are for the next three years, we've been awarded another grant and we're going to expand what we're doing within our pediatric practices throughout the state into both rural emergency departments as well as partnering with our school systems to see how we could be of benefit in equipping them to also care for their students, if it's in the school or patients within the emergency department, better if we are able to provide resources to them as well.

So the goal being, continue to improve access in whatever unique way we can find. And just be that resource for those that need it, that are willing to partner with us in providing care to the patients that we see throughout the state.

Host: Well, you all are very busy. It's amazing what you are implementing there and, you know, what you already have going on. Thank you so much for sharing your expertise with us today. It's been a real pleasure to talk with you and get such an in depth understanding of the breadth of services available at Children's of Alabama.

Brandy Reeve, MSN, RN, CPN, CENP: Thank you so much.

Host: If you would like more information about the behavioral health center or to refer patients to Children's of Alabama, please visit www.Children'sal.org/services/behavioral-health-ireland-center. That's www.childrensal.org/services/behavioral-health-Ireland,I-R-E-L-A-N-D-center. That concludes this episode of Children's of Alabama Peds Cast. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for other topics that might be of interest to you.

Please remember to subscribe, rate, and review this podcast. Thanks for listening to this episode of Children's of Alabama Peds Cast. I'm your host, Dr. Cori Cross.