Critics say Children’s Healthcare should do more to fill gaps in mental health system

Even as its hospitals have seen dramatic increases in the number of children brought to its ERs with mental health crises, Children’s said it determined through careful study that it wasn’t feasible or even wise to try to build an inpatient psychiatric unit.

“We think kids are better served through the specialized psychiatric expertise that is found in many of the facilities across our state, and we work closely with those facilities,” said Dr. Daniel Salinas, the chief community clinical integration officer for Children’s.

Doctors and nurses in the system’s ERs evaluate the children. Some children are sent home from the ER with treatment plans. But those who are seriously ill are held in the ER until beds can be found at psychiatric hospitals for inpatient care. Those deemed most at risk are transferred through involuntary commitment orders, called a 1013, where the child’s parent cannot block the admission or even be assured their child won’t be hospitalized hours away.

That has led some of those working to improve mental health care in Georgia to question why Children’s — an extraordinarily wealthy system with billions of dollars in reserves — isn’t doing more.

With suicide now a leading cause of death for young people and the nation’s leading pediatrics organizations declaring a national “state of emergency” in children’s mental health, pediatric hospitals in many other states are expanding their mental health units or constructing new hospitals devoted entirely to behavioral health.

Rep. Mary Margaret Oliver, D-Decatur, who co-sponsored the wide-ranging mental health parity legislation that became state law this year, said that for 10 years she has urged Children’s Healthcare of Atlanta to do that.

“There’s no question that CHOA is the state’s premier children’s hospital,” Oliver said. “They’re going to save the life of your child who may have cancer or a nightmare of a congenital heart defect. And there’s no question that people all over Georgia will bring their very sick child to CHOA,” Oliver said.

“But that does not mean that they’re serving children with intensive psychiatric needs. . . . I want them to do more, and there are many other people in Georgia that want them to do more for the children who are in crisis, based on mental illness.”

‘High utilizers’ a focus

After Gov. Brian Kemp signed the mental health parity bill into law in April, a commission of experts and lawmakers quickly got back to work, saying much more needed to be done to fix the state’s broken mental health system.

In June, Salinas, of Children’s Healthcare, spoke to the commission to share observations Children’s had about dysfunction in the system.

“Over the last 18 months, the number of kids presenting to Children’s ERs in crisis with a primary mental behavioral health condition has started to really, really go up and those that we have to place under 1013 [involuntary] commitment has gone up dramatically,” he said.

While the AJC found that children in crisis in Georgia often wait hours, even days, for a bed in a psychiatric hospital, Salinas told the experts that Georgia has had enough inpatient mental health beds to meet the demands for most children. However, the rising needs and staffing shortages, he said, are creating challenges.

He also acknowledged that it can be difficult for some children to get inpatient care these days, especially children whose mental illness may be combined with autism or an intellectual disability.

But Salinas was focused on another point: a group of children who visit Children’s ERs extremely frequently.

Children’s studied 68 patients in 2020 who, as a group, accounted for 392 visits to a Children’s ER.

Trauma was common among the patients, with sexual and physical abuse. All had been to inpatient psychiatric facilities at least 10 times. Three in four had suicidal ideation. Many had been in foster care or group homes. They spent an average of 10 hours at a Children’s Healthcare hospital for each ER visit, Salinas said, compared to 2.5 hours in the ER for “regular” patients.

Credit: John Glenn-J Glenn Photography

Credit: John Glenn-J Glenn Photography

Salinas said health plans and the state should focus on these “high utilizers” and do more to coordinate their care, so that they get the range of services needed to avoid falling back into crisis.

Salinas told the AJC that Georgia has “silos of significant, excellent expertise in mental health.” The challenge, he said, is for Children’s and the state of Georgia to help connect all the dots to create an ecosystem of care.

Dr. Sarah Vinson, a child psychiatrist at the Morehouse School of Medicine and a member of the commission, said during the public meeting that coordination issues exist, but she said the challenge is getting children access to care, whether they are on Medicaid or private insurance.

“There is absolutely a tremendous services gap as well,” she said.

And she laid part of the problem on Children’s Healthcare.

Credit: HYOSUB SHIN / AJC

Credit: HYOSUB SHIN / AJC

“It’s really important to keep in mind that if CHOA had their own inpatient child psychiatry unit, those numbers would look better,” Vinson, the director of the Child and Adolescent Psychiatry Fellowship Program at Morehouse, told commission members in response to the presentation by Children’s.

“It’s important to remember, that’s a system that chooses not to provide inpatient mental health care for children and that chooses not to provide outpatient mental health services for children. If major hospital players like CHOA stepped up, this problem would not be as pronounced,” she said.

Later in June, Children’s announced it had hired Dr. John Constantino as its Chief of Behavioral and Mental Health. Children’s has described Constantino’s new leadership as an opportunity to transform mental health services in Georgia, but the system has emphasized that it still does not plan to open inpatient psychiatric beds.

Children’s counterparts expanding

Across the country, some pediatric hospitals have taken bold steps to serve children with mental health issues.

In Columbus, Ohio, the board of Nationwide Children’s Hospital decided to offer services for mental health on par with its top-ranked care for physical illnesses. The planning started years ago, as doctors and public health experts worried about growing rates of anxiety, depression and suicide.

“One in five teenagers have had a significant mental health condition that’s caused severe impairment at some point in their lives,” said Dr. David Axelson, chief of the department of psychiatry and behavioral health at Nationwide Children’s. “Many more have had milder versions, milder conditions.”

In 2020, Nationwide Children’s opened the doors of the Big Lots Behavioral Health Pavilion, which stood out as the nation’s largest center dedicated to child and adolescent behavioral and mental health on a pediatric medical campus.

The nine-story tower, with a child-friendly interior filled with colorful graphics and lots of light, was constructed next to the main hospital, sending a message that the system treats the whole child.

“It’s to say, hey, this is just as important as all the other very important conditions that we treat here,” Axelson said.

A broad range of inpatient and outpatient services are housed in the building, where researchers also search for the best mental and behavioral health treatments for kids. But Axelson says they still need even more capacity and staff to care for kids, with so many in need of services.

In Norfolk, Virginia, the Children’s Hospital of The King’s Daughters Health System learned in surveys measuring the needs of its community that mental health care for kids had become the top priority.

Credit: Courtesy of CHKD

Credit: Courtesy of CHKD

“Our primary care doctors were telling us, ‘It used to be what we saw in our office was a little asthma, a little bit of bronchitis, maybe the flu now and then. Now, almost half or more of our appointments are for families that have children having mental health crisis issues and we as primary care doctors don’t know how to handle it,’” said Jim Dahling, the hospital’s president and CEO.

The hospital waiting room reflected the need, too, Dahling said. Historically, children came in only occasionally to the ER in a mental health crisis and the hospital would usually work to transfer the child to a local psychiatric facility for care.

“All of a sudden, we found ourselves with 10, 15, 17 kids in our emergency room, and they and their families were desperate for help,” he said.

The common experience for families, he said, had been that a child in crisis would come to the ER, get sent to a psychiatric hospital, and spend three to five days in intensive therapy, usually including drug therapy.

“At the end of that point in time, the parents get the child back with a 30-day supply of medication and little to nothing in the way of outpatient care or active follow-up; 30 days later they are back in another ER with the same problem,” Dahling said. “So what we’re trying to do is break that pattern.”

To do that, Dahling said the hospital realized it had to act aggressively.

Credit: Children's Hospital of The King's Daughters

Credit: Children's Hospital of The King's Daughters

It started in 2014 by building out an outpatient program, saying it was critical to have a full continuum of care. But in 2017, it asked its board to establish 24 inpatient psychiatric beds.

Questioning whether that would be enough, the board eventually approved adding 60, and the hospital constructed a 14-story Children’s Pavilion on its main campus to house the new beds along with some other medical services.

The building’s first inpatient unit of 12 beds is opening this month with the rest being phased in through 2023, completing the vision of a full continuum of services.

Already the hospital is getting calls from around the country from other pediatric hospitals wanting to know how they did it.

Credit: Children's Hospital of The King's Daughters

Credit: Children's Hospital of The King's Daughters

Finances are often a big consideration, because of the expense of building and staffing a comprehensive pediatric mental health system, Dahling said. But he said the board told him to expand to meet the need, and they would figure out the finances.

They did not need to be sold on the mission, he said.

“There is nothing that is more sobering than a young person who ends up at the beginning of their life to decide to end their life,” Dahling said.

“There’s just a thousand reasons why this is important to do.”

Whose burden?

Children’s Healthcare of Atlanta said it would take years to gain approval, build a mental health facility and find specialists to staff it.

“We know families and children are hurting and are in crisis now,” the system said in a statement. “We understand parents are scared and need help now.”

It says a “broader view” of the issue would be more effective, because more treatment space wouldn’t solve the mental health crisis. “The issue that we’re in right now is bigger and broader than one that can be solved by beds,” Salinas told the AJC.

So, what is Children’s Healthcare doing now?

It says its plan includes a $112.5 million investment over the next five years. Children’s said it expects to spend even more and wants to raise $70 million from donors to help.

To assess children coming into its ERs, Children’s says it has hired more than 130 professionals in the last two years, including psychiatrists, nurses, social workers and techs. That team arranges placements at psychiatric hospitals, if needed, or sends them home when appropriate, with a plan for next steps.

Children’s also opened an internal referral-based outpatient mental health clinic last year where Children’s Healthcare of Atlanta physicians can send their patients who have physical health issues but who may also need mental health services.

It said it also launched a pilot program at its primary care clinic at Hughes Spalding, next to Grady Memorial Hospital, that is experimenting with having behavioral mental health experts work alongside primary care providers.

Other initiatives include a public awareness campaign focused on resiliency, training for primary care doctors and others, and the hiring of Constantino to lead the system’s work. Children’s said it expected to formally announce new initiatives soon. But Constantino told the AJC this month that his plan will focus on creating new outpatient services that would provide access to effective care and help children avoid falling into crisis. “You should expect that even within a year with a new workforce, with some strategic planning, with a lot of interface with the community, that things are going to start changing,” he said.

Credit: Bob Andres

Credit: Bob Andres

Some say the burden isn’t on Children’s to fill all the gaps when it comes to mental health services for kids. “Ultimately, Children’s mission is not to provide mental health care,” said Kevin Tanner, a former state legislator who is chairman of the state’s Behavioral Health Reform and Innovation Commission. “They’re not in that arena. They’re in the physical health side.”

Tanner, now the county manager in Forsyth County, said there are other ways to address the needs. In Forsyth, for example, the county is planning to build a safety-net facility that will house both the health department and a mental health unit with 30 crisis stabilization beds, including 10 for children. Once stabilized, the patients could move to outpatient care.

“It will essentially be a 24-hour mental health emergency room. “We’re excited about that,” Tanner said. “We have to start filling that need and we have to do it regionally.”

The Children’s Hospital of Georgia in Augusta doesn’t have inpatient psychiatric beds, either. Only a few general hospitals in the state do. Finances may play into the small number of inpatient units. Providers say Georgia’s Medicaid payments for mental health care are low and make it difficult to operate a well-staffed psychiatric unit. Plus, child psychiatrists and other mental health providers are in high demand, which makes it challenging to open a new unit.

Given Children’s financial means, though, and its nonprofit status, others say the system should view psychiatric services as a crucial part of a comprehensive pediatric health care system and recognize that the services children need simply aren’t there in Georgia. Because nonprofit hospitals are exempt from paying taxes and receive favorable bond financing for construction projects, they are supposed to serve the needs of their communities.

“Children’s should put mental health on parity with physical health,” said state Rep. Sharon Cooper, R-Marietta, who is chairwoman of the House Health and Human Services Committee. “They should take a billion dollars from their ample reserves and open an inpatient unit staffed by the best professionals in the country.”

Families go to Children’s in a crisis and assume that the system will have comprehensive pediatric services, including care for mental health, said Rep. Todd Jones, a co-sponsor of the Mental Health Parity Act.

“And they don’t,” he said.

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