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Children of Bellevue

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Jonathan Creem

on 28 November 2017

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Transcript of Children of Bellevue

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CHILD INPATIENT
21 SOUTH

AUTISM & INTELLECTUAL
DISABILITY CARE PATHWAY

AUTISM & INTELLECTUAL
DISABILITY CARE PATHWAY & INTELLECTUAL DISABILITY
Autism Spectrum Disorder (ASD)
1 out of 68 children in the US
Core Domains
Communication Impairment
Social Interaction Challenges
Restricted Interests & Repetitive Behavior

Intellectual Disability (ID)
Core Domains
Delays in cognitive, social & motor domains
Evenly delayed profile across these areas
Impairment in adaptive functioning

DEPARTMENT OF CHILD & ADOLESCENT PSYCHIATRY
WHY HAVE A CARE PATHWAY?
A PATHWAY TO IMPROVE CARE
P
redictability
A
ctivity
T
otal communication
H
igh reward
WAY
to Cope

10-20% of children admitted to Bellevue have ASD or ID

Children with ASD/ID do not respond well to standard inpatient care

Pathway developed with input from nursing, psychology, psychiatry, and clinicians who specialize in autism and intellectual disability
HOSPITALIZATION
CCPEP
INPATIENT
DISCHARGE
Creation and Transfer
of Tip Sheet
Age and Capacity
3-11 year olds
Trauma Screening
To date,
535
patients screened
79%
of admissions ages 7-12 screened
38%
above clinical cutoff for PTSD
% sub-threshold: 10%
Physical abuse: 26%
Witness domestic abuse: 31%
Sexual abuse: 24%
CARES
Targeted Group Programing
Children's Awareness Regarding Emotional Stress
Goal:
To help traumatized children understand & process their traumatic experience & to develop healthy coping skills

610
participants since December 2010
76% of patients (ages 7-11 years old) participated in CARES
68% of eligible admissions attended (YTD)

The group meets 5 times

a week

Behavioral System
Our goal
is to modify and shape children's behavior through constant positive reinforcement
New point system and rewards system (started last year)
Reward times increased from twice a week to twice a day
Crunch and Munch Rewards now three times a week
Healthier snacks added to Reward Store
All staff trained in Positive Behavior Motivation
Added point sheets
Children responsible for their point sheets
Points linked to therapeutic goals
New time-out procedures
Therapeutic Programming
Our goal
is to provide a structured environment with age-appropriate activities, encouraging pro-social behaviors.
Full-time psychologist started mid-September 2016
Retrained in positive behavior motivation last fall
Think Trauma Training this spring
Implemented Comfort and Sensory Program

15 Beds
Clinical Range for PTSD*
Individual Daily Goals
Our 2018 Goals
1. Continuing the implementation of the new and improved CARES group

2. Comfort and Sensory Integration Program: continue training staff in order to utilize the comfort room resources to reduce the frequency of therapeutic holds and help children meet individual goals including learning positive coping skills
Program & Services Delivered
Behavioral & Reward System
Our Comfort Room
Accomplishments
In March 2015, our Day Treatment Program transitioned to the Partial Hospitalization Program which has increased access to intermediate level care for high risk youth in NYC
To meet the needs of our acute patients, PHP provides intensive individual therapies, educational and family support, and has developed extensive group therapy, including trauma groups for children and Dialectal Behavior Therapy (DBT) groups for adolescents
$150,000 NYC OMH capital grant supported the renovation of space
Goals
1.
Goal in 2017:
to implement structured intake and discharge screening with the CDI, UCLA Reaction Index, and SDQ.
60% of patients with complete screens

2.
Goal for 2018
: to analyze 2017 screening data to demonstrate clinical efficacy of PHP interventions.
Admission and Length of Stay
Total Child and Adolescent Admissions
Program and Services Delivered
Our goal
is to provide excellent, accessible, coordinated, culturally competent, and linguistically diverse mental health services to those in need throughout the city
The clinic provides care for approximately
430 patients
at a time
Over the past year, we have maintained our intake show rate of over
70%
compared to the national average of 50%

Positive Behavior Motivation
Began in January of 2012

Students of P35M participate in daily positive behavior motivation program modeled after the Child and Adolescent Treatment Program's system

Teachers complete daily points sheets

Students are invited to "shop at the bodega" if they have achieved the daily threshold for the past 3 days

Students with the highest points for the week shop first
Children of Bellevue Funding
Clinic Accomplishments
Dramatically improved access of care to ambulatory pediatrics and are now screening adolescents in pediatrics for depression and screening new mothers for depression as well.
Received 3 Thrive mental-health service core workers and are providing increased access to ongoing therapy for both children and their families.
Received an additional mural from Splashes of Hope to beautify our group therapy room.
2018 Goals
Institute a new depression treatment protocol for teenagers in conjunction with the Child Study Center.
To redo our physical space which will allow for increased visits and providing additional services like PCIT.
To expand our early childhood mental health program under the leadership of Dan Schechter.
Early Childhood Mental Health
Parent Child Psychotherapy

Group Attachment Based Intervention

Circle of Security
CHILDREN'S COMPREHENSIVE PSYCHIATRIC EMERGENCY PROGRAM (CCPEP)
Program and Services Delivered
Emergency evaluation
Triage and risk assessment
Connection with appropriate services
Pediatric Observation Unit for short-term intensive treatment
Starting medication in a safe, monitored setting
Intensive individual and family therapy
In-depth diagnostic assessment for youth with complex presentations
Interim Crisis Clinic
Bridging the gap between emergency evaluation and outpatient follow-up care
Increase access to outpatient services and avoid unnecessary hospitalization


A Safe Place for Kids in Crisis
Accomplishments

Hosted 4th Annual Conference
"Managing Psychiatric Emergencies in Children and Adolescents"
attended by over
300 participants
from across the country
First paper published in Psychiatric Services,
"A Children's Comprehensive Psychiatric Emergency Program: Contrasts with Usual ED Care for Youth with Psychiatric Problems,"
Gerson, Havens et al.
Second paper submitted to Pediatric Emergency Care,
"Friendly Faces: Characteristics of Children and Adolescents with Repeat Visits to a Specialized Child Psychiatric Emergency Program,"
Marr, Havens, et al.
Third paper on trauma and suicide in preparation
2018 Goals
1. Continue to make the CCPEP child-friendly by investing in child-centered decor, celebrations for holidays, and therapeutic toys and activities

2. Support our innovative CCPEP group therapy program

3. Maintain our work with Autistic youth in coordination with the new Autism Care Pathway project

4. Hold the
5th Annual
"Managing Psychiatric Emergencies in Children and Adolescents" conference

5. Provide greater resources for children and families in our Crisis Clinic

6. Enhance outpatient space with an expansion planned for Spring 2018
To create a safe, child-friendly environment for evaluation, stabilization, and treatment for any child with psychiatric disorder
Many children with psychiatric illness are seen in pediatric medical ERs or adult psychiatric emergency rooms
This can be scary and traumatizing for children who are already under stress

Evaluation, stabilization, and treatment for any child
Many outpatient, inpatient and crisis programs turn away high-risk youth
We treat any child who walks through our doors
We have been treating increasing numbers of high-risk youth, collaborating with ACS and DJJ, and also enhancing services for Autistic youth through our Autism Care Pathway
Our Goal
A Safe Place for Kids in Crisis
Next Steps: Expanding Space, Expanding Service
ASD Care
P
athway Tools
P
redictability

Increasing
Predictability
reduces problem behavior (such as agression, self-injury, and tantrums) in patients with ASD/ID
ASD C
A
RE P
A
THWAY TOOLS
A
CTIVITY


Physical activity decreases disruptive behavior in children with ASD/ID
Patients have fewer problem behaviors when they are doing an activity they like
Motor breaks and
Activity
times are built into the Staff Schedule
Unit-appropriate activity ideas are available
ASD CARE PA
T
HWAY TOOLS
T
OTAL COMMUNICATION

All of our ASD and ID patients require support to communicate effectively.
Total Communication
means helping patients to communicate through any and all modes available to them
Verbal
Sign language/gestures
Written/visual aids
Technological devices/programs
Visual Schedule
ASD CARE PAT
H
WAY TOOLS
H
IGH REWARD
1. Use
Labeled Praise
2. Give the reward when the task is completed
3. Use
rewards
that are rewarding for
this
kid

ASD CARE PATH
WAY
TOOLS
WAY
TO COPE
3. Sends Care Pathway binder upstairs with patient
1. Starts
Tip Sheet
2. Starts
CCPEP Schedule
with patient
1. Team identifies
1 to 2 Goals
and rewards
2. Starts the patient on a
Schedule A

3. Completes
ABC-I
at admission and discharge
Instruct and give tip sheet, staff schedule and coping card to guardian
UNIT SUPPLIES
Available to all staff during all tours
Sensory, activity, and motor supplies
Staff Manual and Materials binder
Instructions for activities
Ideas for motor breaks
Instructions for kid yoga
ASD CARE PATHWAY
STAFF TRAINING
Train the Trainer
42 staff participated
Trainers assisted with general staff training
Staff Training
Four Modules
Overview of ASD and ID, Foundational Strategies
Increasing Predictability and Activity
Using Total Communication and High Reward Strategies
Agitation Management
220 staff members participated from Nursing, Psychiatry, Psychology, Social Work, Child Life, and Creative Arts

Training recorded and available to new staff

ASD CARE PATHWAY EVALUATION
Collecting the following variables before and after implementation for comparison
Seclusion, restraint
Patient and staff injury
IM, PRN medication for agitation
CMT calls
ALOS
Rates of revisit and readmission and time since revisit
IQ or related testing, when available
Number of psychotropic meds
As part of the Care Pathway we are collecting the following
Aberrant Behavior Checklist at admission and discharge
Care Pathway Checklist (fidelity measure)
IMPLEMENTATION STAGE
July 2015 pathway implemented in Children's CPEP and across 45-bed child and adolescent inpatient service

Since July 2015, the Care Pathway has been implemented 46 times
Mean age of the children on the pathway is 11
10%
of children and adolescents admitted between August 2016 and August 2017 have ASD/ID diagnosis
From August 2016-August 2017, 38% of all admitted children and adolescents with ASD/ID put on Care Pathway (13/34)

Ongoing monitoring, adaptation and staff supervision to support pathway implementation
Admission and Length of Stay
Bellevue Hospital Center
Children of Bellevue Funding
2017 Budget Actuals
Children of Bellevue Funding
A calming space where a child can go during periods of emotional dysregulation or distress
Furnished with items to relieve the stress a child may be experiencing, including therapeutic toys
A quiet place for teaching and reinforcing calming techniques to decrease upset, as well as aggression and agitation
Also used as a parent- and child-friendly space for assessments and family meetings
Comfort Room was made possible by the Randolph H. Post Memorial Fund

ADOLESCENT INPATIENT
21 NORTH & 21 WEST

PARTIAL HOSPITAL PROGRAM
Children of Bellevue Funding
Children of Bellevue Funding
A key to the program's success
Rewarding children for their behavior
Encouraging responsibility, developing self-esteem
Structured point system
Positive reinforcement
Earning rewards that are fun, educational, child-oriented, and developmentally appropriate
Tailored to each child:
Each child works with his or her own therapist to identify specific goals
Therapist identifies challenges and works with child, family, teachers and any supports, to improve child's functioning and ties into PBM
Our program serves 36 high risk children and adolescents, providing comprehensive psychiatric, psychological and educational services during the day, and working with the children and their guardians when they go home every night
8 staff include: 2 psychiatrists, 1 psychologist, 2 nurses, 2 social workers, and 1 psychiatric technician
2017: 148 admissions
Average length of stay is 20 school days
Programs and Services
Ages
21 West: 12-14 years old
21 North: 15-17 years old
Capacity
21 West: 15 beds
21 North: 15 beds

Total admissions 2016: 569

Total admission 2017 (Jan-Sept): 282
In 2017, 240

adolescents screened for PTSD
89%
of admissions screened

34%
above clinical cutoff for PTSD:
10% Subthreshold
Physical abuse 26%
Witness domestic violence 31%
Sexual abuse 24%
Targeted Group Programming
STAIR-A Skills Group
Targeted Group Programming: STAIR-A Skills Group

Identification and Labeling of Feelings
Coping with Upsetting Feelings
Skills for Clear Communication
203
adolescents participated this year
61%
of all adolescents discharged this year participated
Problematic Substance Use Screening
2196
adolescents screened (starting 2009)
100%
of admissions (eligible)
29%
screened positive for problematic substance use
36%
of adolescents with PTSD screened positive for problematic substance use

Targeted Group Programming: Mind Over Matter
Targets problematic substance use in adolescents with co-occurring mental illness and substance disorders
79 adolescents participated this year
Positive Behavior Motivation
Creative Arts Therapy Programming
Arts, Drama and Dance/Movement Therapies
focus on embodied healthy self-expression, building pro-social relationships, empathy and self-regulation
These therapies work well in providing adolescents with corrective emotional experiences
18-25 Groups conducted weekly, including evenings and weekends, to support treatment goals and clinical objectives for the entire census
INTEGRATED CARE SYSTEM
Partial Hospitalization Program
CHILD & ADOLESCENT PSYCHIATRIC OUTPATIENT CLINIC
21W/N Trauma Screening
Goal: 70%
of
eligible admission
screened
Skills Group Attendance
Goal: 70%
of
eligible admission
screened
Goal: 70%
of
eligible admission
screened
Goal: 70%
of
eligible admission
screened
Program
Patients have a daily point sheet on which staff record points for their participation in treatment and activities of daily living
Patients get constant reinforcement through points which translates into rewards earned twice daily
2017-2018 Objectives
Maintain consistency of staff in applying the positive behavior motivation system
Problematic Substance Use Attendance (%)
Goal: 80%
of referred
patients
attended
Children of Bellevue Sponsored Volunteer Events
Volunteers participate with kids in a scheduled activity developed by staff approximately once a month per unit

This is a normalizing experience allowing for tremendous support from caring volunteers, including activities such as beautifying projects, tie-dying and rooftop sports events
Recreation and Supervised Free Time
Kids are provided daily opportunities for physical activity with a variety of quality sports equipment not otherwise available to hospital patients

On special occasions, kids enjoy a movie with popcorn!
Embedded Supports
Aleah Gathings
Staff Attorney
MFY Legal Services
Beatriz Matos
Family Advocate
Family Resource Center-Mental Health Association of NYC
Trauma Screening
Playroom
____________________________________________
* First 9 months of 2016
*
Admissions- ASD/ID Burden of Care
Inpatient Average Length of Stay
Inpatient Total Holds/Restraints
Inpatient Child & Adolescent IM Use
*
* First 9 months of 2017
* for first 9 months of 2017
*
* First 9 months of 2017
* First 9 months of 2017
*
Supported by New York City Council

In 2016-2017 the ASD Care Pathway was disseminated to Elmhurst Hospital
data collection is currently in progress

In 2017-2018 it will also be disseminated to the ACS Children's Center
Visits
Full transcript