Ep. 117: Reimagining Children's Health: Insights on Whole Child Health (Part 2 of 2)

There’s a bold idea bubbling to the surface in health care: if we want to address the numerous problems regarding health and wellness in the U.S., as a nation, we must understand what health is, pay for health, and start with children. Woven into this philosophy is the concept of whole child health, which is about addressing 100% of the things that impact a child’s health 100% of the time. In 2021, Nemours Children’s Health founded the Whole Child Health Alliance to help advance the concept of “whole child health."
 
While there is no single solution for achieving whole child health, there are models already in place in communities across the nation that are integrative,  collaborative, and effective. In this second of a two-part series on Whole Child Health, we examine a model in Washington state that aims to diagnose and treat behavioral health concerns in children before they reach crisis levels. This model involves a unique partnership between HopeSparks Family Services, a behavioral health and family services provider, and Pediatrics Northwest, a pediatric health care provider. 

Featuring:
Mary Ann Woodruff, MD, FAAP, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA
Joe Le Roy, LICSW, President & CEO, HopeSparks Family Services, Tacoma, WA

Learn more about the Whole Child Health Alliance.

Advancing the Key Elements of Whole Child Health: State Case Studies and Policy Recommendations (PDF)

Carol Vassar, host/producer

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

Announcer:

Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast, produced by Nemours Children's Health. Subscribe on any platform at nemourswellbeyond.org, or find us on YouTube.

Carol Vassar, host/producer:

Each week we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impact that occur outside the doctor's office. I'm your host, Carole Vassar. And now that you are here, let's go.

MUSIC:

Let's go, oh, oh.

Well beyond medicine.

Carol Vassar, host/producer:

There's a bold idea bubbling to the surface in healthcare of late, and it goes something like this. If we want to address the numerous problems regarding health and wellness in the US, we as a nation must understand what health is, pay for health, and start with our nation's children. Woven into this philosophy is the concept of whole child health, which is about addressing 100% of the things that impact a child's health, 100% of the time.

In 2021, Nemours Children's Health founded the Whole Child Health Alliance to help advance the concept of whole child health. And while there's no single solution for achieving whole child health, there are models already in place in communities across the nation that are integrative, economical, collaborative, and effective. In this second of a two-part series on whole child health, we examine just such a model in Washington State, that looks to diagnose and treat behavioral health concerns in children before they reach crisis levels. This model involves a unique partnership between Hope Sparks Family Services, a behavioral health and family services provider, and Pediatrics Northwest, a pediatric healthcare provider.

Joining me to talk about this are Dr. Mary Ann Woodruff, Physician Champion for Care Transformation with Pediatrics Northwest in Tacoma, and social worker Joseph Le Roy. He's president and CEO of HopeSparks Family Services, also in Tacoma. But before we get into the collaboration between their organizations, I had the chance to ask each of them to describe their specific and unique perspectives on how integrating behavioral health into pediatric primary care advances whole child health.

Here's Dr. Mary Ann Woodruff.

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

Integrating behavioral health, mental health concerns, into our primary care medical home is actually essential to bringing to fruition our vision as pediatricians. And that's that all children grow and develop in safe, loving families, and really supportive communities. Flourishing families, that's our North Star. So pediatrics, what we do every day, is really all about prevention and promotion, and early identification. And we utilize a public health lens to do that, and to provide care for the individual and family needs that we see. And our successes so far, in pediatrics, are related to really that very thing.

For example, in prevention, the success of universal vaccination, newborn screening programs, the early identification leads to better outcomes for kids and families. But that same lens hasn't really been applied to mental health concerns. And I think back on 35 years in clinical practice at Pediatrics Northwest, I became really good at recognizing young infants and children in the office and in the waiting room, who needed immediate attention for perhaps bacterial meningitis. But we didn't settle there on just being good at that, and the resulting preventive vaccines mean I rarely see children now with bacterial meningitis.

I'll continue with that analogy. Now I've become necessarily good at addressing teens with suicidal intent. But one has to ask oneself, "Why not use the preventive lens, here and now?" So those high rates of significant mental health concerns warrant addressing it right at the pediatric medical home, where kids are seen on a routine basis, rather than emergency departments. And that's the pediatric way. Translating the best science into practice, and following that science urges us to focus on the centrality of relationships, and it means rethinking and reframing all that we do and in particular, wellness visits.

So that's what, in our partnership with HopeSparks, we set out to do. We have teams of care at the primary care medical home, instead of a go-it-alone model. And we said we wanted patient and family centered, ultimately driven care, community, connected, coordinated, culturally congruent, and absolutely relationally and equity based. And again, centered on strengths, rather on deficits. And then, with effective teams. Not business as usual, waiting until children are distressed, parents not knowing where to turn, us handing out phone numbers, and then fingers crossed. And by the time they got that appointment, it was three to four months later. Instead, we're using universal screening to identify people early. But I'll stop there, because we have lots to dive into.

Carol Vassar, host/producer:

What you're saying makes so much sense. If we can get kids the mental health care that they need, and really integrate that into primary care where the primary care physician sees them on a regular basis, it is more likely to be addressed earlier, and doesn't need to be seen in ultimately the emergency room when really, it's pretty much too late. Or really, later than it should be. Joe, from your perspective, what would you add from the social worker perspective? As the leader of HopeSparks, how will you identify this, and the need for this, in the primary care setting? Behavioral health, married to primary care.

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

Yeah, thank you, Carol. I was jotting down some notes as Dr. Woodruff was talking, and there's a couple of things that came to mind. One, this is a prevention model. Prevention, prevention, prevention. We're getting up the stream as far as possible to prevent exactly what you just described. In Pierce County here, we've had a 400% increase in our children's hospital emergency room since 2012, for kids coming in with mental health need. And if you look at prevention versus, why do we have a 400% increase in mental health need in our emergency rooms? Because there's barriers and lack of access to services. So without those prevention pieces, what we realized, we're pipelining kids from the doctor's office into the community with a list of names and numbers. And Dr. Woodruff often calls it the golden ticket method, where if you know the right person, or know the right service, or have the right person on your speed dial, you can get a kid in. And that's not what we want.

So last time I checked, kids' bodies and brains are all connected. Back to your point, about whole child. We're all whole beings, and really, we deserve to be treated that way. So for us, from day one, we were not looking to build a co-location model. They were very, very intentional about collaborative integrated care, not co-located care. And we built our clinical systems, our payment systems, our workflows, everything around that concept. So we had the benefit of having some grant funding, and some runway to sit together and be thought partners, and design what those workflows might look like and how to get there.

Peds Northwest and HopeSparks realized we had a 40 plus year referral relationship with one another, but we actually never sat down at the table to actually design what it might look like if we took it past that. So I know we'll talk here a little bit about policies and things that led to some of this work, but having that shared table to actually think about, "What if we dreamed together? What if every child who walked into a pediatric office had a care team waiting for them? Not just a doctor, and the list of phone numbers," to get the other things that are needed.

So to me, those are some of the things integrating Care does.

Carol Vassar, host/producer:

It sounds like you had that partnership informally, as you mentioned, for 40 years. It was not a co-location model. Joe, share with us at a very high level how your two organizations, HopeSparks and Peds Northwest, came together integrating behavioral health services using that team model in the primary care setting. Essentially, what are the program components, from the moment you sat down at the table to implementation?

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

Good question. I wish, I probably could dig up a picture of our early white boarding. It was quite interesting. When we mapped out what we currently were doing, we were realizing, "Wow, there's so many steps and so many barriers," and our system was so fragmented. At the time, the CEO of Peds Northwest and I, we co-wrote a grant together. It was part of our 1115 waiver here in Washington state. They had released what were called catalyst funds to really think about integrated healthcare. And as part of our first Medicaid waiver here in Washington, healthcare integration was a big part of that. So we're sitting in these rooms, having all these conversations, and the CEO of Peds Northwest and I looked at each other and said, "Let's be the pediatric solution for Pierce County. You want to write a grant together?" And so, that's really how it started.

And we actually didn't meet the criteria for the total Medicaid population that the grant required, and we just basically told our accountable communities of health here that, "Please lower the threshold, so that other providers can come into this space, it's not just hospitals and big health systems." And they did that for us, which was really cool. So we co-wrote the grant, we got this initial planning grant, and we spent really, 2018 and 2019, roughly coming together.

One of the first things we did, actually one of the doctors at Peds Northwest, held a dinner at his house. Our executive team and board, and Peds Northwest executive team and board. We came and we had a catered meal, and we sat around together, and we literally dreamed together and built culture really from the very, very beginning. And that just cannot be understated, because when we looked around the country, and we looked around at other models, what we had seen was just putting therapists inside of primary care clinics was not integrated care. It was co-located care. And the clinical interventions and what was really needed were not really marrying well to one another.

So I think some of the genius things we did early are, really we had time to plan, and that really led to the 2020 launch of our work. And I'll fast-forward, we married brief, evidence-based clinical interventions that were designed for primary care with the collaborative care model, with the financing and billing structure. And those things really clicked and married really, really well. So that's really what's contributed to scale, and ultimately, hopefully, sustainability as we look ahead.

Carol Vassar, host/producer:

So what does this look like in practice for patients?

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

I'd love to talk about that, if I could. Families come in for their well-child visit. And at all, well-child visits, from really three on, there is screening done. Mental health screening that are validated and appropriate for that age. And our mantra is that, if we're going to screen, we're going to discuss with the family what we see. And we use it just to help along with the narrative that we get. From that screening, we learn really important things. So it might be an 8-year-old who really, the family hasn't really associated that some of their difficulties about going to sleep, et cetera, are really part of an anxious profile. And so we look at that, and then once we identify those concerns, we just have a discussion right there and then in the appointment. And say, "By the way, we have something that can really be helpful for this. A team of therapists that work right with us, and I can do that referral over to that team today. You'll hear back from them in one to two days."

I don't give them a phone number. Our team contacts them, one to two days, and we've moved from having a 15% connection rate if we hand someone lists of phone numbers to mental health services, to over 90% with doing collaborative care. And that has held over these four years. We've now seen over 2300 families on this model, and we have strong data that shows, it's effective. The changes that families are hoping for, work. So it's early identification, and then referring over to the team who contacts the family. And then the sessions start right then. And because we started in that time around COVID, we had intended for families to come into the office, but we had to pivot very quickly and go to a telehealth model.

And we've maintained that because these are brief sessions, 15 to 30 minutes. Having people drive in, take time off work that way. And so we think that the telehealth model is an equity-based model, because people can join by phone, by computer, a child could be at school, parents could be at work and do this during a break. And our therapists work really hard to make it happen at a time that's convenient for the families.

Carol Vassar, host/producer:

It sounds like you've listed some of the things that are really beneficial, including that telehealth model, which you probably have evidence that shows goes to equity. What are some of the other benefits of this model? Dr. Woodruff?

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

What we say, altogether, is that it provides the right resources in real time, at the right time. Families get the care that they need right away. And here's the other thing it does. The other members of the team, are the pediatric psychiatric provider. The family never meets that person, but they serve as wise counsel to us. Every single family that is referred into collaborative care, there is a psychiatric consult visit that's an hour, where the patients who have been referred into the model are brought to the case consult. And again, this is virtually, where the particulars are discussed. And then as a team, we weigh in like, "What else might be helpful?" And that team has expanded over the last two years. We now have a team of community health workers, and that is remarkable. So every patient at Peds Northwest, not only has their primary care pediatrician, but they have a community health worker as well.

And that person, we use an accompaniment model. They follow families and patients in what those families want and need, not in what we judge to be that. And so, if there's a particular thing that a family, like a child wants some sort of outside activities that they haven't been able to find, the community health worker is on that case consult, listening to that, and then they work from that end as the therapist is working on theirs. From the pediatrician's point of view, I do so much better now, in terms of medication management. The majority of the kids referred into collaborative care are never on a medicine. I don't need to do that, because I can get effective therapy right away. And when I do prescribe, it's better. Because I have the expert psychiatric consultant who can help guide my choices. And guess what? We all chart in the same electronic health record. Unheard of. We all know what is going on.

Carol Vassar, host/producer:

Joe.

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

We find ourselves talking to people a lot about what our model is, but we also find ourselves talking with people about what our model isn't, and really what the intention of it is. And I think once we can do that, we're more successful. Our goal is to continue to try to braid funding. We know building another fee-for-service model is not the answer to... Just more volume-based care, is not the answer. So we're really trying to figure out, "How do we braid funding, and braid resources, putting all of these pieces together?" Community health worker funding, insurance revenue, other sorts of revenue that can come in and really bring this together.

We're trying to work with our local hospitals to show the costs savings. How many kids are we keeping out of the emergency room because of what we're doing? All of them. We're keeping all of them out of the emergency room. For every one kid that shows up in our local emergency room, that's nine routine ED visits that cannot be seen, because of that one mental health kid. Nine. So, it's profound.

Carol Vassar, host/producer:

I'm curious, how have families responded to this? The assessment is made, a referral is made, an appointment is made for the child. What have been the family's reactions? Has stigma kind of come up or are you getting a good response here? Dr. Woodruff

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

An incredible response, and I just happened to have some quotations from families, saying this for themselves. An eight-year-old who was referred into collaborative care, the little guy said, "Well, why do I get so angry?" And the parent said, "I don't even know how to help him." Afterwards, "We can talk things out. He's so insightful." Another family of a 10-year-old referred for treatment for anxiety through our first approach skills training modules. "I will tell anyone and everyone what a blessing this program has been. When I've told my friends and neighbors about the program, they all want to know, 'How did you get that? How do we start something like that for our child?' We were trying to get into services for three years before finally starting with you, and I couldn't have imagined the progress we made."

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

We have actually had examples of families, who have shared things with the community health worker, that they were unwilling to share with pediatrician or the mental health therapist, out of fear of us calling CPS. So even though that would not happen, in many of the examples, or all of the examples. The community health worker is the trusted person, often, on the care team. Our therapy team is diverse and reflective of the community we're serving. Our community health worker team is the same, and our community health workers all have lived experiences that can build trust very quickly, with families. So I will say, in terms of stigma, just think about that other 80% that often goes unaddressed is now being addressed. And you have someone on the team that you can build trust with, more quickly than you could in maybe a more traditional clinical setting. So it's been game changing.

Carol Vassar, host/producer:

It sounds like you're providing behavioral health services at primary care appointments. How does that work in terms of billing?

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

Actually, it works pretty seamlessly. So for the routine visits that we do as pediatricians, the well-child visits, those are billed in the usual way with the codes associated with those. When it comes to collaborative care, there are a set of four billing codes that are used, and this is where it differs from... Like when Joe was talking about the co-location model. Our therapists do not bill psychotherapy codes. They bill collaborative care codes. And those codes are a tally of the therapist, the integrated therapist, minutes per month in service to that particular family. The time they actually spend in the therapeutic sessions. The time that... We didn't even talk yet about the registry that is kept, that's a central tenet of collaborative care. That a registry, outlining all the points of contact with a particular child and family.

This is evidence-based work and it's called treatment to a target. So if someone's not getting better, you do improvements along the way, you make a change. But all those minutes, and the minutes that the therapist spends talking to me, or talking to the community health worker, and in consultation with the psychiatric provider. Those are tallied per month, and then those are put in a billing module in the primary care medical record, with the therapist as the service provider but under the pediatrician's name. So for my patients, under my name, as the billing provider. So one is a service. And then those codes, then those go through, billing at the pediatric medical home. And the collaborative care codes, the minutes per month, can go up to about two hours per month. And that makes sense if you're thinking about 15 to 30 minutes, once a week. The sessions that the therapist conduct with the family are weekly.

Carol Vassar, host/producer:

So there is coding for this, insurance coverage. Does private insurance cover this, as well?

It does, and Joe can talk to that too. But our state, Apple Health, Medicaid, completely covers it. So I look at families and say, "You don't have to worry about anything."

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

No, I like to say that our model is payer-agnostic, which I think contributes to the equity piece. Families are tired of trying to get help, and the first question they're asked is, "What insurance do you have?" That's exhausting. And so, we don't do that. We don't do that. We feel strongly that this model is payer-agnostic.

Carol Vassar, host/producer:

Joe, I want to get to the policy side of things. What has, from your perspective and from a policy perspective, made this collaboration possible? And what barriers remain for helping the collaboration to grow?

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

Great questions. I like to think that we're one of the great successes of our Washington State 1115 Medicaid waiver, and we delivered on what we were asked to deliver. Which was, could you integrate care for kids? And we did. when we first went to the AIMS Center here at University of Washington, AIMS is advanced integrated mental health solutions we're ground zero here in Washington for collaborative care, which is great. If you go to the AIMS center website and look it up, you can read all about it, but it had never been done with kids before. It had only been done in adult settings, and the research and data was in adult settings. Well, if you go to the AIMS Center website right now, you will find a pediatric collaborative care implementation guide that we have helped author. And we're just so proud of that. That didn't exist five years ago.

So I like to think that we really helped deliver on the promise of that first Medicaid waiver. And now, as we look at the second Medicaid waiver, which is actually more focused on community health workers, which is so exciting. People are really recognizing this. Like I said, I think we need to just keep braiding the funding, braiding the work, telling the story, showing the outcomes, and it resonates. It's really resonating. I think we need to focus more on showing cost savings. And Dr. Woodruff, I know there's other policy stuff. We're doing a ton of stuff in the infant and early childhood mental health space, that could be a whole other podcast. But what would you add to that?

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

I want to go back to one thing about, the equity piece is so important to underscore. And just say, we are fortunate to serve nearly 40,000 families at Pediatrics Northwest, and over half of the families we serve are covered by state Medicaid, Apple Health. And when we look at our data, because we work with the University of Maine, and with Seattle Children's, and the data is analyzed. The kids who are seen in collaborative care mirror the demographics of who we see at our group. And that's really important, because we didn't know that at first, right? Would it be just a certain subset of families? No. All families embrace this model, and that they are represented, they represent the wide diversity. And we have community health workers and a therapist who speak Spanish. And that has been really important. I have five colleagues who speak Spanish, primarily, with their patients. And having that team that speaks in their home language has been huge. Because it's not just about language, it's about cultural understanding. "What does it mean, to be in therapy?" And that gets to that stigma question too.

Carol Vassar, host/producer:

So there's definitely an equity component here. As we head towards the end of the podcast, I know time is short. Dr. Woodruff, what advice would you give to other states, other providers, who want to maybe imitate or build on this integration model of behavioral health services and pediatric primary care?

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

I would say look for community partners. They're out there, and we call that initial sitting around the table, when all of us were free to dream. We called it a collective effervescence. And that's from an incredible book by Eric Klinenberg at NYU, talking about social infrastructure. And together, there was no silly idea, there weren't silly thoughts. And we just looked at each other and kept scaffolding, and we do that to this day.

And I have to say, our therapists, we have had zero turnover in over four years. It's unheard of.

And then, I say to pediatricians, "You have to implement universal screening first," because you have to have that lens.

And I would say also, focus as early as possible. I'm ecstatic that I'm able to help the sixteen-year-olds and up with really significant mental health concerns, but we think not only upstream, but keeping families out of the stream to begin with. So they can just be on the side of the river, having a picnic. We think this is such a preventive model, and it requires screening. And then Joe mentioned the AIMS Center information, taking a look at that. So those would be my initial...

Carol Vassar, host/producer:

Joe, do you think that the federal government or the states can be incentivized to make this kind of model available across the nation, this behavioral health integration model?

Joe Le Roy, President and CEO, HopeSparks Family Services, Tacoma, WA:

Yeah, great question. I'm seeing it more and more and more. I know there's been some federal legislation passed. We recently just secured a Congressionally directed spending from Senator Patty Murray here in Washington, for $2 million, just very recently. And those funds will help us scale. That's the intention, to grow this work. We're very grateful for Senator Murray and her colleagues, we spent multiple years talking with her about this work. She's making an investment in it, so that's exciting.

Carol Vassar, host/producer:

Dr. Woodruff.

Mary Ann Woodruff, MD, Physician Champion for Care Transformation, Pediatrics Northwest, Tacoma, WA:

I would just say, a few other things that would make a difference, like from state and national levels, is that the collaborative care codes and how it's defined needs to be uniform across all the states. There are some differences. Fair reimbursement for screening at the primary care medical home, because the screening rates are typically really low, and if those are a little elevated to actually help pay for the actual doing of it. And that is a way to model payment for community health workers. So Joe alluded to it earlier, but we have to have a way that people can have established community health workers.

And then, I would say startup funds for practices, for anyone doing this work. And the way we've looked at this, we don't want anyone to have to do all the things we did. It was a joy, but no one's going to be able to do that, spend a year or so developing it before they get going. But they're still going to need a runway where there are some funds. And actually, our legislature did that, where they provided some funds for 10 practices to begin to do this work, and that made a difference.

And then, I'm going to go down to those really early years. We need dyadic codes where, you don't have to have a diagnosis for a two-year-old, a three-year-old. Because it's all about relationships. I started with that, I'm going to end with that. What we're really doing is talking about how people relate. There's always rupture in relationships, and then the repair. And it's that repair that's central to human well-being from the very beginning. The predictability, that with my parents, I can get to repair. And that's what we're really helping with.

Carol Vassar, host/producer:

Dr. Mary Ann Woodruff is a pediatrician with Pediatrics Northwest in Tacoma, Washington. We also heard from social worker Joseph Le Roy, president and CEO of HopeSparks Family Services, also in Tacoma

MUSIC:

Well beyond medicine.

Carol Vassar, host/producer:

Thanks to both Dr. Woodruff and Joe Le Roy for joining us on this episode of the Nemours Well Beyond Medicine Podcast, to talk about what they're doing to advance whole child health. And thanks, as always, to you for listening.

If it has to do with whole child health, and what's happening beyond clinical walls affecting kids, we're talking with the experts about it on the Nemours Well Beyond Medicine Podcast. Coming soon, we'll celebrate National Women in Sports Day, explore growth in the pediatric APRN workforce, and learn more about the work of the crisis text line.

Previous episodes are all available for you to hear on our website, nemourswellbeyond.org, where you can also leave a review for the podcast and subscribe to it, too. All of our podcasts are also available on the Nemours YouTube page.

Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, Steve Savino, Hannah Wagner, and Daniella Gratale. I'm Carol Vassar. Until next time, remember, we can change children's health for good, well beyond medicine.

MUSIC:

Let's go, oh, oh.

Well beyond medicine.