Speaking of Design

Listen, Mental Health Matters: Justin Olsen and Jen Katzenstein, Johns Hopkins All Children's Hospital

In the sixth episode of “Listen, Mental Health Matters,” Brian Giebink, HDR’s behavioral and mental health practice lead, speaks with Johns Hopkins All Children’s Director of Psychology, Neuropsychology and Social Work Dr. Jennifer Katzenstein and Vice President and Chief Operating Officer Justin Olsen. Their discussion explores the importance of providing the proper continuum of care for children, how novel therapies — like the use of virtual reality in telepsychiatry — can contribute to both physical and behavioral health, expanding training programs, and implementing programs for staff well-being.

Duration:: 32m
Broadcast on:: 12 Aug 2024
Audio Format:: mp3

I'm John Torrick, and I'm Danny Sullivan, and you're listening to Speaking of Design, bringing you the stories of the engineers and architects who are transforming the world one project at a time. Today, we bring you another episode of a special podcast series on behavioral and mental health called Listen, Mental Health Matters. As part of this series, Brian Geebenk, behavioral and mental health practice leader at HDR, visits some of the world's leading health care providers for candid conversations about the challenges they face and the opportunities to transform the patient and caregiver experience. I'm Brian Geebenk, and I hope that by listening, the series helps us consider new perspectives in our quest to create transformational mental health facilities that improve the quality of life for individuals and families and promote a shared sense of community. And now, we bring you a conversation from Brian's visit to Johns Hopkins All Children's Hospital in St. Petersburg, Florida. There he spoke with Jen Casenstein, co-director of the Center for Behavioral Health and Justin Olson, Chief Operating Officer. This is Brian Geebenk. With HDR, I'm an architect and behavioral health planner at Lead HDR's Behavioral Health Practice, we're here in St. Petersburg, Florida with Johns Hopkins All Children's. This is a very special episode because we're focusing specifically on pediatric behavioral health care. With me today are Jen Casenstein, the co-director of the Center for Behavioral Health and Justin Olson, the Chief Operating Officer for Johns Hopkins All Children's. Justin and Jen, welcome. Thank you for being here. Thank you. It's a pleasure. Thanks for being here. Glad to have you here. Jen, would you like to introduce yourself briefly and tell us a little bit about what you do and then Justin will do the same with you. Sure. Thanks again for having us. I'm Jen Casenstein. I, by training, I'm a pediatric neuropsychologist, meaning that the majority of my clinical work is focused on evaluating the cognitive strengths and challenges of children in the context of their medical conditions and then working to set up treatment planning and educational planning for success. At my time here at All Children's over the past nine years, that has evolved to building not only our neuropsychology services, but also all of our behavioral health services, including both our behavioral health social work team and our medical social work team to initially really expand our outpatient care services. And then as time has evolved and as behavioral health needs have evolved and access to care, think about what a continuum of care looks like and how to best be able to treat the significant behavioral health concerns our kids have in a way that is financially viable and also in a community context, utilizing the resources that we have here in our Tampa Bay area. You mentioned financially viable sort of towards the end there and I think that might be a good segue to you, Justin. I am the chief operating officer. So I mean, I have a broad array of areas and services that I help support and certainly part of my job is making sure that we have the team and the resources and the structures to support the care we provide. So my angle is a little different. I have been a children's health executive for about 15 years now. So I'm well versed in the pediatric universe and I'm excited to do this podcast and shed some light on a really important topic. I think the first question would be great for both of you to answer what we'd really like to know is how is your focus on behavioral health evolved over the past few years? Jen, maybe we start with you. Absolutely. So as we went through the COVID pandemic, we did see significant increases in suicidality in our youth and significant utilization of the emergency room for a crisis. So we see that through multiple pieces of literature that were published during that time. And I think as a behavioral health community, we were really focused on the crisis piece and inpatient psychiatry. What an inpatient psych unit looks like. And as I took a step back to think about that and as we've emerged from the pandemic, we're still missing a really important piece of the puzzle, which is the continuum of care. You can't go from a 72 hour inpatient stay back to one hour a week of therapy, and we can't expect that cycle not to continue, right? So as we have evolved really over the past probably seven to eight years here, we had inpatient psych kind of in our mindset as a one potential option. But it taking a step back, you know, what is the outcome? What is the positive of a 72 hour inpatient stay? Does that result in long-term change? And really the answer is no, unless you have the right continuum of care supporting a child. And over that time, the Tampa Bay Area has also evolved in the number of pediatric beds available. So is it our responsibility? And I feel that it is to be able to provide a stronger continuum of care with more intensive services so that we can break that cycle of emergency room visits for a crisis of inpatient psych crisis stabilizations and move us back to intensive intervention and programming that best needs our kids needs instead of thinking about it more as crisis to an outpatient appointment. When I think back over the last 15 years, I believe behavioral health has always been an important component in children's health. I think it really reads fever pitch status during the pandemic and it brought new light and new focus to it that I don't think maybe had been there before. We'll talk at many times today about probably payment parity and it's not equitable in terms of that surge at this point in time. But frankly, this really has created new energy and need to solve and at least provide some solution set for what is a crisis. As an organization, we have just below a 70% Medicaid rate. So our patients are Medicaid and in the behavioral health space, it's higher than that. What we've discovered is we do have to use our other services that generate better revenue to support this work. And so our strategic plans have been about both, but really bringing together service lines with higher revenue so that we can support critical services. That's not new to us, but it's just in terms of how it's worked. But we are prioritizing those dollars that revenue offset to dedicate towards programs like behavioral health. Point out, this has been an ongoing concern for years and really a challenge that hasn't had a financially viable solution for probably any system really in the country. It's been a really challenge. So yeah, I don't think it's new. I do think it's intensified. So are there any novel therapies that you can expand on as you're thinking about what you're currently focusing on and shifting your focus? As telepsychology, telepsychiatry services have evolved over the past couple of years, we've found mixed acceptability of our families to tele services. Sometimes it is accessibility and convenience that's preferred. Other times we're hearing feedback that it feels impersonal. They're not getting the care that they would get in person and our providers are often challenged by that too because they're not setting their eyes on the full patient, especially for our disordered eating patients, where we really do need to see them and have them in here to get vitals. So we've worked through collaborating with our providers for really three different areas that have been evolving. One is in virtual reality. So thinking about virtual reality headsets to provide intensive services, to be able to do education, to make those mistakes on a virtual reality headset and getting feedback and coaching on that during your therapy appointment, maybe in a social interaction or in a reaction. And then using that, leveraging that technology for intervention services. And then our two other areas have been in the psychological components of pain management and our disordered eating teams. So again, we're using a lot of technology in our pain management program. We have a day program that combines biofeedback, a typical therapy intervention, single individual therapy session, acupuncture, and then also time with our educational liaison so that we can reintegrate our kids back into school because oftentimes they're really struggling to get back to school with pain or potentially needing to utilize a wheelchair and having negative impact on that. And our eating disorders team has been really working on an intensive outpatient program that balances virtual so that teleservices with in person because how better to treat a eating disorder than a family meal time in your own home. So your dietitian and your therapist could be joining you virtually in your home as you prepared food together, talked together about food in general. What did this parents say about this? What did this parents say about this? How did you react? Is the youth in this situation? And then really rethinking food in that context as nutrition and being again to be in the home environment to do that, but still having our patients come in during the course of the week so that we can lay eyes on them and be able to have that one-to-one contact. So those are a few of the innovative approaches we've been taking, really trying to balance the virtual with the in person from an access point of view, but also making sure that it is still high quality care. The VR sounds really fascinating to me. So the ideas that you would have a VR headset, a parent might come in and put on the VR headset. A child. There's some great research where one of our colleagues in Baltimore on fear of heights. And so you're in the V for exposure therapy, you can do a lot of different exposures on a VR headset. And so you're right up against, you know, a height on the headset and you're working on your coping strategies during that time. And then you're working up to actually being in that in person situation. That's amazing. I've done VR where you're right on the edge of things or even floating over nothing. It is absolutely terrifying. So that's really cool. I love that night. I was thinking, I don't know if you're doing it with parents as well, but patient child interactive therapy might be an opportunity there for a parent to learn without really being, you know, learn in a virtual environment before applying. Yeah, exactly. So for PCIT right now, we have a trial looking at the total tele psychology administration in our cancer population. So that's the first time we're sending earbuds to the parents at their house so that we can be coaching them just like we would be in person. But then those little earbuds are getting the coaching from their provider in their ear while they're in the home environment. That's amazing. How does your behavioral health service line contribute to your system's overall strategic goals? So a couple of things. We, in 2023, refreshed and launched a new strategic plan to really set the stage for the next 10 years. Again, recognizing that we had had a crisis happening in behavioral health, it was the only service line as an organization that we called out in our strategic plan to address. And so as a quaternary tertiary care facility, we are routinely, I will call it the last resort for other hospitals to send their sickest and highest complex kids to. And so our strategic goal is really to provide the continuum of services, including in behavioral health services. We want to be a place that has the destination programs that are treating complex illness. We want to be a provider of, again, I don't mean last resort, but really when the care is too complex or not sure where to go, we want to have those experts. So as an organization that is in our strategic plan, because we really want to bring forward that continuum of care to our community. It's an honor, really, to have the organization be so focused on behavioral health and understanding that physical health and behavioral health impact one another and recognizing that we exist in a system and making sure that we're expanding our services to meet our patients' needs. It's great to hear that the organization is supportive and focused on it and able to help with the great work you're doing every day in those novel therapies and everything that comes along with that. What Roblox do you face? Or are there any Roblox such as funding or reimbursement or stigma that you've faced and have you been able to pivot to some of your initiatives forward? I think there are several Roblox, right, to providing access that's convenient and that works. I mean, I think funding is clearly a major issue for us. Behavioral health services aren't paid on parity with medsurge admissions. In fact, it's multiples lower than medsurge. The other piece is while we might be able to make an inpatient unit, maybe a break even. It's the wrap around services and Jen talked about this really well, but it's not just about that inpatient admission. It's about the post admission treatment, having the intensive programs to really stabilize and return to their school environment and home environment that's successful. So those are very poorly compensated and so every time we expand our panel, we really expand a loss. And it's not that our providers aren't working really hard to see enough kids or that our teams aren't being successful in the work they're doing. It just is a fact that the payment methodology isn't where it needs to be to support this vulnerable population and so funding happens every day. And I think other systems may cherry pick, but it really services that only pay and really expand there. But again, it is important to us that we offer that continuum. So we haven't done that and it does continue to challenge the financials. But also, would you add some? I think we've had to think really uniquely about how to provide high quality care at the lowest possible cost, right? And sometimes what's challenging is existing in an amazing children's hospital. There's equipment that our medical team members need to get their work done that really helps make it easier or streamlines things or can kind of take over certain parts. But at the end of the day, for behavioral health, it's brains, I need people, right? And so as we thought about especially being all children's, right, we need to serve all children. How do we do that even if we're not handled on a certain provider or with such a high percentage of patients who have a state-funded Medicaid program here for us? So that's where we really expended our training programs so that we could have fellows and interns providing those services at a lower cost in the supervision of an attending who has the expertise. And then we're both providing that training opportunity, but also providing those services at a lower cost to that bottom line. And I think that's another issue that we actually have. So teaching is another obviously very important part of our mission and we are a teaching facility. We have learners in any discipline you can think of, we're training people. But there aren't enough people interested in pediatrics subspecialties, including and maybe specifically in behavioral health. And so we have a crisis of available providers, because even if we wanted to grow the programs, we talk about recruitment of pediatric psychiatrists as an example, and it can be, I mean, you're talking a very long lead time to find someone interested in it, and there are many jobs for every fellow that's graduating with the right experience. So I think that team recruitment is really a significant challenge. Can you elaborate a little bit more? What are you doing to provide care for your workforce and to attract and retain? Because this is an issue we hear across the board. It's across the country, even across the world. People seem to be less interested in going into this field, especially with behavioral health care. Are there any strategies or any ideas that you're implementing that you feel are working well? So of course we serve our team a couple of times a year and say, you know, what's on your mind? What's bothering you? What do you think could be improved? And then we really use that to build action plans and teams. And I think you might want to talk about the RISE program and some of these other programs that we've done to really support our team members, but I think a lot of that came out of really the feedback from our team saying, hey, I need more support when something challenging happens. So do you want to talk a little bit about RISE? Absolutely. So we have a RISE program, resilience and stressful events that was born out of our colleagues in Baltimore and brought here where we have peers available 24/7 to respond to a situation that might occur, whether that's a stress that an employee is feeling a significant event on a unit or with a patient, and that can be there in the individual or group setting. We've recently re-initiated Schwartz Round, so having regular kind of preventative time where our team members get together. Most recently for our social work team, we talked about needing to be helpful, but feeling helpless, especially when you don't have the resources to meet the needs. Could you expand a little bit more on the Schwartz Round and describe what that means? Schwartz Round was born out of an individual with the last name of Schwartz who was involved in treatment. Right? You can jump in, Justin, if you know this better than me. Yeah. He was an attorney and patient. And I believe he saw the stress that care could cause for caregivers and wanted to start away for them to be able to talk about that. And so I think it extends beyond the medical staff. It does. Yeah. And for everyone from our food services to EVS team across the board, Environmental Services. Yeah. And so it's an opportunity for them to come together and talk about how a specific case that may or care about that didn't, in the way they wanted, or was more challenging than they wanted to really be able to freely express what concerned them and was challenging for them in an effort to have that camaraderie and the healing process if you will from whatever circumstance happens. And there's, it's a hospital. So there are clearly challenging things that happen here and we wanted to have that as a level of support. So I think that's one thing. And then a huge support from the hospital, our organization as well, and Justin has been having a EAP therapist on site. So we have our EAP therapist here, she's here three days a week and available to anyone. And everybody who is on, who's an employee of the hospital is able to have five sessions for each issue. So that can lead to quite a few sessions free of charge, which is fantastic. Our respite room has been a huge success. Yeah, again, from our surveys, we just, we heard this need, I need somewhere to kind of get away and not necessarily the cafeteria that is surrounded by patients. And so we did take some underutilized space and make an investment in it to create a really a team member space where they can just slip in, there's some massage chairs. I've been surprised that actually the utilization of people really are from all disciplines in this hospital, providers, nursing staff, you know, EVS workers, it doesn't matter. People are going in there just having their lunch, listening to music, reading a book, I mean, just really trying to get away a little bit from that stress of the day. The other thing I think that we've done as an organization is work really hard on improving our staffing. And while that may not seem as obvious, quite frankly, if you're being asked to come in to additional shifts a week, you can imagine you don't have any time for that recovery. And so we've done, our chief nurse has really done an amazing job in re-staffing, I will call it, following the mass exodus that happened in the pandemic. We are down to just a handful of travelers. Our team scores have gone up a lot. So it's just really, I think, important that's, that's the, the missed piece of staffing is that really, you know, when you're supposed to be working three days a week and you're working five, it's, it's an end and the patients are challenging and there are stressful situations happening. And it's important that you get that away time. And I'm going to come to behavioral health specifically. We've been very much lucky that we were building services. So in the past nine years, for example, we went from, I was the third psychologist to the hospital that ever hired and now we have 19. And so with that, one of the primary predictors that burnout more broadly is not having autonomy and decision making and surrounding your specialty. And so even within behavioral health, there's different specialties. And as we recruit our team members to come in, this is a unique opportunity to build what you want and to build your specialty area. And I feel like I should knock on what, but that's why our retention has been really well in behavioral health too, because our team members have come in to build their programs and feel supported in that, which we've been so grateful to the organization and out to our philanthropy partners for that. But with that autonomy and that ability to really build what they're passionate about that keeps them here and keeps them tied in. So again, knock on what we haven't seen in the psychology and neuropsychology workforce and even really in psychiatry that turn over that many other people have experienced. Daniel Pink, I don't know if you've heard of, he's an author. He says for people to be successful in their careers, they need autonomy, mastery, and purpose. Yeah. And it sounds like you're giving your staff all three of those things and I think that's really important. I want to focus a little bit more on, we were talking about roadblocks that you typically face and how you're able to pivot and move some of those initiatives forward. How do you measure success? What are some of those success metrics and then how do you communicate those to the community and to your leadership? I can start some global metrics that we track. I mean, we obviously look at how long it takes our patients to get an appointment. That lag time is an important metric. We do look at how busy we are, the utilization of our templates, all those things that I think would be standard work to really ensure that we are accessible in providing access and then you want to talk about some specifics. I think that for our team too, it has been where are the needs and what are we missing. So as we see referral volumes come in, I'm looking at lag time for scheduling, but I'm also looking at what are we not scheduling and what has a longer lag time. So interestingly, pain management, you can get in pretty quickly for psychological needs. When it comes to getting a diagnosis on the autism spectrum and an evidence-based evaluation and then related treatment, that's where our lag time is the longest. And so I'm looking to see what are those patterns, where do we need to think about strategically building what is available in the community because we do exist in a community and we don't need to see every patient because there are other great community providers. Getting back to the workforce perspective, for me, it's been really important to have a well-trained workforce in the region. And that's where some of our local community agencies have been instrumental in collaborating with us, not only given our pretty robust training programs, but also a real willingness in the community to hear our team members say, for example, no, we need trauma-focused cognitive behavioral therapy in our providers in the community, to the point where we were able to get our local agency that distributes our tax funds to offer a scholarship program for 30 providers in the area to get free certification in trauma-focused CBT. And just then knowing that we might have a lag time in some of our referrals, maybe we're not the best place for these patients to be seen. I know trusted providers in the community that you can go to who have the right training and are able to meet your needs. Can you share strategies you're implementing to improve access and follow up with the behavioral health patients? So we are actually about to make a pretty significant investment in our physical footprint for behavioral health services. We're really trying to double the square footage we offer to outpatient behavioral health. And I let you talk about some of the programs that you're creating there. And a little bit forward-looking, but we're revamping really our ambulatory platform and our goals to bring these services closer to home is really a strategic initiative across our service lines. But behavioral health is the same. We really would like to have care close to home. So outpatient care in our outpatient settings, we don't necessarily have that today. And that is our goal for future iterations as we continue to develop and expand these outpatient centers. What other things are you saying? I definitely agree with Justin. We're thrilled to be doubling our footprint. That's going to allow for a significant expansion, not only of our clinical services, but of the training programs as well, to keep that pipeline moving forward in terms of having positions filled more quickly. Psychiatry remains our biggest challenge, but psychology, neuropsychology, and social work, we do a little better because we have our own training programs in those areas in terms of filling quickly. Thinking about expansion of services, one of the great pieces about this new space that we'll be working in is it has a whole setup for really our program of our priority areas. So there'll be a kitchen there. We can have eating disorders in a kitchen, have them perking on meal prep together, again, having that group time. Also involved in that is some opportunity for some activities of daily living work to happen with our pain management team. And then one of the biggest holes I see in our community is intensive outpatient services for mood and anxiety disorders. And so this gives us an amazing capability to look at other children's hospitals, see how they have been successful in doing a four day a week program, right, three to four hours per day, four days a week, and getting families engaged, both in person and via teleservices, again, to step down from those crisis services and hopefully prevent that cycle of going back into a crisis intervention situation. And you know, I'd also add, we've really, in the last couple of years, taken a look at the services where behavioral health patients show up and how to make those environments safe and ready for them. And so I think one investment we're making a small expansion to our organization. And as part of that, we plan to create behavioral health safe emergency department rooms that are really purpose built to house this population as they come in, are assessed, and the appropriate level of care is determined and that process can take time. And so we will have space that is purpose built to make sure, again, it's safe, all there in it, there's a high likelihood, high, there's an interest in a low beam. And we are building this space to really try to mitigate that risk. And so anyways, I just, I do think we are continuing to look across our organization and say, where are our behavioral health patients showing up? And what do we need to do to make the care safer? And that's just another example of a capital investment, really, to meet that need. And then another organizational investment too, certainly because with the burnout piece and thinking about workplace violence has been in our behavioral personal protective equipment, our BPPE, and having carts available to our team members for maybe some more challenging patients, some patients who may be going through an active psychosis or substance misuse or substance abuse, or even who are really our most challenging behavioral health patients. So as our team members see us, dedicating that time, not only to safe facilities, but having the equipment they need to do their job safest as well, that's helping, I think, with our attention. And they're coming to us with ideas and with the voice and whenever possible, we're trying to see how we can make that happen and how it fits into not only our work here, but overall health system. I think that highlights, for me, an important distinction in children's health, and we're not just taking care of the child, clearly that is our patient, but we have the family that shows up too, and that family can have just as many sort of maybe needs as our patient. And so routinely our teams are confronted with situations where they have, they're trying to deliver care. And they have a family member who may have their own behavioral health issue, and that manifests itself in what can be violence, it can be aggression, you know, so we just, as a children's hospital and the children's health space, we have to take care of the whole family while they're here, that's part of our job, and while we aren't providing that in terms of treatment, we are providing that in ways of de-escalation and making sure that we're providing a safe environment for the patient and our team to take care of that patient. And that's actually, takes a lot of energy and a lot of work. And Jen actually also didn't say that she totally is our workplace violence prevention committee, and they've done some really good work to work on this. Is that focused just on behavioral health? It's system-wide. It's been a great learning opportunity for me to think about all these different pieces, and it all really comes back to in a lot of ways a healthy, thriving workforce. And as we approach everything from facilities to things as a neuropsychologist, I never thought I'd know about, like public safety-related pieces, a lotement, where is the boundary on our property, right? So important for our staff to have clear expectations on that, and to know that the organizations behind them, to both stay safe and keep our patients and families safe. We're investing in new training, we've just agreed on a new module, then we're actually sure what the terminology should be, but to make sure our entire team has that sort of base level of understanding and education with respect to challenging families and patients. How do you tap into system-best practices from across our organization? I know you think you've kind of been alluding to this with what you're doing with the safety and some other things. Is there anything else you want to expand on? I'd say we have the luxury of being in the Hopkins system, so we have a number of different organizations and hospitals, and really just the opportunity to chat openly about what everyone's trying across the whole system, and we have a very close relationship with our behavioral health pediatric partners at Children's Center in Baltimore, and so we are constantly talking back and forth with visiting. We go, our behavioral health providers go up to visit there, they come down here, lots of good cross collaborations, so we have the best minds really thinking about how to approach these areas and then thinking outside the box, especially sometimes when you are just so honed into what's happening at your own hospital. I think to add to that, Hopkins is a data intensive organization, they are the research component. It is nice to have access to some of the most cutting edge research and treatment, and even when I look outside of the treatment protocols that we are connected across to the system in areas like security and other pieces where we can really share best practices on how we are keeping our patients and families safe, and so I think it is great to be part of a system in that perspective, and again, there is so much good stuff that comes out of the work that our researchers here and in Baltimore do, I think it's a good value for this community. Are there any team members you want to highlight? Actually, Jen and Mark Abbott, who are co-director of our Center for Behavioral Health, keep this drum going, to be honest, they are passionate about their work, and I think it's important. So they are keeping this going, they are always, again, we talk about funding, right? Funding issues, so they are always willing to have a discussion about how we could do something. We won't ever, we are not willing to jeopardize the way we do care, but we appreciate you can get good results and quality results in different ways, and so we have worked really, I think, as a team to try to figure out what that balance is, and then we have talked a lot about it today, but I think there is this conception that behavioral health patients really impact one group, or there is one group we are taking care of, and it's not like that at all. It's every division, every ED is an example of ICU's, you have behavioral health patients that may have a medical need, and they are there as well, and so I think it really is a team, an entire team, to make sure these kids get the care they need and are safe throughout their visits, and so I think it is a misconception to say that it's, you know, it's a unit or a division. It really is across the organization. Now I echo that, Justin, I'm so grateful for our senior leaders, our executive leadership has been, again, incredibly supportive, ensuring that behavioral health is right up there in the strategic plan, grateful for our philanthropic partners, we couldn't do it without philanthropy, and our amazing generous donors, as well as the government affairs team, I mean, we're being able to expand some services based upon collaboration with the children's hospitals and the state of Florida, and then I can't echo what Justin says enough. Every team member at every position in this organization is working to ensure the safety of all of our patients, but when a behavioral health issue or an aggressive patient happens, it can be traumatizing, it can be upsetting, and we haven't always prepared well throughout all of our education and training to be able to manage that, so this is a full organization effort, and I truly couldn't be more grateful to be working with this team and to have the support that we have. Well, thank you both. This has been a very enlightening podcast, again, really focused just on pediatric behavioral health care and the challenges that you're facing. I think our listeners are going to have a lot to learn from listening to you, and they may want to get in touch, so it seems like you would walk in that, so we will be sure to correct it. For more information on our Listen Mental Health Matters series, please visit hdrink.com/listen. There you'll find more on HDR's approach to behavioral and mental health design, meet our team, and see samples of our work. If you like what you heard, be sure to rate us or leave a comment on Apple Podcasts, Spotify, or wherever you get your podcasts. of the world. (upbeat music) (gentle music)