Healthy Minds Make Healthy Bodies & Money

An Interview with Experts at Children’s Hospital of Wisconsin

By Patricia Obletz, Editor, www.MilwaukeeRenaissance.com/PeaceOfMind/

“It is easier to build strong children than to repair broken men.”
---Frederick Douglass

1/4/17: http://children.wi.gov/Documents/OCMH%202016%20Annual%20Report%20to%20Legislature.pdf

3/31/16 Update: As you’ll note in the following interview, Wisconsin has funded a pilot project that offers pediatricians and other caregivers the opportunity to teleconsult Children’s Hospital of Wisconsin behavioral health specialists on individual cases, despite the fact that Wisconsin has no parity mental health legislation activity. Recently, President Barack Obama finalized the new mental health rules for Medicaid. Why is this critical to society in general?

Behavioral/mental problems run in every family. Helping children and their parents manage the symptoms is a driving passion for two experts at Children’s Hospital of Wisconsin (CHW) Psychiatry & Behavioral Medicine Department: Medical Director, Robert P. Chayer, MD, and Director of Mental Health Services, Tracy R. Oerter, MS. Chayer is a Child and Adolescent Psychiatrist, and Vice-Chair of Child and Adolescent Services at Medical College of WI Psychiatry Department; Associate Professor. Oerter launched her career in mental health 20 plus years ago and has been at Children’s Hospital for the past 12. She works overtime to reduce stigma, promote suicide prevention and improve access to mental health services to all children and adolescents with innovative and collaborative partnerships.

When asked about the health disparities seen at Children’s, Chayer said they find a disproportionate amount of concurrent physical and mental health issues because they’re based in a pediatric hospital. Oerter added that kids don’t often come to Children’s for emotional trauma, but the trauma surfaces once they’re admitted.

“A lot of the kids we see have adverse childhood experiences,” Chayer said. “Their families work harder to meet basic needs. They’ve been traumatized by neglect or abuse, or are witnesses to or victims of violence. Traumatized children have lots of symptoms, including anxiety and depression, but their admitting diagnosis might be asthma, diabetes or ADHD.”

“We also have co-located therapists with Child Protection Center,” Chayer said. “(They) get a lot of referrals (because) a lot of kids there are assessed for trauma. We see kids who are chronically traumatized through lack of resources or unstable living situations. A lot of the kids we see are from areas that don’t have as many advantages as have some of the kids in suburban school districts,” Chayer said.

Oerter added, “Many of the kids we see get meals from convenience stores – the central city of Milwaukee is often referred to as a ‘food desert’ because, even if the convenience stores have apples, they’re not fresh. Health disparity also shows up in the disproportional number of kids on Medicaid in Milwaukee; New Berlin (where CHW has another outpatient clinic) is also home to many kids who rely on Medicaid.”

Chayer said that Children’s is one of the few providers in the area that will take Medicaid, and that Children’s has “the support of the hospital system to take those kids on, even though we treat them at a financial loss.” Early intervention is cost-effective.

Creating Healthy Children

To meet the needs of Milwaukee area kids, Children’s has developed multiple programmatic approaches. Chayer said that Children’s has been involved in varying degrees over the years with the decade-old School-Community Partnership for Mental Health (SCPMH). He said they were in the midst of “negotiations with them to provide mental health therapists in a couple of schools.” At least one parochial school has recently joined SCPMH, in addition to Milwaukee Public Schools (MPS). “We’re exploring the idea of collaborating with the Children’s Medical Group to provide both mental health and primary care services directly in some central city schools.”

Chayer said Children’s also is working on a small pilot project with potentially three primary care offices at which they will embed a therapist to collaborate with the pediatricians and the nurse practitioners. He added that most psychotropic medications are prescribed by primary care providers now.

“Probably the project furthest along,” he said, “is the one funded by the state to have consultations with pediatricians and child psychiatrists: the Child Psychiatry Consultation Program (CPCP). The goal ultimately entails five or six hubs of pediatricians, family practitioners and nurse practitioners around the state; Milwaukee County could be separated from the Southeast Wisconsin hub because of its size and density. He said that “they can send us an email or pick up the phone to ask our advice on diagnosis, treatment and medication management.”

Chayer said, “We’ve been looking at a 12-year old program in Massachusetts as a model. We’re adding an educational component since we are finding that most primary care providers have minimal experience in providing mental health services. So this program is a combination of access to the psychiatrist, educational modules and support. We’re just getting into these practices now, so we’re about to find out exactly what they need from us.”

Children’s long waiting list to access specialty services means that primary care providers need to treat mild to moderate issues such as ADD, poorly working medication, mild anxiety and school avoidance, Chayer said. “We also help them find therapists in their area — the fact that there are more therapists in the suburbs is one of the things that drove us to look at integrating mental health – putting therapists in pediatrician offices so there’d be more options in some of the central city locations.”

“Intuitively, this seems like a no-brainer,” Oerter said. “Everybody’s now trying to work through the primary care office, because that’s where the child is most comfortable. But, mental health is so fragmented, not just in Wisconsin, but across the country. This fragmentation evolved with the managed care movement in the 1990s: what’s billable, what’s reimbursable; there was/is competition among agencies for limited funding, and the politics of working across industries, such as mental health and public schools. The School-Community Partnership on Mental Health took about five years just to get their foot in the door at Milwaukee Public Schools because of many of these factors.”

Chayer said, “School psychologists going from school to school focus on what gets in the way of education. So their treatment isn’t comprehensive in terms of holistic mental healthcare, but you have to limit your scope in that sort of setting. And (the Partnership isn’t) talking about replacing school psychologists; the goal is to add therapists to help with mental health needs that aren’t strictly related to learning. It’s a great model, but we just have to see where the funding is.”

What to Do Until 24,000 More Child Psychiatrists Arrive

Chayer said that nationally, there are about 8,000 child and adolescent psychiatrists, but the need is for at least 30,000 to 32,000. In Wisconsin, 135 child psychiatrists are registered with the American Academy of Child and Adolescent Psychiatrists; some are retired. “Students come out of medical school about $160,000 in debt. Child psychiatry requires five more years of training, like a lot of the surgical sub specialties. Pediatric or psychiatry students have to be passionate about child mental health to resist the more lucrative practices.

“At least the American Academy of Child and Adolescent Psychiatry is advocating for loan reimbursement programs, or other forms of incentive,” Chayer continued. “But the real incentive is the shift in the perceived value of mental healthcare: they’re getting it that ‘just sitting there talking to someone’ can lessen a child’s need for emergency rooms and expensive ICU stays. This fact shows up in the bottom line. (W)e need to become a valued member of the healthcare team and be treated with the same esteem as the surgeons who are reimbursed in a way that makes surgery enticing. Psychiatry isn’t quite seen as ‘medicine.’ But I think a lot of things will change. I think the increased funding in healthcare is going to encourage more mental health funding and growth.

“We’re hoping to alleviate this shortage with our consultation program. The hard part of this is that a number of kids with moderate to severe mental health issues need to see a mental health specialist rather than work with their pediatrician. Every other pediatric sub specialty has kids that they’re treating on referral. The phone consult program doesn’t help these children.”

“And we have a waiting list of about 150 children,” Oerter said.

Outreach

Answering the question about community outreach, Oerter said that Children’s public services provide in-school presentations and lectures to staff, parents and community members wherever requested. Common topics are brain development, trauma, depression, ADHD – whatever the school or the communities want. “Usually we present to the staff, parents and community members. Children’s Community Health and Education Center does training and creates online modules for students. I don’t know if this is standard in all the schools, but it is available statewide,” she said. “My kids are in a (suburban) school system and they are going through Children’s modules on bullying, depression, and other related topics. We (CHW) are also are trying to get our services out in the community more because there are a lot of barriers to coming to the hospital – transportation, stigma, fear…

“We’ve been doing some work statewide, trying to get into schools to (provide) school-based mental health. That’s really starting to take off,” Oerter said.

Commonsense Shift in Funding Priorities

“In the past, the more patients you treated, the more you got paid. Not anymore,” Chayer said. “Mental health services don’t bring major reimbursement in the same way as do ICU stays.”

Oerter said, “My job didn’t exist two years ago. There were different management and director positions throughout the hospital overseeing pockets of mental health services. It was fragmented. When health care reform (the Accountable Care Act) came into effect,mental health was at the crux of most of the conversations (about) the shared risk of keeping kids healthy and out of the hospital. I’ve been in mental health for 20 some years and I’ve never, ever felt in such demand before. We used to say, ‘What about us? What about us?’ But now, there’s more grant money, more research and more attention, more of almost everything.”

When asked if the passage of the Affordable Care Act had anything to do with this commonsense shift in funding priorities, Oerter said, ”The ACA had a lot to do with it. Also significant were and still are the clamoring statistics of incarceration and the global access to information (i.e. social media) exposing more people to the significant acts of violence occurring, capturing the attention of legislators, including Wisconsin.”

Chayer said that “Insurance companies targeted the asthma population – the small percentage of kids who frequently utilize emergency rooms and need hospitalization. Insurance companies said, ‘We’ll pay you an incentive if you can reduce the number of high utilizers.’ But why are they high utilizers? They’re not always taking their medicine, but why not? How do we change this behavior? Well, now comes the realization that we need a behavioral expert to help us figure this out. And so mental health services became much more important to keeping kids healthier and out of the hospital emergency room and ICU . . . . At some point we’re going to get paid to keep people healthy. The hospital leadership is seeing mental health as an important part of that, so they are supporting us.”

At the Crux of Good Health

“I am seeing the same shift that Bob talked about,” Oerter said. “This shift to understanding that mental health is central to all of medical health, and that holistic care saves money and pain. Insurance companies are saying, if we have x dollars for the 20 percent of high utilizers of asthma-related ER visits, and we offer this shared risk with this hospital to keep kids out of high cost services, we keep whatever we save when behavioral health services as part of the medical team teach children how to live with and manage their asthma (or diabetes or . . .). The dollar is talking, there are more advocates, more legislation being passed, and increasing understanding that you can’t treat mental health and physical health in isolation from each other.

“Insurance companies are slowly getting it. I’ve been having more friendly conversations with insurance companies. Children’s Community Health Plan,” Oerter continued, “has mental/behavioral health navigators that get it. They don’t create all of those time-consuming barriers demanding prior authorizations that others who are more slowly coming on board are still throwing at us.”

Chayer said that, a few years ago, Children’s became more interested in a few of the central city zip codes and began to work on helping the communities address their significant health needs, including mental health needs. “This is why,” he said, “we’re looking at some of the schools in the central city, and collaborating with some of the Children’s Medical Group primary care offices in some of those neighborhoods, and also partnering with the YMCA and other community agencies there. A lot of this work is happening through the Population Health Office, but they’re including us in their thinking and I think that’s an important step.”

Oerter said that one of the ways that they deal with disparities is that they don’t say no to anybody. They might have to refer people out, she said, “if we know that there’s an organization down the block that can help the child faster than Children’s wait list permits. We need to establish our strengths. The county specializes in crisis intervention, and we don’t do that. We do outpatient services, consultations with hospital and other specialties, and we’re trying to do even more community-based services.”

Although Children’s Behavioral Health doesn’t have inpatient care, Chayer said that Rogers Memorial Hospital is opening a facility in Brown Deer, which, added to their Oconomowoc facility, would be 100 child and adolescent psychiatric beds within a 25-mile radius among: the county, all the Rogers facilities plus Aurora Psychiatric, and beds in Racine as well. “There are lots of psychiatric beds available for an area of our population,” Chayer said. “We may have more beds for a city of our size than a lot of places. It’s the shortage in outpatient services that’s the problem. When kids come out of the hospital, finding them follow-up treatment is a big issue. A lot of the emphasis has been on inpatient and day treatment, not so much in ongoing care, which is one of the things we try to provide. But there’s only so much that we can do.

“Because so many of the children we see have adverse experiences, it’s hard to change perceptions without offsetting the negative with positive experiences – whether you’re primarily in an African American neighborhood and you don’t have any experience with other ethnic groups. Or the other way around. If you live in a predominately Caucasian environment and all you see is the negative things on the news from the central city, but don’t have personal experiences to offset the stereotypes, you perpetuate stereotypes. I think this happens because Milwaukee is so segregated; there are not a lot of cross-cultural connections that change perceptions. The thing is, people are more comfortable with the familiar, which is why bused students many times tend to stick with their own ethnic or cultural group rather than fully integrate with their schoolmates.”

When asked if a racist who assumes the right to kill another human being has a mental illness, Oerter said, “I think that racism is a social illness. There is such long-standing generational racism and it’s challenging to think about how to start changing it. But any step, even a baby step, in the right direction is a good thing for our community.”. In a recent study about health outcomes for Wisconsin’s children, five zip codes in Milwaukee’s central city brought down the entire state’s health outcome. Children’s Hospital’s vision is to have the healthiest kids in the country.

“Because so many of the children we see have adverse experiences, it’s hard not to perpetuate them without offsetting them with positive experiences, whether you’re primarily in an African American neighborhood and you don’t have any experience with other ethnic groups. Or the other way around: if you live in a predominately Caucasian environment and all you see is the negative things on the news, but don’t have personal experiences to offset the stereotypes, you perpetuate stereotypes. I think this happens because Milwaukee is so segregated; there are not a lot of cross-cultural connections that change perceptions. The thing is, people are more comfortable with the familiar, which is why bused students tend to stick with their own ethnic or cultural group rather than get to know their schoolmates.”

When asked if a racist who assumes the right to kill another human being has a mental illness, Oerter said, “I think that racism is a social illness. There is such long-standing generational racism and it’s challenging to think about how to start changing it. But any step, even a baby step, in the right direction is a good thing for our community. In a recent study about health outcomes for Wisconsin’s children, five zip codes in Milwaukee’s central city brought down the entire state’s health outcome. Children’s Hospital’s vision is to have the healthiest kids in the country.”

Wisconsin Health Outcomes Worse than Some Third World Countries

“When someone did a study about health outcomes for Wisconsin’s children, five zip codes in Milwaukee’s central city brought down the entire state’s health outcome. If we can elevate the health outcomes for the poor children in these zip codes, we will elevate the health outcomes for the entire state. Right now, Wisconsin has health outcomes that are worse than some third world countries in terms of infant mortality rate. I’m really excited to be a part of what Children’s is doing. You need top leadership who are willing to invest money in order to improve health outcomes for children in these zip codes. And Children’s Hospital of Wisconsin has top leadership with the foresight to know that early intervention prevents high-cost healthcare needs in the future.”

Chayer said that this “vision to see that change is coming, and although we don’t know what the timing is, at some point we’re going to get paid to keep people healthy. The hospital leadership is seeing mental health as an important part of that, so they are supporting us.”

Chayer said that kids come in sad and unhappy, “but talking to them, you find that someone’s always yelling at them about underperforming at school, and you find out that this all started at school when they couldn’t focus. So you treat their focus problems and their grades improve, and their mood improves, and their family conflicts lessen because you have treated the root cause. Other kids who are failing in school and not paying attention, you find out that they had a major loss or became depressed, and their concentration suffered because that’s a symptom of being depressed. This isn’t a school problem, it’s a mood problem, but it all is tied together. The question is, what do you treat first? What symptoms do we address and in which order?”

When asked about child suicidal ideation, Chayer said they “see a fair number of kids with suicidal thoughts, which speaks to the severity of the illness that can make you start thinking you don’t want to live anymore with the kind of pain you’ve been enduring.”

Access to healthcare is limited in poverty-struck neighborhoods. That’s why Chayer and Oerter work so hard on building relationships with primary care providers, public schools and community organizations. Learning resiliency and overcoming trauma create a hard and scary path that the behavioral health group at Children’s Hospital of Wisconsin is taking with children who need them. No wonder Wisconsin’s Children’s Hospital wins so many national awards.

“When healthcare providers are paid to keep a population well,” Chayer said, “mental health services become much more valuable. At some point, that’s going to shift around to where mental health services are seen as very valuable. Of course, I don’t know how soon this will happen. But, as (administrators) look at healthcare finances, rewarding keeping people well is going to be where the field heads.”

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Last edited by patricia obletz. Based on work by Tyler Schuster.  Page last modified on January 04, 2017

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