Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding

The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric "boarding"). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital's approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.

Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems

OBJECTIVES

Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.

METHODS

As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.

RESULTS

Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.

CONCLUSIONS

The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Digital Mental Health and Its Discontents: Assumptions About Technology That Create Barriers to Equitable Access

Despite the potential of digital mental health interventions to aid recovery for people with serious mental illness, access to these digital tools remains a key barrier. In this column, the authors discuss three key assumptions that shape the integration of digital mental health tools into community health settings: clinical context, digital literacy, and financial burden. Clinical contexts have shifted with the increased use of telehealth, altering intervention environments; access to a mobile device is not the same as digital literacy; and digital mental health care is not necessarily affordable. Context-centered study design through ethnography will facilitate transfer of digital resources to real-world settings.

The Costs of Implementing a Conversation Aid for Uterine Fibroids in Multiple Health Care Settings

BACKGROUND

Health care organizations considering adopting a conversation aid (CA), a type of patient decision aid innovation, need information about the costs of implementation.

OBJECTIVES

The aims of this study were to: (1) calculate the costs of introducing a CA in a study of supported implementation in 5 gynecologic settings that manage individuals diagnosed with uterine fibroids and (2) estimate the potential costs of future clinical implementation efforts in hypothetical settings.

RESEARCH DESIGN

We used time-driven activity-based costing to estimate the costs of CA implementation at multiple steps: integration with an electronic health record, preimplementation, implementation, and sustainability. We then estimated costs for 2 disparate hypothetical implementation scenarios.

SUBJECTS AND DATA COLLECTION

We conducted semistructured interviews with participants and examined internal documentation.

RESULTS

We interviewed 41 individuals, analyzed 51 documents and 100 emails. Overall total implementation costs over ∼36 months of activities varied significantly across the 5 settings, ranging from $14,157 to $69,134. Factors influencing costs included size/complexity of the setting, urban/rural location, practice culture, and capacity to automate patient identification. Initial investments were substantial, comprising mostly personnel time. Settings that embedded CA use into standard workflows and automated identification of appropriate patients had the lowest initial investment and sustainability costs. Our estimates of the costs of sustaining implementation were much lower than initial investments and mostly attributable to CA subscription fees.

CONCLUSION

Initiation and implementation of the interventions require significant personnel effort. Ongoing costs to maintain use are much lower and are a small fraction of overall organizational operating costs.

Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure

BACKGROUND

Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience.

METHODS

Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated.

RESULTS

The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery.

CONCLUSIONS

A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.

I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding

PURPOSE

Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE.

METHODS

A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically.

RESULTS

Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers.

DISCUSSION

I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.

Multistakeholder Perspectives on Interventions to Support Youth During Mental Health Boarding

OBJECTIVE

To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care.

STUDY DESIGN

This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method.

RESULTS

Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important.

CONCLUSIONS

Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts.

Psychotropic Polypharmacy and Antipsychotics in Children: A Survey of Caregiver's Perspectives

OBJECTIVE

We examined caregiver's knowledge, attitudes, and concerns about their child's psychotropic medication regimen and the potential side effects, describe how they seek information regarding treatment, and ascertain their perspectives toward deprescribing.

METHODS

We surveyed 48 caregivers of children 6-17 years old treated with two or more psychotropic medications or an antipsychotic medication, analyzing outcomes using descriptive statistics.

RESULTS

Almost all (N = 44, 92%) participants reported feeling very knowledgeable about why medications were prescribed, but only one-third (N = 16, 33%) reported feeling very knowledgeable about potential problems with long-term use or polypharmacy. Half of respondents (N = 24, 50%) reported asking their provider about reducing/stopping medications due to concerns about harmful effects, and nearly half (N = 20, 42%) reported stopping medications earlier than recommended.

CONCLUSIONS

Interventions to engage caregivers in shared decision-making about complex medication regimens and to support prescribers to safely deprescribe psychotropic medications are needed to address caregivers' concerns regarding psychotropic medication use.

Individualized Intervention to Support Mental Health Recovery Through Implementation of Digital Tools into Clinical Care: Feasibility Study

Myriad digital tools exist to support mental health but there are multiple barriers to using these tools in routine care. This study aimed to assess the feasibility of an intervention incorporating a support role to help the clinical team identify and use technology to promote recovery. The technology specialist intervention is 3 months in duration and comprises four stages: goal setting, researching and evaluating tools, demonstrating and selecting tools, and ongoing support. We implemented the intervention in a community mental health center and a dual diagnosis treatment program, working with eight clients and their case managers. Clients and case managers willingly engaged with the technology specialist and found the intervention beneficial. Integration and collaboration with the care team facilitated implementation of the technology specialist in these real-world settings. Clients reported that the intervention made it easy to try a digital tool. Six of the eight participants stated that they made substantial progress toward their goals. The technology specialist is a promising new role for mental health care delivery to augment traditional services and enhance individualized recovery.

Comparative effectiveness of direct admission and admission through emergency departments for children: a randomized stepped wedge study protocol

BACKGROUND

Approximately 2 million children are hospitalized each year in the United States, with more than three-quarters of non-elective hospitalizations admitted through emergency departments (EDs). Direct admission, defined as admission to hospital without first receiving care in the hospital's ED, may offer benefits for patients and healthcare systems in quality, timeliness, and experience of care. While ED utilization patterns are well studied, there is a paucity of research comparing the effectiveness of direct and ED admissions. The overall aim of this project is to compare the effectiveness of a standardized direct admission approach to admission beginning in the ED for hospitalized children.

METHODS/DESIGN

We will conduct a stepped wedge cluster randomized controlled trial at 3 structurally and geographically diverse hospitals. A total of 70 primary and urgent care practice sites in the hospitals' catchment areas will be randomized to a time point when they will begin participation in the multi-stakeholder informed direct admission program. This crossover will be unidirectional and occur at 4 time points, 6 months apart, over a 24-month implementation period. Our primary outcome will be the timeliness of clinical care provision. Secondary outcomes include (i) parent-reported experience of care, (ii) unanticipated transfer to the intensive care unit within 6 h of hospital admission, and (iii) rapid response calls within 6 h of hospital admission. We anticipate that 190 children and adolescents will be directly admitted, with 1506 admitted through EDs. Analyses will compare the effectiveness of direct admission to admission through the ED and will evaluate the causal effect of implementing a direct admission program using linear regression with random effects for referring practice clusters and time period fixed effects. We will further examine the heterogeneity of treatment effects based on hypotheses specified a priori. In addition, we will conduct a mixed-methods process evaluation to assess reach, effectiveness, adoption, implementation, and maintenance of our direct admission intervention.

DISCUSSION

Our study represents the first randomized controlled trial to compare the effectiveness of direct admission to admission through the ED for pediatric patients. Our scientific approach, pairing a stepped wedge design with a multi-level assessment of barriers to and facilitators of implementation, will generate valuable data about how positive findings can be reproduced across other healthcare systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04192799 . Registered on December 10, 2019).

Deprescribing psychotropic medications in children: results of a national qualitative study

BACKGROUND AND OBJECTIVE

Prescriptions for psychotropic medications to children have risen dramatically in recent years despite few regulatory approvals and growing concerns about side effects. Government policy and numerous programmes are attempting to curb this problem. However, the perspectives of practising clinicians have not been explored. To characterise the perspectives and experiences of paediatric primary care clinicians and mental health specialists regarding overprescribing and deprescribing psychotropic medications in children.

METHODS

We conducted 24 semistructured interviews with clinicians representing diverse geographic regions and practice settings in the USA. Interview questions focused on clinician perspectives surrounding overprescribing and experiences with deprescribing. We transcribed audio files verbatim and verified them for accuracy. We analysed transcripts using a grounded theory approach, identifying emergent themes and developing a conceptual model using axial coding.

RESULTS

Analysis yielded themes within four domains: social and clinical contextual factors contributing to overprescribing, opportunities for deprescribing, and facilitators and barriers to deprescribing in paediatric outpatient settings. Most participants recognised the problem of overprescribing, and they described complex clinical and social contextual factors, as well as internal and external pressures, that contribute to overprescribing. Opportunities for deprescribing included identification of high-risk medications, routine reassessment of medication needs and recognition of the broader social needs of vulnerable children. Facilitators and barriers to deprescribing were both internal (eg, providing psychoeducation to families) and external (eg, parent and child preferences) to clinicians.

CONCLUSION

Our findings highlight a discrepancy between clinicians' concerns about overprescribing and a lack of resources to support deprescribing in outpatient paediatric settings. To successfully initiate deprescribing, clinicians will need practical tools and organisational supports, as well as social resources for vulnerable families.

The technology specialist: a 21st century support role in clinical care

Mental health clinicians, clients, and researchers have shown keen interest in using technology to support mental health recovery. However, technology has not been routinely integrated into clinical care. Clients use a wide range of digital tools and apps to help manage their mental health, but clinicians rarely discuss this form of self-management in clinical interactions. This absence of communication is concerning because the safety and quality of the digital tools and apps people use may negatively affect their mental health outcomes. Mental health systems could benefit from someone to help identify technology-based supports that reflect current evidence and minimize privacy and security concerns. This technology specialist may also enhance the therapeutic bond between the client and the clinician. In working with a technology specialist, clients may begin to gain a sense of control over their mental health, and perhaps use fewer mental health services.

Use of Mobile and Computer Devices to Support Recovery in People With Serious Mental Illness: Survey Study

BACKGROUND

Mental health recovery refers to an individual's experience of gaining a sense of personal control, striving towards one's life goals, and meeting one's needs. Although people with serious mental illness own and use electronic devices for general purposes, knowledge of their current use and interest in future use for supporting mental health recovery remains limited.

OBJECTIVE

This study aimed to identify smartphone, tablet, and computer apps that mental health service recipients use and want to use to support their recovery.

METHODS

In this pilot study, we surveyed a convenience sample of 63 mental health service recipients with serious mental illness. The survey assessed current use and interest in mobile and computer devices to support recovery.

RESULTS

Listening to music (60%), accessing the internet (59%), calling (59%), and texting (54%) people were the top functions currently used by participants on their device to support their recovery. Participants expressed interest in learning how to use apps for anxiety/stress management (45%), mood management (45%), monitoring mental health symptoms (43%), cognitive behavioral therapy (40%), sleep (38%), and dialectical behavior therapy (38%) to support their recovery.

CONCLUSIONS

Mental health service recipients currently use general functions such as listening to music and calling friends to support recovery. Nevertheless, they reported interest in trying more specific illness-management apps.

Real-World Technology Use Among People With Mental Illnesses: Qualitative Study

BACKGROUND

There is growing interest in using technology-based tools to support mental health recovery. Yet, despite evidence suggesting widespread access to technology among people with mental illnesses, interest in using technology to support mental health, and effectiveness of technology-based tools developed by researchers, such tools have not been widely adopted within mental health settings. Little is currently known about how mental health consumers are using technology to address mental health needs in real-world settings outside of controlled research studies.

OBJECTIVE

This qualitative study examined current practices and orientations toward technology among consumers in 3 mental health settings in the United States.

METHODS

Ethnographic observations and semistructured interviews were conducted. Observations focused on if and how technology was salient within the setting and documented relevant behaviors, interactions, and dialogue in fieldnotes. Ethnographic data informed the development of a semistructured interview that inquired into technology use and interest among consumers (n=15) in a community mental health setting. Fieldnotes and interview transcripts were reviewed and coded by multiple researchers. Key concepts and patterns identified were refined by the research team to develop the main findings.

RESULTS

Ownership of technology, although common, was not ubiquitous and was varied across the sites. Participants had varying levels of awareness regarding the key capabilities of modern technologies. Participants used technology for many purposes, but there was limited evidence of technology use to support mental health. Technology-based tools specific to mental health were not routinely used, although some participants found widely available mobile apps to be helpful in recovery.

CONCLUSIONS

Qualitative findings suggest that many, but not all, clients will be interested in using technology to support mental health needs. The variability in type and quality of technology owned by participants suggests the need to design for a range of functionality in the development of mental health tools. Findings also suggest thinking broadly about using existing platforms and widely available tools to support consumers in mental health recovery.

Psychotropic medications for highly vulnerable children

INTRODUCTION

At least 20% of children in the U.S. are highly vulnerable because they lack healthcare and protection. Several factors produce vulnerability: trauma, disruptions of parenting, poverty, involvement in the juvenile justice and/or child welfare systems, residence in restrictive settings, and problems related to developmental disabilities. These children receive psychotropic medications at high rates, raising numerous concerns.

AREAS COVERED

The authors begin this review with a description of the population of highly vulnerable children. They then follow this with a review of the effectiveness and side effects of psychotropic medications for their most common diagnoses, using the highest-quality systematic reviews identified by multiple database searches.

EXPERT OPINION

Highly vulnerable children receive numerous psychotropic medications with high rates of polypharmacy, off-label use, and long-term use, typically in the absence of adjunctive psychosocial interventions. The current evidence contravenes these trends. Future studies of psychotropic medications in vulnerable children should include long-term effectiveness trials and polypharmacy in conjunction with evidence-based, family-centered, psychosocial treatments.