Welcome everyone to the Becker's Healthcare podcast series.
I'm Mariah Muhammad, writer and moderator with Becker's
Healthcare. I'm thrilled to have with me today
Renee Rafferty. Senior vice president of behavioral health
and wellness is Sabrina Shally, director of behavioral
health integration and program coordinator at Children's Nebraska.
Renee and Sabrina, welcome to the podcast. We're
very excited to have you join us today.
To get a start, would you mind please
introducing yourself and telling us a bit about
your background? Yes. Thanks so much, Mariah.
I'm Renee Rafferty,
senior vice president of behavioral health and wellness.
I am a therapist by trade and have
been in a leadership role for over twenty
years. I have will worked in the full
continuum of care, outpatient,
inpatient residential crisis services,
as well as integrated behavioral health. And and
just I'm very excited to talk with you
today.
And, yes, it's lovely to meet you, Mariah,
and get a chance to share about our
program. My name is Sabrina Shalley. I'm a
licensed clinical social worker by discipline,
and this is actually my thirtieth year in
the field. I began as a,
clinical counselor and therapist for adolescents,
and working with kids and their families has
remained
my passion throughout my career,
and,
have also really been excited to lead Children
Nebraska's efforts for suicide prevention,
in hopes that we can accomplish zero suicides.
So excited to talk more about our efforts
in that space today.
Yes. Yes. Thank you both for giving us
that background and, obviously, amazing work that you
are doing, in that field. Sabrina, going to
you for,
my first question. How did the idea for
implementing caring context in a pediatric setting originate?
And what made Children's Nebraska decide to adopt
this historically adult focused intervention
and lead its utilization
for children and teens?
Well, thank you so much for giving us
a chance to tell this part of our
story.
I am celebrating eight years here at Children's
Nebraska. And prior to the role I'm in
now, I had the great opportunity to,
support and lead the medical social workers, which
included our emergency department
social workers who in our continuum of care
provided the mental health assessment for kids who
were coming in for suicide ideation or suicidal
behaviors.
And when I joined Children's in 2017,
it was right as we really began to
see a ramp up in the number of
kids needing to come in for those services.
And as I was supporting those social workers,
I was hearing
about how difficult it was for them, you
know, in a eight or twelve hour shift
to be working with child after child after
child.
And so we were doing some things to
try and support them.
The medical team that surrounded them was amazing,
but that was on my brain. At the
same time,
as a leader continuing to hear about we
were we were nearly doubling our rates of
kids needing new services.
And I'll be honest, it was,
fall season because I was watching a Kansas
City Chiefs football game.
We are in our glory years. I readily
admit that. But during commercials is when I
like to catch up on magazines.
And there was a Time magazine article in
the 2019
all about these handwritten note cards that were
used in adult substance use and misuse recovery.
And I thought, oh, I don't really want
to read this article right now. It's Sunday.
I'm watching football. And I thought, no. I
probably really need to read this.
And I read it and I just thought
that magic of that personal touch of when
you get to meet someone in their most
vulnerable moments
and,
they tell you their story and then you
help them make recommendations of what the next
step on their journey is,
but then you don't have contact with them
again potentially forever,
how that must feel to the patient, let
alone how that was feeling to the social
workers. So I brought it to our emergency
department social work team, and I said, what
would you think if we tried something like
this?
And they all immediately got on board,
and we're really excited about the opportunity. So
we really dove in. We learned
about zero suicide.
We traced the history of these handwritten caring
contacts note cards.
We did some benchmarking with the Children's Hospital
Association and found out this wasn't being utilized
in any sort of environment that we could
uncover. We had an amazing practicum student that
helped us roll it out. And I want
to bring back to attention the timeline that
we started this, which was fall of twenty
nineteen. We had no idea what was coming
in March.
We had set a go live date of
05/01/2020,
which took us about six months to develop
the program,
to create what we thought would be an
effective clinical intervention.
And I'm really proud to say that despite
the COVID pandemic happening, we did go live
on May 1.
And since that time, we just celebrated,
five years. We have enrolled nearly 1,200
patients into the program.
And the best news of all is we
have zero deaths by suicide in our patient
population in this space. So,
that's how it came about, a random article
being read,
that was used in the adult space.
Wow. That's absolutely amazing. Thank you so much
for sharing that. And you're now five years
into the program,
and, obviously, it's going really well. But what
outcomes or trends have surprised you the most,
especially in terms of patient response and impact?
Oh my goodness.
You know, our biggest hope as we as
we went into this is that,
we really wanted to reduce
our kids that were returning to us, for
repeat suicide ideation or suicidal behavior.
We also,
thought that it might give us a chance
to decrease the number of kids who died
by suicide.
We thought it would help normalize mental health
and needing to come in for support with
our pediatric health care team, but also we
thought there was potential for it to impact
our community in a positive way. And
just showing a token
of support
for these individuals. I wanna be really clear
that we never intended to replace the needed
steps
for kids after they come in for
suicidal ideation or behaviors.
We always needed to encourage them on to
go into inpatient care or to connect with
an outpatient
or intensive outpatient team.
These were really, like, we met you, we
care about you, and we're gonna continue to
cheer you on in your journey. So the
cards are written really carefully,
so that they speak to that component.
But really, magic started to happen, and it
started happening right away when the kids started
writing back to us. And I have some
cards I could read you some quotes from.
We had no idea that the kids, you
know, unprovoked, would choose to write. We've had
kids that have called, like, our our Children's
Nebraska agency line and say, hey. We're trying
to track down a social worker,
you know, and we don't we only remember
her frictioning with this. And they literally, like,
ping ponged through our system and are leaving
messages for those social workers.
We had no idea that we would hear
from their families,
that families were writing us and sending us
pictures of their
child. We got one picture where it was
the child on their on their bed with
their comfort
cat,
and all of the handwritten note cards. We
send six in that year.
We're all hanging
by the side of her bed, and the
mom was saying, this is the most amazing
thing. They're concrete. They're tangible. She reads them
over and over,
and I just wanted you to see this
picture of my happier and healthier child than
when you first met her.
We also then
really didn't know that we would begin to
see our social workers that were doing this
work no longer felt like it was a
churn and burn or a one and done
environment. They actually felt
that empowerment
to continue to support the patients,
in this really profound way. So the retention
rate improved for us with our emergency department
social workers.
I think since we started, we've lost only
one or two to moving out of state
or, different positions in our organization, and so
it's really stabilized that team.
And then as we began to share
successes after we've run the program for one
year,
it we heard from our division chief,
of our emergency department. He said, hey. None
of my peers are hearing any you know,
they're not doing anything like this. We need
to start telling people about the results.
And so we've done a bit of that.
We created a replication kit, and we've been
able,
to share that,
with over 70 different,
health care systems so far.
So that's been been really exciting.
Yeah. Yeah. As of that definitely sounds exciting.
And you answered,
my next question a little bit, but, obviously,
the program has expanded significantly with over a
thousand patients, enrolled,
and replication kids share with hospitals and schools
nationwide. Can you explain what the adoption process
looks like? And you say you share you
have,
over 70 institutions that have adopted the model?
We've shared with over 70 institutions, Mariah,
and we're really pleased to do that. We're
happy. We've presented on this program to conferences,
to larger groups, but we also get thrilled
to meet with,
health care institutions
one on one and really talk through
how we've lifted the program here. I mean,
you've got things like
HIPAA and compliance. Right? We need to get
guardian permission to be sending these note cards.
We,
need to ensure,
that the patient expects that these cards are
coming.
And so we have a ninety per ninety
eight percent of our patients that we offer
this program to,
choose to enroll. So that's really amazing.
But I will say I don't know how
many who have chosen to adopt the handwritten
part.
We're really grateful to Children's Nebraska that we
are able to allocate our social workers time
to writing these cards.
I know there are some other health care
institutions that are doing some really neat things
with regard to texting
and those components,
but we haven't been able to argue with
the results of zero suicide.
We also have a substantial decrease in kids
that are in the program that return to
the emergency department,
with regard to any sort of suicidal thoughts
or or gestures.
And,
actually, we begin to see more and more
of our kids,
that we are seeing if they do come
back, are able to discharge home with a
safety plan and lethal means counseling as opposed
to going into a higher level of care.
So all of those things have told us
we've really that we aren't at this time
going to change our process, and we're gonna
stick with the hand written cards.
Got it. Got it. Thank you so much
for explaining that. And read it Renee, how
do you maintain the personal and meaningful nature
of the handwritten notes, especially as the program
scales?
Can you share any memorable stories or feedback
that really
importance of using innovation and text is great,
and those things are wonderful tools. And I
think what we've realized through this program,
when you send that card and that child
was able to connect with the person that
they sat with during their most difficult moment,
they're able to recognize that
this connection
is a sign of hope and healing, and
they get these multiple reminders of that courage
it took to reach out, the ability to
trust their own inner wisdom, and work with
the the the person that's shared their story.
So I think those cards,
themselves are really a testament to the importance
of connection and that however we heal is
usually through connection with our caring team. And
I think that the
I'll have Sabrina read a card to you
of of what is said because I think
that just is is a one card from
a child touches hundreds of caregivers because we
do share the exciting words and not sharing
the identity of the child, but just the
healing that happens. And that, like Sabrina says,
is so healing for the our team to
remember that this treatment actually works. People do
heal from mental health conditions, and they do
really respond to powerful visits,
and it can be trajectory changing. So, Wendy,
you wanna go ahead and read one for
us? Yes. Yes. I'm happy to.
So, Mariah, here's a card we got back
from one of our patients, and she writes,
thank you so much for sending that letter.
I can't even begin to tell you how
much it meant to me. I got the
letter the day of my birthday and started
sobbing in the car. I'm glad I know
I have someone rooting for me. It was
so kind of you to reach out.
I'll take a moment to read another one
that I think is really impactful.
This is someone,
who wrote back after all six cards had
been sent for that first year. And she
says, I have always meant to write back
to you.
The cards mean so much to me. Each
one is hanging up in my room. I
wanted to let you know how much of
an impact the cards have and to know
someone I met once cares so deeply for
me. I'm doing the best I have been
since a year ago. I never imagined this
much happiness was waiting for me. There have
been hard times, but I have been able
to overcome them and become better in the
end. I can never thank you enough for
all you have done in my healing journey.
And, again, that's just a reminder that that
social marker met this patient once and six
handwritten note cards. I mean, again, just a
bit of magic.
Yeah. Absolutely. Thank you so much for sharing
those. And looking ahead, how do you envision
caring contacts evolving with Children's Nebraska? Are there
any plans at all to expand beyond behavioral
health into,
other areas of care where connection might also
improve outcomes?
Yes. And I'll I'll answer the being that
somebody you weigh in. But I think, ultimately,
it's very important to say that, you know,
interventions for kids experiencing mental health conditions happen
across our continuum.
We are training within Jones Nebraska. We have
a program called COPE, which is children's outreach
and provider education. And we train pediatricians to
treat mild to moderate conditions within,
primary care. And I think there's opportunities to
expand in those types of settings to bring
to outreach to other hospitals and to continue
to talk about the importance of that personalized,
deep trauma informed connection that allows for that
sense of hope, which we know is really
the key to healing. So I think we
plan to you know, Sabrina's
excellent at being able to support and to
continue to provide that implementation. And we are
gonna be using it as we expand our
services.
We have used it in our behavioral health
urgent care,
out in Kearney, Nebraska and have found that
the kids absolutely love it out there as
well. And so it's it's just a very
it's a tool that we'll continue to support
and offer to others as well as inside
of our, inside of our programs, that are
not just behavioral health programs or behavioral visits.
They're,
treating behavioral health in other parts of the
continuum.
Yeah. Agree with that, Renee.
We've really been on a robust
journey with zero suicide, and caring contacts falls
under the transition arm of that.
But what it's also taught us is that
ability to have a conversation with the family
while they're with us in crisis
and saying, hey, we're gonna continue to support
you, and this is what it'll look like.
And we've added some other tools to that.
We've really created a robust lethal means counseling
program. We're not only we providing the concrete
objects like lock boxes and gun locks and
those sorts of things, but we also teach
them how to do a home sweep. We
send them home with those materials so they
know how to make their home safer for
their child to return.
We have adapted
the safety plan and are using it in
really unique ways across our entire continuum.
We do universal screening for depression and suicide
across our Children's Nebraska,
programs on units and clinics, which helps us
identify kids, who are at risk.
And just over last year, we identified
well over 100 kids who actively had a
suicidal plan that we're here for some other
reason
besides mental health care. And I think those
are the things that keep us motivated
moving forward just like these really amazing responses
we get from our patients in the caring
contact program.
Wonderful. Thank you so much for explaining that.
And, Sabrina, Renee, before I let you go,
the last thing I wanted to ask is
beyond caring context,
how is Children's Nebraska leading excellence in pediatric
behavioral health?
What's on the horizon for bringing hope to
children and families right now?
That's a great question. I love answering it.
It's such an exciting time to be part
of Children's Nebraska. In January,
we will be opening a behavioral health and
wellness center that's part of our hospital system
that provides a full continuum of care of
behavioral health services.
And this building,
as being part of our health care system
is unique in that it is also no
wrong door. So when, kids have a behavioral
health crisis, they can walk in our front
door and they can receive behavioral health urgent
care so they can meet with a therapist
and work on, you know, a crisis that
is occurring. But they can go back home
and see be with their family if they're
stable and can return back home. But we
also have crisis stabilization
that is, twenty three hours and fifty nine
minutes. Kids can come in and stay for
a while to provide more stabilization,
be able to see a psychiatric nurse practitioner,
psychiatrist,
get therapy as peer support, and be able
to receive those services that also can hopefully
stabilize,
them back to go home. But if need
be, they can also be,
admitted to an inpatient
psychiatric
unit that will help to offer that higher
level of care for for acute services.
We also will have a day treatment program
that provides mental health care,
as partial hospitalization.
And then we have our eating disorder program
that will also be expanding. It's a partial
hospitalization we have,
but we'll be expanding. So we have 10
patients that can be in that program. So
just a really large continuum of care, behavioral
health service, as well as we'll have primary
care located in our wellness center too. And
the goal is to really help, destigmatize
care, recognizing that please reach out early.
Please,
come in the door. We'll help you navigate
the system and really create that seamless transition
depending on what the child needs that families
don't have to figure out where to go.
We have excellent services right now, but it's
just gonna be so exciting to offer the
this, full continuum in January.
Wonderful. Wonderful. Thank you both so much for
those final thoughts. It's definitely been a very
informative discussion. So, again, I wanna thank you
so much for coming on Becker's Healthcare and
explaining that. And I look forward to connecting
again with you both soon.
Thank you so much. So much, Brian.