By Melinda Young
Adolescents are at risk of anxiety, depression, and suicidal ideation. In response, a health system created a program that uses case management to help them.
This is how the program works:
• Receive referrals and screen patients. Referral sources include providers, parents, and others.
“If we have a patient from a referral source where we don’t have access to notes about the patient’s presenting concerns, I can reach out to the referral source, parents, or caregivers,” says Hilary Smith, MEd, a family advocate case manager at Seattle Children’s Child Psychiatry and Behavioral Medicine.
The referral screening process includes patients’ primary concerns, diagnoses, and general background information.
• Make appointments with patients and guardians. “Once scheduled, they come in for the first appointment within a week of when they were referred,” Smith says. “There’s a provider for the patient and one for the parent or guardian. I’m closely involved and work closely with providers during the visit and after the visit.”
The model is to assign one clinician to work with adolescents and another to work with parents, says Elizabeth McCauley, PhD, ABPP, a professor in the department of psychiatry and behavioral sciences at the University of Washington.
“We work with the adolescent to understand the key factors or drivers and processes, and what are their triggers to thinking about suicide,” McCauley says. “We look at what can be done to minimize and handle those triggers.”
Provide Safety Information
Clinicians provide education about suicide, home safety, and management. “We make sure they don’t have access to a means of suicide, and that means changing the way the family lives during a crisis period,” explains McCauley, an associate director of child and adolescent psychology at UW/Seattle Children’s and an adjunct professor in pediatrics and psychology at Seattle Children’s Child Psychiatry and Behavioral Medicine. “There should be no access to firearms. We go through every means for suicide they had explored and make sure there is a safety plan.”
At the first visit, providers generally determine the patient’s needs and concerns, and then send the case manager their clinical recommendations.
“Then, I start to look for whatever is needed,” Smith says.
This could be an outpatient therapist and a medication prescriber. “Sometimes, they need support with getting their basic needs met, and we’ll have them meet with the social worker or provide other services the family needs,” Smith explains.
The case manager is the family’s main point of contact. The crisis clinic provides adolescents with a safe place to talk about their feelings and issues.
“We see ourselves as a bridge, with one session a week for four weeks,” McCauley says.
In four sessions, they learn what the patient needs. The care manager gives them a connection to more help in the community.
“If they have any questions or safety issues that are not emergent, they reach out to me, and I communicate with the family and providers to determine what needs to be done,” Smith says.
For example, Smith recalls a teen patient whose parents sought the clinic’s help because the teen told the mother about thoughts of suicide.
“The mom reached out to me to see if there was anything I could do to connect them with crisis clinic providers,” Smith explains. “I reached out to Dr. McCauley, and she scheduled a phone call with the patient, based on what the mom reported to me.”
Together, they created a safety plan and talked about the patient’s immediate triggers for suicidality. They also discussed the patient’s coping techniques that would work until the next in-person session.
• Find mental health support. “I search for whatever mental health support is needed for families,” Smith says. “I coach them on how to do the outreach once I find a provider who is accepting new patients.”
Case managers contact psychologists and therapists to determine availability. Just checking mental health providers’ online blurbs can be misleading because they may not have openings, even though their profile says they are accepting new patients.
“I get enough responses to give a family several options, and I work with the family on how to contact those programs and what to say,” Smith says.
The crisis center at Seattle Children’s provides youth and families with four weeks of care. This brief intervention needs to be followed up with continuing care in the patient’s community. That is where case management is particularly helpful.
“One thing about suicidality and youth is it’s a problem area where it’s hard to get people connected to long-term care,” McCauley explains. “People reappear in the emergency department because they haven’t addressed the problem, and it’s not an efficient way or useful way to provide care.”
Connect Families with Therapists
Even if a patient is stabilized, they are fighting the issues that led them to thoughts of suicide. These could involve family communication, self-esteem, and other things.
Families that have to try to find a therapist on their own may just give up because it is challenging to find a mental health professional who takes their insurance and has an opening. Case managers can make these connections, saving the family time and stress.
“Mostly, our care managers are really active in identifying rich resource lists of people and finding someone who is willing to deal with suicidality,” McCauley explains. “They build a resource pool and build good relationships and partnerships with providers and agencies.”
They conduct a warm handoff, giving the patient’s new therapist important information and factors they need to know and address. “We also want the care managers to remain as a resource to them if issues come up and to be a go-between with the family,” McCauley says.
“We have a lot of success with having patients go to the next step in their care immediately when they are discharged from our service,” Smith adds.
• Identify care options and recommendations. “We work with providers and families in sessions, talking about clinical recommendations of care and outpatient therapy, or other options,” Smith says.
They learn patients’ preferences for characteristics in a therapist. This could be related to gender or knowledge of LGBTQ issues.
“Finding care is extremely challenging, even for me as a person who has a lot of experience with it, and there may be fewer options for people with specific preferences,” Smith says. “Generally, we can accommodate any preference a patient has, but it can be challenging, and it can take longer to find someone.”
• Provide guidance and follow-up. Occasionally, people who have gone through the crisis center program will contact their case manager. Smith is open to staying in touch if the patients ask any questions or need help.
“I don’t provide as much intensive case management support after they’re discharged from our clinic, but I do provide them guidance on who to reach out to, how to access care, or tell them of crisis resources they might need,” Smith says.
Adolescents are at risk of anxiety, depression, and suicidal ideation. In response, a health system created a program that uses case management to help them.
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