As the Academy prepares a CLP 2023 preconference course for Advanced Practice Providers working with us in interdisciplinary teams—triggered by the Interdisciplinary Subcommittee’s workshop at last year’s Annual Meeting—we highlight how one such team evolved at the second largest US children’s hospital headed up by an ACLP member.
Nationwide Children’s Hospital (NCH), a level one pediatric trauma and burn center, is the second largest children’s hospital in the US, with 551 licensed pediatric beds. NCH is a national leader in pediatric mental health care, serving more than 41,000 unique behavioral health patients per year across the service line. Expansions in its service line over the past five years paved the way for changes to the hospital’s C-L Psychiatry service, leading to a truly interdisciplinary team able to meet the needs of both psychiatric and medical patients requiring consult services.
Here’s their story…
How our service came about
In 2020, two events significant to the development occurred near-simultaneously, and neither were related to the pandemic. The larger event: in March 2020, NCH opened the Behavioral Health Pavilion (BHP), a nine-story freestanding facility on our main hospital campus dedicated to behavioral health care that houses a psychiatric crisis department with a 10-bed extended observation suite, and at that time three (now four) inpatient units with then 34 (now 52) beds. The building dramatically increased access to care and provided a new location for our acute inpatient units. This expansion allowed for the second smaller event: the redesign of the NCH C-L Psychiatry service.
Before the BHP, Nationwide Children’s Hospital, like many other institutions, carried a high daily census of psychiatric ‘boarders.’ For nearly a decade prior to 2020, NCH C-L Psychiatry cared for these patients with a team comprising the equivalent of approximately 2-2.5 FTE of psychiatrists, 3-4 masters-level clinicians per day, and eventually a clinical psychologist with a small amount of dedicated FTE. Boarder census during peak season could exceed 35 patients per day, placing strains on the C-L Psychiatry team and other medical units. Due to those volume demands, physicians on service rarely had adequate time to fully meet the needs of consults for medically admitted patients in the hospital, even with the addition of 0.5 FTE psychiatry physician time dedicated for medical consult work.
With the opening of the BHP, we started to think more strategically about areas for growth and improvement, not only in patient care, but also the staffing structure of the C-L Psychiatry service. With the future increased availability of psychiatric beds, we anticipated our boarder census would decline, allowing more time for medically admitted patients requiring psychiatric consult. To spearhead these changes, Nadine Schwartz, MD, was appointed as the new medical director of the service.
Dr. Schwartz notes that while she envisioned many areas for change, the service would remain physician-led, with an emphasis on using physician FTEs as sparingly as possible. Dr. Schwartz recalls: “The driver for that aspect of the plan was the recognition of my own inability to be in two places at once. The previous director had most of her FTE dedicated to C-L Psychiatry. I was bringing to the role a background in pediatrics and 13 years of doing C-L Psychiatry at a prior institution, but my FTE is allocated over a wider set of departmental responsibilities.
“This is when adding an Advanced Practice Provider (APP) first came up. We had an internal PMH-APRN (psychiatric mental health advanced practice RN) candidate for our initial pilot who had completed an APRN fellowship with us and done some additional training with our C-L Psychiatry attendings. Bringing her into the team went so well, we quickly realized we should expand the role.
“Today, NCH’s Psychiatric C-L team consists of 20 team members—which sounds huge! However, not all of us are there every day. Many of our team members have additional responsibilities throughout the department and other areas of the hospital. For example, one attending dedicates 50% of her time to the palliative care department.”
On any given weekday the team is staffed by:
Weekends and holidays are generally staffed with one attending physician for the full day, one APP, and one to three clinicians.
Training of team members
Training of new C-L APP team members is progressive to allow development of skills for increasingly complex patients. C-L APP caseloads initially focus on ‘psychiatric’ patients in the early stages of onboarding, allowing newer APPs to the team time to hone C-L-specific interview skills, and acclimate to the daily workflow and team. Gradually, the APP will start seeing well-established, stable medical consults, to expand their knowledge base of common consult concerns.
Once the trainee and the attending physicians on the team feel comfortable, the APP will progress to seeing low-acuity, new medical consults; for example, a teen with increasing depression in the context of prolonged hospitalization. Throughout this process, in addition to learning via daily rounds, the APP will shadow more complex medical cases with attendings or other APPs, attend multidisciplinary care conferences, and complete supplemental readings.
Ultimately, the goal is for the APP to advance to seeing higher acuity patients for initial consults, such as those with concerns for delirium or catatonia. It’s important to note that APPs have access to an attending physician throughout the workday and complete clinical discussion prior to initiating recommendations on complex patients.
How patient care is determined
Patient assignment and workflow is straightforward for the team, even with such a large and diverse staff. Daily patient census consists of ‘psychiatric’ and medical patients, with the bulk of consults coming from patients admitted for medical care. Every day, every patient on service is assigned either to an APP (+attending), or to a fellow (+attending), or to an attending physician alone.
Youth who are admitted for psychiatric considerations are also assigned to one of our masters-level clinicians each day; but the medical patients typically do not get assigned a clinician as often they are being treated by a pediatric psychologist embedded within one of the medical services following them. NCH is fortunate to have a rich team of psychologists throughout the hospital, many specifically embedded with various medical teams/subspecialties and available to consult to any patient in the hospital.
Throughout the day, there are opportunities for care coordination, case conceptualization, and interdisciplinary collaboration. Full team rounds are held in the morning, followed by two shorter huddles at midday and later afternoon. Team members are available via Vocera, Microsoft Teams, and Epic Secure Chat.
High patient census prevents us from discussing all patients in depth with the full team at rounds; however, those with significant clinical questions, unique clinical presentations, or challenging patient/family dynamics may be discussed in greater detail as teaching cases. Additionally, each provider (APP, fellow, psychiatrist, or clinician) who met with the patient can convey their concerns or differences in conceptualization to the team, leading to improved clarity and better patient outcomes. Ultimately, final treatment decisions rest with the attending psychiatrist assigned to the patient, however, the decision relies on input from all team members involved with the patient.
Learning from our team building
Effective, cohesive teams develop over time and have a few vital characteristics. These include individuals who are motivated to be part of a team, have a willingness to collaborate with multiple medical teams, and have an openness to feedback and learning. The other piece, which may seem obvious but can be challenging, is implementing the behaviors. Dr. Schwartz believes that, ultimately, the responsibility of ensuring values of collaboration and active listening rest with her as an attending physician and medical director. “Most likely, if there is someone not listening, it’s going to be a physician not listening to a clinician,” says Dr. Schwartz. “This could be a physician trainee new to our service who doesn’t understand how our team works yet, or maybe a senior doctor who is tired that day.”
One strength of our team is the diversity of skills and background of each team member. Of our five PMH-APRNs, two are former PICU/NICU RNs and one worked for several years as an outpatient pediatric endocrinology APRN. Our psychiatry attendings have additional expertise in pediatrics, palliative care, neuroimmunology, and research. Our psychologist’s skill set enables her to provide diagnostic clarity, advanced safety planning, focused family and individual psychotherapy interventions, and she liaises with psychologists on other medical services as well as our inpatient psychiatry units to ensure continuity across the spectrum of care. The masters-level clinicians are trained in advanced de-escalation techniques and safety procedures for escalated patients and respond to Code Violets (behavioral codes) throughout the main hospital.
In whatever combination we are working on any given day, there are a variety of individual strengths on the team that contribute to improved patient care.
Developing an interdisciplinary team can feel overwhelming and time-consuming; however, the long-term benefits are worthwhile. It requires understanding and respecting the skills and knowledge your team members bring to the table, and it requires some initial and ongoing investment in employee development. We manage a large volume of patients daily with a relatively small amount of physician effort.
One concern our physicians had with bringing on APPs was that adding them would impair their ability to meet RVU requirements. This did not occur. Instead, following the addition of the APP role in June 2020, our C-L psychiatrists continued to achieve 150% of their annual RVU goals for 2020, 2021, and 2022. Our APPs have separately generated RVUs with their independently-billed but collaboratively-managed C-L patient visits. This happened because we were able to extend the functioning of our C-L service by better meeting the needs of the medically-admitted patients.
Previously, largely only the emergent and urgent medical consults were getting attention. On average, most medical consults were being seen once or twice over the entire course of their admission. Currently, we are seeing medically admitted patients 1 to >300 times over their admission, as clinically appropriate and depending on length of stay. Simultaneously, our psychiatrists have developed a greater presence in their adjacent roles within the overall service line and other areas of the hospital.
Overall, the introduction of the APP role to NCH’s Psychiatry C-L services has improved our team’s capacity to meet patients’ needs and our physicians’ capacity to be productive, not only via the C-L service but in other aspects of the department and hospital, clinically, academically, and administratively.