Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods, you can call me Rae. Rae Woods: I spend a lot of time on this podcast talking about the COVID-19 crisis, but there's another crisis looming in the background and that's behavioral health. We've talked about the impact of behavioral health among adults before, but the problem is actually a lot worse among children. These are kids who've grown up during other major crises in our nation and in our world. The added trauma of a global pandemic makes it feel like generation screwed. Rae Woods: To help us understand how big of a problem the pediatric behavioral health crisis is and what to actually do about it, I've brought a team from Seattle Children's to Radio Advisory. We've got Executive Director, Ginger Hines, Medical Director and CMO, Sheryl Morelli, and Chair of Pediatric Psychology and Behavioral Medicine, Larry Wissow. Rae Woods: Welcome to all three of you. I will say, we have never had three guests at the same time on Radio Advisory. So I am very happy that Seattle Children's gets to be the first. Quick question for the three of you before we get into the details. Have any of you ever been on a podcast before? What about you, Sheryl? Sheryl Morelli: Yeah, this is actually number two for me. Rae Woods: Wow, okay, Ginger? Ginger Hines: Also number two. Sheryl and I did one a couple weeks ago together. Rae Woods: Larry? Larry Wissow: We used to do our collaborative program with a high school run radio station in coastal Maryland, so lots. Rae Woods: Wow, okay so podcast veterans. Rae Woods: I want to start by reflecting on the past. I know that Seattle Children's has been focused on pediatric behavioral health for some time now. Give me a sense of what the state of pediatric behavioral health was before the pandemic. When did you realize this was a problem that you needed to invest in? Larry Wissow: Well, I can take a crack at that. One way of looking at it is that we knew ahead of time that it would be a problem. The kids who are junior high and high school students now are the children of the great recession from 2008. They lived through the opioid crisis, it was pretty clear from the get-go that this was going to be a really big second hit and we'd have to be ready to see a big surge in demand. Rae Woods: Yeah, let's talk about what happened when COVID-19 hit. We talked about the kind of effects of stress, isolation, just the trauma of living through a global crisis when it comes to adults. We've talked about that on the podcast before, but how has it specifically affected kids? Sheryl, let's go to you. Sheryl Morelli: Yeah, sure. Well so definitely we've seen increased rates in depression, anxiety. One that surprised me was a pretty big increase in eating disorders, and then a very significant increase in suicidal ideation, we are seeing this across all healthcare sectors. So in primary care, our emergency departments, our inpatient units, our ICUs. Rae Woods: So you're primed that this problem is going to be big, it's something that we were tracking before the pandemic. Certainly the numbers have not gotten better, but I guess my question for Ginger is, when did you decide that you wanted to make a big investment here? Were there specific metrics? Was there a specific moment that you knew, we need to put our money where our mouth is? Ginger Hines: Well, one advantage of working in a clinically integrated network and having arrangements with health plans is that we get a lot of claims data. So even before COVID, we were seeing trends in growth for children and behavioral health crises and services growing. There's obvious clinical indications and reasons to invest that Larry and Sheryl can speak to, but from a financial perspective, over several years of claims data from these contracts, we found that by in large children with behavioral health comorbidities were often upwards of three times more costly in terms of their utilization of other services. That's not dissimilar to what is found in the adult population as well. Rae Woods: Yeah, I do appreciate you bringing up cost but I'm always super wary of talking about cost in the healthcare space because it can mean different things for different organizations who are in different business models. If you have risk based arrangements, it makes sense for you to try to reduce total cost, but not every hospital, not every health system has arrangements that incentivize that sort of work. Do you have advice when it comes to the financial picture, for other leaders who might be thinking, I know I need to invest in behavioral health but honestly, it's going to be a loss leader? Ginger Hines: From a population health perspective, and Larry and Sheryl can chime in on this too. I think our goal is to put ourselves out of business. Rae Woods: Oh, really? Ginger Hines: Well, right? We don't want kids in the hospital, we don't want them seeking treatment, and it's working. So we're early in on this but our goal is to break even. Rae Woods: Yeah, okay, your goal is to break even. Larry Wissow: I mean, I think there are other incentives when you look at it also from the perspective of being in a major referral hospital. I think you've probably seen the national data that shows that the proportion of children coming to emergency rooms with mental health problems have gone way up. I mean, some of that's because the overall volume has gone down somewhat, but one of the huge drivers for us frankly, are the complaints from our colleagues in the emergency room, our complaints from our colleagues in the hospitalist services, that they don't want our mental health patients crowding out their other business. Rae Woods: So it sounds like at Seattle Children's, you've identified the problem. Things are not good and you've established a business case, and I appreciate you being a little bit more wholistic in what that business case is. Rae Woods: Let's talk about the actual investments that you made. I want to ask each of you to just say quickly, in your mind, what's the single most impactful thing that Seattle Children's has done when it comes to the pediatric behavioral health crisis? Sheryl, let's start with you. Sheryl Morelli: Gosh, Rae, that's a hard... oh, to get to one thing is difficult, but I mean, I really think our Guild Association, having the foresight to designate money to pay for behavioral health professionals to get into pediatric primary care practices has been instrumental in us starting to be able to make a dent in treating behavioral and mental health more effectively. Rae Woods: Ginger, what about you? Ginger Hines: Yeah, similar, helping to support the cost for private practice, pediatricians, to embed help in their practices and to get way upstream of the problem. Rae Woods: Larry, what would you say? Larry Wissow: I think that the biggest thing that the COVID crisis has done to help us respond has actually been to make our own department work as a system. Previously, it really hasn't. We have an inpatient unit, we have outpatient services and they almost negotiate with each other as if they're separate entities. COVID has meant that we have had to come together, we've had to really think of ourselves as a system and not as just a collection of individual activities. We've had to think about how to round it out. Larry Wissow: I think the final thing is that the thing that will ultimately be the biggest payoff I think is realizing that we've got to be truly family centered, which is a huge challenge for a child defined organization. Rae Woods: Part of me keeps thinking that gosh, doctors have so much on them right now, especially during this pandemic, and primary care is not excluded from that. I know from experience in trying to get primary care physicians to shift their workflow can sometimes be like pulling teeth. Ginger, how do you actually make it easy for those PCPs to tap into the behavioral health support that you're providing them or that you're pushing them towards? Ginger Hines: Yeah, one of the things we recognize, there's a lot of whirlwind at a primary care practice. They're busy all day, there's not a lot of time. So we come alongside with practical support for care transformation coaching. So people who've worked in primary care and they understand, and they can come alongside and support with, well, how do you actually organize and get this work done? Also, project manage that and help coach the staff along the way, and be the wind under their wings to come alongside with some real practical side by side support for them to make these changes. It's hard, it's hard to change what you're doing when you've got your clinic's busy all day from the time you open to even after you close. So we recognize, that's a key piece. Larry Wissow: But there's tremendous motivation for doing it. I mean, first of all, because such a large proportion of visits have a psychosocial or a mental health component. Secondly, because it really only takes one unanswerable doorknob question of, oh yeah, on the way out by the way, he cuts himself, to wreck your day. So the bottom line is that there's pretty good evidence that being more psycho socially oriented in the course of your primary care visit and being able to address these kinds of things efficiently in the practice actually makes you more productive, not less. Rae Woods: I don't want to say that there's a silver lining to greatest crisis moment of our time or certainly of our professional careers, but one of my bright spots has been how many institutions have named this kind of system-ness as something that really came to the surface and really grew amid the pandemic. Now the next question is, or the next step is, how do we make that last? How do we keep those deeper connections that maybe were a little fragmented prior to the pandemic. Larry Wissow: I think that one of the big transformations that I think has happened here that's also driven it is our clinics have had to change their, if you will, almost ethical approach from saying, "Well, we just take the next in line," to really thinking about how we prioritize patients and also how we recognize if you will, family. Now I'm not thinking about family from the point of view of parents and kids, I'm thinking about who's in our clinical family. How do we recognize the fact that we need to have these very close working relationships with primary care sites, with community organizations? That we can actually best serve families if we can do these kind of intimate handoffs among ourselves, that that's the highest quality level of care, rather than having a disjointed system that families have to navigate themselves. Rae Woods: I couldn't agree more with that, but you're making me think about what I hear as the biggest barrier when it comes to behavioral health, period, which is that we just don't have enough behavioral health professionals to come even close to matching demand. Frankly, we didn't have enough to match demand before the pandemic and now as you've said, the problem is a lot worse. So, how has your organization really addressed that bottleneck? Sheryl Morelli: I mean, part of it is improving the training for our primary care professionals. So we really can be part of the answer and we're not the whole answer, but we receive very little training in residency, especially those who are in my boat, more than 10 years out of training. We received almost zero training in behavioral and mental health. It was taboo in some ways and scary for us, and we just wanted to refer it to the expert or to somebody else. Sheryl Morelli: But Larry has taught me, it's not that hard and it's not that scary and actually with a couple of hours of training, we really can enhance our skill to be really effective. Rae Woods: What about the non-physician clinicians? What role do they play in helping expand some capacity? Sheryl Morelli: I think they play a tremendous role. I will say personally in my practice we have a position called a Health Navigator who, she has no clinical training at all, high school education, excellent people skills, and grew up in the community where my clinic is located, speaks more than one language. She has just been an instrumental member of our team in helping patients and families to feel comfortable in receiving care from us, in helping to coordinate care. So I think there is great potential, and as well, there's nice evidence actually, for these peer support models or community health worker models that we really can use a lot of lay people, for lack of a better word, to help support behavioral and mental health in the primary care setting and out in the community as well. Rae Woods: So in general, we've got to just expand the bench, we've got to expand the bench of people and increase our team to be able to tackle this problem. That can be nonclinical, it can be among primary care physicians, other clinicians that are a part of the team. But part of my head is going to, if we need to expand the bench, that also might mean protecting the, I'm going to guess, extremely burned out group of behavioral health clinicians that we have. If I think about the impact of this pandemic, there has been a ton of extra stress on an already stressed part of the workforce. Larry, you're a behavioral health clinician yourself. Do you have concerns about people on your team leaving the industry due to burn out, moving to a disrupter, putting their hands up and saying, "I can't do this"? Larry Wissow: The burnout comes when somebody says, "I have a 30-minute or a 50-minute session. I really want to do my evidence based mental health intervention and I have to spend half of that time trying to help people figure out where they're going to get their next meal from, or figure out how they're going to advocate for their kid to get the services they need in school which is at least a huge part of this child's problems." Larry Wissow: Going back to what Sheryl is saying, most of the mental health people that I know love their work and they actually love challenging work. That's why they went into this, but they really want to work as part of a team. They need the resources, they need that navigator, they need that person who can work alongside them who knows the community resources and can plug families into these other things. They realize that the bio psycho, social model is real but they're not being given the tools to put it into play. Rae Woods: So, Ginger then, from an administrative perspective, what's the best thing that administrators can do to give clinicians the tools they need and to give them the space they need to be able to provide that excellent care? Ginger Hines: Yeah, one thing about the model and Sheryl and Larry can speak to this as well, is that it's not a traditional, we identify a child with a behavioral or mental health condition and you immediately refer them off to a therapist whose panel gets full right away. It's like the same old care. So one of the beauties of this model is that, as Sheryl was saying, it's training more staff upstream to identify and address maybe low acuity issues. So then we save the professionals for the more acute cases. I'm not sure that we talked much about actually the model that we're implementing, maybe that would be helpful. Sheryl Morelli: Yeah, yeah, I'm happy to start. I mean, one, we really are trying to get upstream and implement universal screening for one. So in the past we were a little nervous or scared to ask some of these questions. So, what if I asked somebody if they're having thoughts about suicide and then they're going to say yes and I have nobody or no skill to help them. So I just am not going to ask. Sheryl Morelli: So now, we have a behavioral health professional on the team. So one, we're comfortable asking these questions. Two, we're creating standard processes, pathways of what you do when kids say yes to these different questions, and really linking them with services and doing whatever possible brief intervention. So a couple sessions with a patient and family when we identify a symptom that does rise to the level of a diagnosable condition, that we can train behavioral health professionals to do in primary care. But it's not the traditional, I'm going to go to the therapist and I'm going to see the therapist maybe forever, for years and years for ongoing therapy. We really are trying to identify conditions early, symptoms early, intervene early, so that we really can get upstream of this. Sheryl Morelli: Then we do have pediatric psychiatrists that are available as consultants to help us for those cases where we need it, and also to provide oversight. So that ideally, we know all of the patients that we're taking care of with behavioral and mental health conditions, we're very systematic and talking about that patient list. How is Ginger doing? Is she getting better, is she getting worse? Do we need to change what we're doing, change tactics? So it's a very different approach for us, versus the just screen and refer and just hope that they kid got connected to care. Then two years later they come back to me for the same problem and I say, "Hey, how's it going with the therapist?" They're like, "Therapist? I don't see a therapist." Rae Woods: Or, that therapist was booked for six months, I couldn't get in. Sheryl Morelli: Right, and so it's a very, very different approach that we're actually screening these patients, using registries to keep track of these patients, ensuring that they're getting connected to the appropriate care, and really monitoring them and if things aren't going well, changing course. Rae Woods: What else really makes the Seattle Children's model different from the status quo behavioral health model? Larry Wissow: Well, one thing is we layer on the social determinants of health and try to have a navigator. The part that will ultimately be the hardest nut to crack for us is also the, how are we going to pull in the help for parents as well? But one of the ways we are doing that already is also by saying that this isn't just about what goes in the clinical visit. This is making the whole practice be a healing place. A lot of this comes out of the trauma literature but the whole idea is that from the minute you pick up the phone or whatever you do to get in touch with the practice, you feel wanted, you feel understood, and you feel confident that this is a place where you're going to get help. That's another big piece of the work that Sheryl and Ginger are doing within the network. Sheryl Morelli: Well, and I would just add on real briefly to that, Rae too, that Larry and colleagues had encouraged us to have family advocates as members of our integrated behavioral and mental health teams at every practice. So there is at least one parent who's actually on our behavioral health team as well, helping us to make decisions about what types of interventions do you need, where are you struggling, what kind of help? That has just been instrumental and really I'll have to say, revolutionary in how we're approaching things too. I don't know why we didn't think to do it before but to have the parents here at the table telling us what they need. Rae Woods: Yeah, and that's really important and I think different, from the adult versus pediatric world because the child might be the patient but they're not necessarily the consumer of care. They're certainly not the decision maker of the care. Larry, you mentioned that some of these problems are going to manifest not just in the child but in the home, in the family. So, how do you actually take a multi generational approach to these kinds behavioral health challenges, especially as a children's institution? Larry Wissow: I think the big thing that you do is you listen to parents and you partner with them and you in your interactions, address their needs. We know that people have brought their child but the child lives in the family and we've got to connect with and empathize with the parent right from the get-go. Rae Woods: But practically, how do you do that? Because I'm thinking, Seattle Children's to my knowledge doesn't provide adult care. So, if a even red flag happens, I mean, what's the next step? Larry Wissow: Fortunately, CMMS has made it fairly clear that there's wiggle room in the billing and how we define visits to say that things that we do for parents on behalf of their child's ultimate benefit are fair game. So we encourage people to spend time with parents and to listen to their concerns. It's true, we can't directly provide psychotherapy for them, but the fact of the matter is we are. Larry Wissow: One of the things that we are exploring though, is how we can coach parents to use self-help tools that are available online that we know are effective. We all know are more effective if you're coached in using them. Rae Woods: Yeah, and you just brought up some of the digital self-help tools which is something that I'm seeing grow dramatically across the course of this pandemic, in part because the demand for behavioral and mental health has been so high. I'm talking about everyone here, not just kids but certainly of adults. That's something that I hear a lot of people saying this technology is going to be the solution to that bottleneck problem we talked about earlier. Yes, we need to expand training, yes, we need to make the most out of the bench that we have and protect the bench that we have, but technology is really our way to boost efficiency. Has any of that happened at Seattle Children's when it comes to treating kids? Larry Wissow: Certainly the COVID made us move to almost... we're still at almost 100% virtual visits at this point, which is clearly not benefiting some people who really do need in-person care, so some stuff is going on in person, but the ability to see people regularly from a distance to bring different family members together who aren't in the same place, that part has been effective and advance. Larry Wissow: I think the issue with the digital stuff is that there's really strong evidence that it has some baseline level of effectiveness but it's effectiveness goes up linearly, at least linearly, maybe more so with the amount of time that you spend coaching people on and supporting them in how to use it. It's a tool, it's homework, it's something that allows you to have a very efficient interaction with somebody that then allows them to access material in a way that's easy for them, but it's not a complete substitute for the human interaction that seems to be important to healing. Rae Woods: Absolutely, absolutely. We've been talking throughout this conversation about this behavioral health challenge as being something that is really in the forefront, something that got much worse throughout this pandemic, but I have to believe that maybe living through this crisis has actually helped us make some progress towards our behavioral health goals. Is there anything that COVID-19 has helped us with, in terms of making progress here? Sheryl Morelli: Yeah, I think it really has worked to elevate this in that everybody knows now. So even our own governor in the past couple weeks declared a mental health state of emergency for our pediatric population in the state. That has never happened before and it's been an emergency for a very long time. More teens die from suicide in our state than any other combination of conditions. That wasn't enough for this to be a crisis but it is now, so I think it has done that for us so it's at the forefront. Then money has followed behind that. Sheryl Morelli: The other thing I think it is, it's made it okay to talk about it for many people. Rae Woods: Reduce the stigma, yeah. Sheryl Morelli: Absolutely, so everybody's talking about it. I mean, you can't turn on the news on any given day, there's somebody talking about the impact to our behavioral and mental health because of COVID, and that's never been the case where we've really talked that openly at that level before. Rae Woods: Well, I've got two questions left before we wrap up this interview. Before I ask you to give some advice to the healthcare leaders who are listening to this podcast, I actually want to give, especially the physicians on the line, a moment to actually give some advice to parents. This has got to be a very scary moment for moms and dads out there who don't know how to help their kids who are really suffering. Larry, what advice do you have for parents? Larry Wissow: Well, it may seem trite but I think the advice that comes out of every disaster since people have thought about this, it can be probably be summed up at least for people who have now flown within recent memory as put your own oxygen mask on first. We know that kids do best when the grownups around them can make sense of what's going on and can give them a sense of security and a sense that things are going to be okay or at least we're all in this together. So I think the first thing is for parents to do what they can do to try to be as good as they can be themselves and to do have the kinds of routines and safe home base that they've always had reestablished as quickly as they can. Larry Wissow: I've got one more, if you want? Rae Woods: Go for it. Larry Wissow: Which is again in some ways age old advice and comes a little bit from the great child analyst, Winnicott, but it... which is just the whole idea that this is a time for just being good enough. That to really say to your kids, especially around school and education, that this is going to be the year that everybody's going to write off. What seems urgent now in the course of a long life is going to be a blip and we don't even know, as you say, what good things will come out of it. So take a deep breath, don't sweat the small stuff. The fact that you're here, you're in the game, that's quite good enough right now. Rae Woods: Yeah, well, Sheryl, Ginger, Larry, I want to thank you so much for coming on Radio Advisory. I've got one question to leave you all with, it's the question I ask at the end of every episode. When it comes to pediatric behavioral health, what's the one thing that you want our listeners to take away or act on? Ginger, let's start with you. Ginger Hines: Yeah, I guess mine would just be encouragement to get creative to solve the problem, and ask other people in the community to come together to do this with you, whether it's your health plan, your MCO, people who are paying for this and seeing the trends along with you. Just encouragement to come to the table and try to figure this out as a society will reap benefits, for health systems and providers we will, and definitely for kids. Rae Woods: Yeah. Sheryl, how about you? Sheryl Morelli: Yeah, I think what I would love to see is that we invest in kids and families. That we're not an afterthought, that we really... we have such a unique opportunity in pediatrics, which is why I love being a pediatrician, to change the course of life, the trajectory for our patients and families. It just is incredible, so invest in primary prevention programs in your communities. I agree complete with Ginger, partnering with people in the community to make that happen. We just have such a unique ability in pediatrics to really the change the course or the path for our patients and families that you don't have with adult populations. Rae Woods: Yeah, Larry, what about you? Larry Wissow: Well if I'm talking to healthcare leaders, I would say that whether you do it in collaboration with others as Ginger has said, or you do it yourself, the operative thing here is that doing more is actually better than doing less. In other words, trying to just hold up one tiny little piece of the system is going to lead you to some of the things that Sheryl and Ginger were talking about, just people getting overwhelmed, people getting frustrated. That the more you're part of a continuum of care, whether you're providing that yourself or you're doing it in partnership. The more that it's really wholistic mental health care, the better it's going to go, the happier your workforce is going to be, and the better you're going to serve people. Rae Woods: I could not agree more. Thanks all, for coming on Radio Advisory. Sheryl Morelli: Thank you, Rae. Ginger Hines: Thanks, Rae. Rae Woods: We'll be right back with more from our Behavioral Health Expert, Clare Wirth. Rae Woods: Clare, what did you think of our conversation with Seattle Children's? Clare Wirth: Well, I really enjoyed hearing all the different perspectives, particularly Larry, given his long professional career in the behavioral health space and how it's evolved today. Rae Woods: Yeah, what was the most important thing that you learned about Seattle Children's model that you want other people to adopt as well? Clare Wirth: I think what struck me in particular is that they haven't just thought of this in terms of integrating behavioral health, they've thought of this from a very wholistic perspective. So they are thinking about embedding the patient navigator, they are including someone akin to a community health worker, in terms of that model who knows the community, can build that trust, and help with the psychosocial needs that go beyond just the behavioral health diagnoses. Rae Woods: Yeah, I was so impressed by that too. It sounds like they've really built the infrastructure to make that happen. Ginger and Sheryl were very specific about training and who the different people on the team are, and taking a team based approach in general to it. It's like they didn't just set their goal post at wholistic care, they really figured out a way to operationalize it. Clare Wirth: On that note of training, our health plan colleagues just did a survey of primary care physicians and they asked that question, if we provide more screening, do you feel more comfortable with addressing behavioral health needs? There's a direct correlation from our data. The more training you receive, the more comfortable you are. So that bears out in our data too. Rae Woods: Oh wow, interesting. Was there anything that you were really surprised by that they either talked about or maybe didn't talk about when it comes to their strategy? Clare Wirth: So maybe this is me just reading headlines, but I am curious about the amount of screen time these kids are getting. So the solution is oftentimes we have to provide tele mental health services, but that's just more screen time. These kids are in school eight to nine hours a day oftentimes, virtually. Rae Woods: They're probably interacting with friends virtually, they're playing games virtually. Then if they're also receiving essential healthcare services virtually, what does that mean? I mean, I also appreciated Larry's realistic, don't let the perfect be the enemy of the good, especially this year. It's probably all going to be okay. So maybe that's the case too for screen time. I mean, I would like to believe that kids don't want to be going to virtual school forever or having virtual play dates forever. So maybe this is one of those things that'll all work itself out in the end. Clare Wirth: I think that theme of, something is better than nothing, was resonant throughout the conversation. We need to be screening as early as possible, providing even just a brief intervention, even if they don't have an actual diagnosis, is better than nothing. Letting this ruminate over time and suddenly there's a crisis. Rae Woods: I am cognizant of the fact that we spoke to a children's hospital and an integrated health network that focuses on kids, that focuses on pediatrics. Based on what you heard, is there anything that you would absolutely recommend that any provider adopt beyond just in the pediatric space? Clare Wirth: I think that there is sentiment around becoming more of a system and thinking more cross continuum when it comes to behavioral health, is essential for any organization right now. I think that historically in our research, we've had executives say, "We have a lot of behavioral health patients in the ED. What do we do?" So it's a lot of times focused on embedding tele psychiatry in the emergency department or even a behavioral health professional or standing up a clinic dedicated to that, but we're not getting earlier upstream, as well as integrating it into different specialties and screening folks there. Clare Wirth: So I was really impressed to hear that they were thinking of that cross continuum approach and hope that they keep focusing on the systemness perspective. Rae Woods: That's our best way to prevent the problem from getting worse. Clare Wirth: Absolutely. Rae Woods: Not just keep addressing the problem when it literally knocks on our door. I don't want to pretend that we or even Seattle Children's has all the answers here. So for you as a researcher, what in your mind are the big unanswered questions when it comes to behavioral health? Clare Wirth: Oh gosh, there are just so many. I think that my big question right now is, where do we go from here? So what does patient demand look like in the near term and the long term? So in the near term we have, how are these behavioral health needs going to manifest? It's why employers are more interested in behavioral health than they ever have before. Then long term, we know young people are reporting the highest rates of behavioral health needs amid COVID. So what does that do with our demographic's shift longer term? So just from a patient demand perspective, I'm really curious. Rae Woods: Oh, interesting, yeah. Clare Wirth: The other one that's interesting to me is the stigma piece. You started to get at that in the conversation. In some ways we've become more aware of behavioral health than we ever have before. It has breached the national consciousness in a real way and my hope is that it instigates more change at the legislative level but of course, we've had very slow progress when it comes to behavioral health for our entire history of our country. Rae Woods: Yeah, but that has been a huge silver lining that I've seen. I mean, Clare, we have conversations at work about this, and I cannot remember ever doing that before. Rae Woods: I wonder if there are any red flags that you want other organizations to avoid? Clare Wirth: So something that Sheryl said is a comment I've heard from a lot organizations, of let's screen, refer, and then hope that that patient receives that type of care. Rae Woods: I know. Clare Wirth: I think that's resonant of the hot potato that is behavioral healthcare in the United States so often. It is, oh, we figured this out, we got to pass it to somebody else, maybe a community based organization can handle it. Patient ends up into the ED, it just becomes this hot potato effect. Clare Wirth: So if there's one lesson or push I would really stress for executives right now, came from a conversation I had earlier this week with somebody who's focused on behavioral health and her point was, we have to transition from hot potato behavioral health to fully integrated care across the care continuum. Rae Woods: Is that the one thing you want our listeners to take away from this conversation? Clare Wirth: Absolutely, it is about thinking about filling gaps across the care continuum. Behavioral health cannot be siloed any longer. These needs are so prevalent and so it's about standing up those services across the care continuum and building blinks across it to match patients' needs as they move up and down the continuum themselves. Rae Woods: Well, thanks for coming back on Radio Advisory. Clare Wirth: Thanks for having me, Rae. Rae Woods: At the beginning of the pandemic, Clare came on to talk about the behavioral healthcare crisis among adults. A year into this pandemic, there is no way to sugarcoat the fact that the challenges are great and in many ways getting worse. But there's also reasons for some cautious optimism, and organizations like Seattle Children's are at the forefront of what gives us hope. If you're looking for more on this, we've added some resources to our show notes because as always, remember, we are here to help.