It was around 2 a.m. when Carmen realized her 12-year-old daughter was in danger and needed help.<\/p>\n

Haley wasn\u2019t in her room \u2014 or anywhere else in the house. Carmen tracked Haley\u2019s phone to a main street in their central Massachusetts community.<\/p>\n

\u201cShe don\u2019t know the danger that she was taking out there,\u201d said Carmen, her voice choked with tears. \u201cWalking in the middle of the night, anything can happen.\u201d<\/p>\n

Carmen picked up Haley, unharmed. But in those early morning hours, she learned about more potentially dangerous behavior \u2014 provocative photos her daughter had sent and plans to meet up with a boy in high school. She also remembered the time a few years back when Haley was bullied and said she wanted to die. Carmen asked KHN to withhold the family\u2019s last name to protect Haley\u2019s identity.<\/p>\n

Carmen drove her daughter to a local hospital \u2014 the only place she knew to look for help in an emergency \u2014 where Haley ended up on a gurney, in a hallway, with other young people who\u2019d also come with an urgent mental health problem. Haley spent the next three days like that. It was painful for her mother, who had to go home at times to care for Haley\u2019s siblings.<\/p>\n

\u201cLeaving [her] in there for days, seeing all those kids, it was terrifying for me,\u201d Carmen said.<\/p>\n

That week last October, Haley was one of 115 children and teenagers<\/a> who went to a Massachusetts hospital ER in a mental health crisis, waiting days or even weeks for an opening in an adolescent psychiatric unit. The problem, known as \u201cboarding,\u201d has been on the rise<\/a> across the country for more than a decade. And some hospitals have reported record numbers during the covid-19 pandemic.<\/p>\n

\u201cWe see more and more mental health patients, unfortunately, languishing in emergency departments,\u201d said Dr. Chris Kang<\/a>, president of the American College of Emergency Physicians. \u201cI\u2019ve heard stories of not just weeks but months.\u201d<\/p>\n

But now a handful of states<\/a> and counties<\/a> are testing ways to provide urgent mental care outside the ER and reduce this strain on hospitals. Massachusetts has contracted with four agencies to provide intensive counseling at home through a program called emergency department diversion<\/a>. It\u2019s an approach that could be a model for other states grappling with boarding. For Haley, so far, it\u2019s a game changer.<\/p>\n

To determine what\u2019s best for each child, hospitals start with a psychological evaluation, like the one Haley had on her second day in the ER.<\/p>\n

\u201cI didn\u2019t know if they were just going to send me home or put me in a really weird place,\u201d she said. \u201cIt was, like, really nerve-wracking.\u201d<\/p>\n

DeAnna Pedro, a liaison between pediatrics and psychiatry at UMass Memorial Medical Center, reviewed Haley\u2019s report and considered recommending time in a psychiatric unit.<\/p>\n

\u201cShe was doing a lot of high-risk things,\u201d Pedro said. \u201cSo there was a lot of thought given to: Would we need to go to something extreme like a psychiatric admission?\u201d<\/p>\n

During an at-home counseling session, Carmen became momentarily frustrated when talking about
\ndaughter Haley\u2019s behavior.(Jesse Costa \/ WBUR)<\/span><\/figcaption><\/figure>\n
But both Pedro and Haley\u2019s parents worried about this option. It would be a dramatic change for a 12-year-old whose only experience with mental health care was with her school counselor. So instead Pedro contacted Youth Villages, a youth diversion agency Massachusetts hired during the pandemic. Haley\u2019s family met with a supervisor right there in the ER.<\/p>\n
Later, during the first home visit, there was a safety sweep.<\/p>\n
\u201cWe look under rugs, we look behind picture frames, we look in the dirt of plants,\u201d said Laura Polizoti, the counselor from Youth Villages assigned to Haley\u2019s case. Youth Villages also provided window and door alarms that Haley\u2019s parents could activate at night.<\/p>\n
Counseling for Haley and her parents started right away. A key goal was to understand why Haley was sneaking out at night and taking inappropriately sexual pictures.<\/p>\n
During a counseling session one afternoon in December, Polizoti focused on Haley\u2019s anger at herself and her mom.<\/p>\n
\u201cHave you ever done an emotional thermometer before?\u201d Polizoti asked, laying a large graphic of a thermometer on the table. It had blank lines for five emotions, from cool to hot.<\/p>\n
\u201cIt can help you see where your feelings are at,\u201d Polizoti explained. \u201cThen we\u2019ll come up with coping skills for each level.\u201d<\/p>\n
In the blank next to the bottom of the thermometer, Haley wrote \u201cchill.\u201d At the top, in the red zone, she wrote \u201cinfuriated.\u201d<\/p>\n
\u201cInfuriated \u2014 that\u2019s a good word,\u201d Polizoti said. \u201cSo when you\u2019re infuriated, how do you think you feel physically? What do you notice?\u201d<\/p>\n
\n
\n
\n
\n\t\t\t\t\t $\"One$
\n\t\t\t\t\t\t\tThe \u201cEmotional Thermometer\u201d worksheet used by Youth Villages counselors when working with patients.\t\t\t\t\t\t(Youth Villages)<\/span><\/figcaption><\/figure>\n<\/p><\/div>\n
\n
\n\t\t\t\t\t $\"One$
\n\t\t\t\t\t\t\tThe \u201cCognitive Triangle\u201d worksheet used by Youth Villages counselors when working with patients. \t\t\t\t\t\t(Youth Villages)<\/span><\/figcaption><\/figure>\n<\/p><\/div>\n<\/p><\/div>\n<\/div>\n
Haley told Polizoti her palms get sweaty, she stops talking, and she makes \u201ca weird face.\u201d Haley scrunched up her nose and frowned to demonstrate. Polizoti laughed.<\/p>\n
As the exercise unfolded, Polizoti asked Haley to think of ways to calm herself before irritation turns to anger. Haley suggested spending time alone, watching TV, playing with her siblings, or jumping on the family\u2019s trampoline.<\/p>\n
\u201cThat\u2019s a good one, the trampoline,\u201d said Polizoti. \u201cCan we come up with one more?<\/p>\n
\u201cI could, like, talk with my mom?\u201d Haley said.<\/p>\n
\u201cAwesome,\u201d said Polizoti.<\/p>\n
Initial numbers suggest this diversion program is working. The Massachusetts Department of Mental Health said that as of early February 536 young people, ages 4 to 18, had worked with one of the four agencies. A large majority, 82%, have not returned to an emergency room with a mental health concern; 92% have met their treatment goals, or were referred for additional treatment once stabilized by the initial diversion service.<\/p>\n
Advocates for parents of children with mental health issues said the main complaint they hear is that hospitals don\u2019t present the home care program option quickly enough, and that when they do, there is often a wait.<\/p>\n
\u201cWe would love to have more opportunities to get these diversions with more families,\u201d said Meri Viano, associate director at the Parent\/Professional Advocacy League<\/a>. \u201cWe\u2019ve seen in the data and heard from families that this has been a great program to get children in that next place to heal faster.\u201d<\/p>\n
And then there\u2019s the relatively affordable cost: $8,522, on average, for the typical course of care. At Youth Villages, that pays for three 45- to 60-minute counseling sessions a week, in a patient\u2019s home or other community setting, for three months. The savings are significant. One study calculated the cost<\/a> of pediatric boarding at $219 an hour, or $5,256 for just one day. And that\u2019s before the expense of a psychiatric hospital stay.<\/p>\n
In Massachusetts, the diversion program seems to be relieving overburdened hospitals and staff. A report<\/a> from the Massachusetts Health & Hospital Association shows youth ER boarding numbers dropped as more hospitals started referring families to home-based options. MHA said the numbers are hopeful.<\/p>\n
Kang, with the American College of Emergency Physicians, is optimistic about mental health organizations like Youth Villages offering urgent care outside of hospitals, but said starting diversion programs isn\u2019t easy. If state and local governments don\u2019t take the lead, hospitals need to vet community mental health partners, create care agreements, and figure out how to pay for home-based services. All this while hospitals are overwhelmed by staffing shortages.<\/p>\n
Making these kinds of systemic changes may require \u201cgetting past some inertia as well as some reluctance to say, \u2018Is this really what we need to do?’\u201d said Kang.<\/p>\n
Some families hesitate to try diversion if their child takes psychiatric medications or they think the child should be prescribed those medicines. Youth Villages does not have prescribers on staff. Children who need medication see a psychiatrist or primary care doctor outside the program.<\/p>\n
It\u2019s not clear what percentage of children and teens who go to a hospital ER for mental care can be treated at home rather than in a psychiatric unit \u2014 home isn\u2019t always a safe place for a patient. But in other cases, home care is the best option, said Matthew Stone<\/a>, Youth Villages\u2019 executive director in Massachusetts and New Hampshire.<\/p>\n
\u201cMany of the mental health challenges that these children are facing are driven by factors in their natural environment: their school, their neighborhood, their peer system,\u201d said Stone. \u201cIt\u2019s our view that you really can\u2019t work on addressing those factors with a child in a placement.\u201d<\/p>\n
Clinicians in psychiatric units do work on family and social issues, sometimes bringing family members into the hospital for sessions. There\u2019s no data yet to compare the outcomes.<\/p>\n
Some mental health advocates argue that the need for diversion will subside as Massachusetts launches a multiyear plan<\/a> to improve mental health care. But for the time being, Carmen and other parents coping with a new mental health crisis will likely still head to an ER, where they may be offered intensive counseling at home.<\/p>\n
\u201cA lot of parents don\u2019t know what the kids are going through because they don\u2019t want to accept that your kids really need help,\u201d Carmen said. \u201cHopefully this can help another family.\u201d<\/p>\n
*This article is from a partnership that includes <\/em>*WBUR<\/em><\/a>*, <\/em>*NPR<\/em><\/a>*, and <\/em>*KHN<\/em><\/a>*.<\/em><\/p>\n*
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\n\t\t\t\t\t\t\t\t\t\t\tMartha Bebinger, WBUR: <\/span>
\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t marthab@wbur.org<\/a>,\t\t\t\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t@mbebinger<\/a>\n\t\t\t\t\t\t\t\t\t<\/p>\n<\/aside>\n
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