High Risk Care Management at Mary Bridge Children’s Hospital

Jamie Kautz, MSW, LICSW | Director, Pediatric Care Continuum
Mary Bridge Children’s Hospital & Health Network

In 2018, Mary Bridge ushered in a targeted program for patients and families receiving care in our high volume sub-specialty clinics.  The High Risk Care Management (HRCM) program is based on both the University of Washington’s AIMS model and existing understanding of the impact of social determinants of health (SDoH) on pediatric chronic illness.

The AIMS model is built on the professional triad of behavioral health care manager, psychiatric consultant and primary care provider.  Mary Bridge has psychiatry resource that allows us to pilot a version of the AIMS model in our outpatient neurology clinic.  The embedded clinic social worker administers both an SDoH and behavioral health screen to new or provider-identified patients.  The psychiatric consultant conducts chart reviews on those patients and provides recommendations to the neurologist and social worker.  The screening and psychiatric consultation inform a treatment plan that includes a short- and long-term goal targeted at behaviors that support resolution of barriers to treatment, participation in activities that enhance quality of life, and patient engagement.  The social worker carries out brief interventions with both patients and parents as well as resource connection and management.  A patient registry is maintained to monitor program performance.  Patients are discharged from the HRCM program once goals have been achieved.

A modified version of the model is used in sub-specialty clinics where psychiatry support is not available.  The same screening tools are employed, absent the psychiatrist chart review, and a treatment plan is developed and deployed.  All embedded social workers use evidence-based practices such as cognitive behavioral therapy and the Incredible Years as the basis for their brief interventions.  PDCA cycles are conducted weekly to inform clinical practice and program effectiveness.

Early process analysis indicates increased engagement with patients and parents and a high degree of satisfaction among providers.  Most importantly, some of our most vulnerable kids are having great things happen for them – returning to school, making friends, visiting the zoo, and feeling just a bit stronger in the face of chronic illness.

Editor’s note: To learn more about the UW AIMs Center applications of Collaborative Care for kids, join us in Yakima on Sept. 21 at Inspiration for Integration: Bringing Behavioral Health to Pediatrics. If you are interested in learning more about integrating behavioral health into pediatric medical settings, please contact Sarah Rafton