Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Allison Williams: Hi, welcome to That's Pediatrics. We are your company-hosts, I'm Alli Williams, a Pediatric Hospitalist here at UPMC Children's Hospital of Pittsburgh.
Dr. Sameer Agnihotri: And I'm Sameer Agnihotri I'm an assistant professor in the Department of Neurological Surgery at Children's Hospital.
Dr. Williams: And we are so excited to be joined today by Dr. John aka Jack Rozel. He is the medical director for the resolve Crisis Services. Thank you so much for joining us today.
Dr. Jack Rozel: Thank you so much for having me.
Dr. Williams: Can you tell us a little bit about first and foremost about yourself? How did you end up coming to Pittsburgh? And how did you get involved in this work?
Dr. Rozel: Got it. So I did my undergrad and med school in Rhode Island at Brown University. And one of my big mentors had done his own residency training at Western Psych. And so as I started to look for training opportunities he said, You got to take a look at Pittsburgh. And I was really impressed by it. And I matched here. And from 99 to 05, I did my general child and forensics training here including six months of peds back at the old children's in Oakland, and left for about five years after training. And then in 2010, my old boss, Ken Nash, who's the director over Western Psych, invited me to come back and I've been back at Resolve ever since.
Dr. Williams: Sounds very similar to my story too, one of the ones where you get drawn into Pittsburgh, and you might try to escape but you never quite leave, right? Tell us a little bit about more about the resolve Crisis Services.
Dr. Rozel: Got it. So resolve Crisis Services was created back in 2008. And at the time it was created, the greater Pittsburgh region didn't really have a consolidated point of access for crisis services. There were a couple of different crisis lines, there were more than a dozen different mobile crisis providers, there weren't consistent walk-in or residential programs. And a few things came together around the same time.
One was that there were some reinvestment dollars from the financial downturn that were able to provide some startup cost coverage. There were some changes in state funding around some of the state hospitals, where there was pressure or I should say the opportunity to keep some of those state dollars in the Allegheny County region as Mayview State Hospital was closing down to help start certain highlighted programs, including crisis services.
And frankly, there were some bad clinical outcomes in the community that people wanted to have a better solution to going forward. And there was this sort of perfect storm coming together that said ah, there's this big opportunity, and Allegheny County Human Services, and Community Care Behavioral Health, which is a managed care carve out company, came together, put out the RFP, and a lot of different organizations sort of put their name in the hat and put a proposal for it.
And UPMC and Western Psychiatric Institute and Clinic got the contract because they did something that I think was really important, instead of just walking in and saying, Oh, we're just going to offer this to you're gonna love it. They spent a lot of time doing leg work, doing interviews and focus groups with people living with mental illness and substance use with their loved ones and family members, with first responders, outpatient mental health professionals, primary care professionals, law enforcement, you name it, and sort of said, what do you need in crisis services?
And one of the folks was involved in that design process, said that the community designed resolve and Western Psych built it. And I think that really sort of captures the zeitgeist of what we tried to do out there.
Dr. Agnihotri: Great. So Jack, can you tell us a bit more about what CACTIS is? What the acronym is and for our listeners, the importance of it?
Dr. Rozel: Yeah. So when resolve was created, the idea was to consolidate crisis services for the county, and we do phones, mobile crisis, walk-in, residential, we do it 24/7, 365. We do it without any charge to the individual. There's no copay, there's no back billing, there's no network stuff.
At the time we were created, there was only one program of all the crisis programs that were out there that sort of imported into resolve whole cloth, and that was CACTIS. Or the Child and Adolescent Crisis Treatment Intervention Service. And that program has actually been around since the mid 90s.
And it was another program created at the request of the county to provide consolidated child and adolescent crisis mental health services, including at the time, a little bit of coverage out at Schumann's Juvenile Detention Center. But when resolve was created, we imported that whole cloth. And conveniently enough back in the later years of my residency and fellowship I had been the acting medical director for the CACTIS program, so it was a little bit of coming back home to some old friends with that. And we continue to operate that through our services, primarily through a little bit of phone support and an awful lot of mobile crisis support.
Dr. Williams: And how would you recommend for our providers here, letting community members know about this program or determining who might benefit from this program?
Dr. Rozel: Got it. So when we think about CACTIS, CACTIS is specifically for children and adolescents, really if they're up to the age of 21 and still in those sort of developmentally appropriate child and adolescent types of services, we can work with them who are already engaged or enrolled in some kind of mental health service or mental health program or about to be linked in, right?
So these are the folks that we've identified that they might have higher utilization of crisis services. And what we're able to do is we proactively enroll them, we meet with the family, or the legal guardians, get some of that paperwork taken care of, so we have releases in place. And that allows us instead of waiting for the crisis to pop, it allows us to go out and have a proactive meeting at home, maybe go to a school meeting, do a little advanced planning.
Now, by the way, and I want to be really clear about this. Any family in Allegheny County at any time who needs help, can call and they can call 24/7, 365: 888-796-8226. And we can provide phone support, we can have teams coming out, we can even have support folks who are 14 and older in our crisis residential program for a couple of days, if they need help.
And one of the really nice things about what we get to do, now CACTIS, usually these folks already engaged in some way in the mental health system, but overall for resolve, we're not attached to a diagnosis as a prerequisite to engaging in services. You can have a bad day, you can have a rough interaction at school, you can be upset because you or your family's going through some kind of crisis. And we can come and we can chat, and we can figure out what the next steps might be.
Dr. Williams: I'm so glad you brought that up and describe that a little bit better for me, because one of the questions that I had listening to you is what kind of crisis do you see? Do you do you help with?
Dr. Rozel: Yeah, so we always ask about this in the emergency mental health crisis field about how do we define what's an emergency and what's the crisis? And I guess there might be a family out there, where the parents are like healthcare economists, where they care about that too. But ultimately, if your kids having a rough day, if you're scared about your kids well being or they're scared about their own well being, they don't care about medical necessity criteria, they want help, and they want someone to show up who's compassionate, who's understanding, who's going to be able to help them out. And so our crisis program, like a lot of the sort of new wave of crisis programs across the country, we're by and large adiagnostic, right? We help with whatever that person needs help with today.
Dr. Agnihotri: Right. And the other question is, the last two years, we've been in a pandemic. So one is, how has COVID-19 affected your program? And if you could also touch upon how COVID-19 has affected you?
Dr. Rozel: Yeah. So when COVID first rolled out, one of the things we do is we send mobile crisis teams out, we do 30 to 40 times a day, we're sending folks out into the community. Sometimes we'll meet someone at a primary care office, sometimes we might show up at Children's to support a family who's, the kids in the bed, and the CL (Child Life) team can help with that kid who's registered to the bed, and certainly the social work and chaplain team are incredible.
But when the parents are in crisis, that might be a mobile crisis response. But mostly, we're going into people's houses. And obviously a lot of concerns about exposing our staff to stuff and a lot of concerns about exposing the families and the kids who are in crisis to contagion as well. So we actually tried making a pivot to try doing video support, and discovered what is, in hindsight, painfully obvious, which is that when you're in crisis, when your loved one is in crisis, figuring out a new damn app on your phone doesn't really help resolve the crisis.
So we tried it, we had a couple people take a nibble at it, but by and large, people really want someone to come out and work with them. And we can do amazing things over the phone as well. But a lot of folks really want that personal presence. And so that's what we've continued to do throughout COVID. We've had a couple bumps here and there where we've had exposures but within the workplace and have had to block off access to our walk-in program to some degree or another. We've weathered through it and like most other employees, or employers, I should say, we are struggling with workforce issues. But we continue to provide all of our services. So.
Dr. Williams: Have you seen a change in the call volume over the past couple years?
Dr. Rozel: So it went down a little bit at first, right? And when you think of, you hear about like the tsunami is coming, right, the first thing that happens is the water goes out. And the folks who know to look for see and say, uh oh, something's coming. And the water went out, the water went out pretty far, and actually volumes dipped in the first couple of months. For a couple of different reasons, and it's certainly come back. And it's come back in a lot of different ways.
But one of the things is, the ability to say, I'm in crisis actually requires a little bit of attraction, right? People don't necessarily think I'm in crisis, they think I'm hungry, I'm cold. My kids school situation is a disaster, either we're doing cyber school with no technology or bandwidth, or the kid's back in school and is anxious, is being bullied what have you.
So to be able to put that into a larger bucket that is crisis takes a little bit of abstract reasoning. But, we work really hard to get the word out through any channel we can such as, hey, podcasts, to let folks know that we're available. And, again, we're anchored to the idea that if someone needs help, we want to help, and lead them to the right types of resources.
Dr. Agnihotri: Great, and then towards that, in the future, let's say you had unlimited resources, what would be on your wish list to grow this program, getting awareness out? Blank check.
Dr. Rozel: This is an amazing time to be in crisis and emergency health. Crisis services over the next five to 10 years are going to be profoundly transformed for a couple of different reasons. First of all we've had two years of a global, syndemic poly disaster that has had a huge impact on healthcare in general. And I think, in general, healthcare is going to be transforming quite a bit. But for crisis, specifically, we've got a couple big things happening. One is 9-8-8. Have you guys heard about 9-8-8?
Dr. Williams: Not at all.
Dr. Agnihotri: Not at all.
Dr. Rozel: All right, so, all right we're in a hospital, so it's sort of an abstract, it doesn't work quite the same way. Let's say we're out at a bar or we're in your backyard, and I go over with a heart attack, or it's obvious I'm having a stroke, what number do you call?
Dr. Williams: 9-1-1.
Dr. Rozel: All right, let's say and talk about being suicidal. What number do you call?
Dr. Williams: 9-8-8?
Dr. Rozel: Ah, you win the prize. I am super impressed, right?
So the National Suicide Prevention Lifeline, which has been around for like 20 years, and when you turn on the TV, and there's a story of some tragic event, maybe a celebrity dies of suicide, or something like that, across the bottom on the screen, they sort of throw that chyron on there, and maybe if we're lucky, the media spokespeople will say something like, if you are someone who care about us thinking about suicide, then the National Suicide Prevention Lifeline is available 1-800-273-TALK, right?
But here's the thing, if I walk into a room of psychiatrists, and say, hey, what's the number for the National Suicide Prevention Lifeline? Like the group that should know, a lot of us are going to scratch our heads. So over the past couple years with lots of Washington DC stuff happening, effective July, I want to say July 17, so 140 some odd days from now, every phone number in the country will be mapped so that if you punch in 9-8-8, it will route to the National Suicide Prevention Lifeline.
Now, the National Suicide Prevention Lifeline is a network of 200 or so network partners. resolve is one of them, we cover Allegheny County, and we handle the calls for the National Suicide Prevention Lifeline. So this is going to be sort of a big game changer.
Rough estimates, volumes are going to go up somewhere between 300 to 1,000% over the next couple years. So we're getting ready for that.
At the same time, for the first time ever, SAMSA (Substance Abuse and Mental Health Services Administration) is requiring and providing every state with funding specifically for crisis services. We've had an expansion and re-visioning of what crisis is, which by the way, it looks a lot like what we do at resolve, and in fact early in SAMSA's design process for what crisis services need to look like, I had the privilege of being able to share some of the awesome things that we get to do at resolve. And the model that they talked about is the model that we've been doing since 2008, which is somebody to talk to, somebody to come to you, someplace to go. So our phone and soon, very soon text messaging services, mobile crisis services, and then are walk-in and residential programming.
Dr. Williams: So that 9-8-8 number is coming and sounds, not that I want to say we need a number for this, and that sounds amazing, but the resource itself sounds so important. You had mentioned text messaging too, I know as a hospitalist here, we've seen an increase in the number of teens that are experiencing crisis, suicidal ideation. And a lot of them don't like using the phone.
Dr. Rozel: Yeah. Yeah, right. Different people have different channels and modes of communication that they prefer. And certainly, as folks get younger, they seem to really like that text messaging option.
In fact, one of the things that we're really excited about is that resolve already and in partnership with Allegheny County's Human Services Department is working towards making our own phone number available for texting. We're in sort of the final stages of that, we're going through some interesting processes with the ISD to get everything set up just so. But we're hoping that that's going to be rolling out in the next couple of months.
And then of course, we're already providing some of those same services for the National Suicide Prevention Lifeline, where people can text into the 1-800-273-TALK line. And that currently gets routed nationally, we're in a large planning process to make sure it stays local. But there's a lot of technical stuff within that immediately rollout that, frankly, a lot of it is not stuff I was prepared for in my residency training. So.
Dr. Agnihotri: And Jack, you're definitely a giant thought leader in this field and well respected in your work in the National Council for Behavioral Health has been well noted in 2019. And still ongoing now. Could you describe some of that work and how rewarding it is and the impact that you've made?
Dr. Rozel: Yeah, so the project I was involved in for the National Council for Behavioral Health, which has since rebranded to National Council for Mental Wellness, and they've had a branding cycle, I think that's like their third name and a couple years, invited me in sort of wearing my emergency mental health hat, but also my violence subject matter expertise hat, because they wanted to do a report of position statement on mass violence, right? And here's the thing and your next guest, Dr. Saliba will be able to speak to this supremely well, the vast majority of violence isn't mass violence, right?
Now, don't get me wrong, what we wouldn't give to stop mass violence, right? But if we try to snap our fingers, and we never have another mass shooting, we're still gonna have 99%, probably 95% of the firearm homicides that are out there. And by the way, most of the firearm deaths happened to be suicides, not homicides.
But not the National Council wanted to bring together a group of folks around violence and mass violence prevention. And I was able to sort of be a part of that project. And I think maybe what I'm most proud of, to make sure that the team that was coming up with this guidance wasn't just the typical behavioral healthcare leaders, the folks in the executive suites, and, no disrespect to them, they're wonderful folks. But they aren't necessarily operational or subject matter experts in mass violence. So we brought in folks from the FBI, we brought in folks who'd spent a career studying school violence, and so forth. And we produced a really good document that matches up with a lot of very consistent recommendations, including some of the stuff we've done with the National Suicide Prevention Lifeline around violence prevention, as well. So.
Dr. Williams: We have talked about so many important resources here. And sometimes I worry that our message might get lost because we talked about so many big things for our community. So if you could give one kind of summary or one kind of hit home point for our listeners, about your work with resolve Crisis Services, what would that be?
Dr. Rozel: If you or someone you care about needs help, whether it's stress, whether it's a psychiatric concern, whether it's substance use, whether it's feeling overwhelmed, give us a call. Again, 888-796-8226, we are there 24/7, we are free. And most importantly, we will help you with whatever somebody needs help with. We aren't treating because of a diagnosis or insurance or anything like that. If someone needs help, we're gonna find a way to help them.
Dr. Williams: Great. Well, thank you all so much, again, for listening. Thank you so much Dr. Rozel for being here with us. We really appreciate it.
Dr. Rozel: Thank you for having me. Yeah.
Dr. Agnihotri: It's amazing.
Dr. Williams: And as we're gonna start seeing here on our pediatrics podcast, good, better, best is what we do here at UPMC Children's Hospital of Pittsburgh, never let it rest, always do your better, and always, what, how does it go Sam?
Dr. Agnithotri: Good, better, best. Never let it rest until you're good is better and your better is best.
Dr. Williams: And That's Pediatrics signing off.
Voiceover:You can find other episodes of "That's Pediatrics" on Apple Podcasts, Google Podcasts, Spotify and YouTube. For more information about this podcast or our guests, please visit chp.edu/thatspediatrics. If you've enjoyed this episode, please be sure to rate, review and subscribe to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to "That's Pediatrics." Tune in next time.
John “Jack” Rozel, MD, MSL, is medical director of resolve Crisis Services and a core faculty member for the Center for Bioethics and Health Law at the University of Pittsburgh. Dr. Rozel earned his medical degree from Brown University School of Medicine and his master’s degree in law from the University of Pittsburgh School of Law. He completed both a residency and fellowship at UPMC Western Psychiatric Institute. His clinical interests include emergency and crisis psychiatry, violence prevention, and treatment of trauma and his educational interests include violence prevention, risk management, and resilience and wellness for professionals.
