According to the CDC, nearly 1 in 5 children between the ages of 3 and 17 has a diagnosable mental health disorder, and more than half of those children never receive treatment. The reasons most cited for this lack in care include problems getting an appointment, issues related to cost, and lack of access to services in the child’s geographical area. Certainly, these challenges are not good for kids in need of treatment; it also places extraordinary pressure on the people trying to treat them, including licensed clinical social workers, marriage and family therapists, and professional counselors, many of whom carry overwhelming caseloads.
A model developed by telehealth provider Handspring Health is working toward alleviating these provider pressures — increasing access to clinical support, investing in clinician training and prioritizing manageable caseloads.
Guest:
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health
Host/Producer: Carol Vassar
TRANSCRIPT
Announcer:
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Carol Vassar, podcast host/producer:
Each week we’ll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar. And now that you’re here, let’s go.
MUSIC:
Let’s go-oh-oh, well beyond medicine.
Carol Vassar, podcast host/producer:
According to the CDC, nearly one in five children between the ages of three and 17 has a diagnosable mental health disorder, and more than half of those children never receive treatment. The reasons most cited for this include problems getting an appointment, issues related to cost, and needed services being unavailable in the child’s geographical area. It’s not good for kids needing treatment certainly, but it also places extraordinary pressure on the people trying to treat them, including licensed clinical social workers, marriage and family therapists, and professional counselors, many of whom carry overwhelming caseloads. Yet a model developed by the telehealth provider, Handspring Health, is working toward alleviating that provider pressure by making available clinical support, investing in clinician training, and making manageable caseloads a priority, not to mention the telehealth aspect, which helps many clients overcome distance and transportation barriers.
Joining me to talk about what this model of care looks like for families and providers is Dr. Amy Kranzler, chief clinical officer for Handspring Health. So, how did this particular model come about? Here’s Dr. Amy Kranzler.
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Handspring Health came about around a shared vision, which was to increase access to high-quality, affordable pediatric mental healthcare, and to do that by investing in clinicians. And we came to this vision from different facets of healthcare. So, our co-founders, Kwasi and Sahil, were working closely with health plans, and what they found was just a growing need for pediatric mental health care and an absence of high-quality options. And so there were a lot of companies that were working to increase access to care, specifically through telehealth in the adult space, and very few companies that were doing that and certainly that were doing that well in the pediatric space. And so there was this real need.
And on the clinical leadership side, what we were seeing was this real tension, similarly, between access and quality. So the more hospital system or clinic was trying to increase access to more kids, to care. What was happening is that it would often come at the expense of quality. So, things like, we’ll just give more cases to each therapist, to the point that caseloads got really unreasonable, and it was really hard to do kind of high-quality care. And then, beyond that, system after system was just really failing therapists in getting them the resources they needed to do their job well. Reasonable caseloads, training that they needed, reliable and livable wages. And so we kind of came together around this idea that it actually doesn’t have to be one or the other. We can hold this dialectic, we can increase access to care, and we can do that while still really focusing on quality. And that the key to holding both of those pieces is investing in our therapists.
So, what we do differently at Handspring is that we have a very comprehensive training program. All of our therapists get very high-quality, evidence-based training, consultation, supervision, team consultations. Their caseloads are capped so that they can really provide high-quality care to every single family they work with, and they have reliable salaries. And what we are finding is that that ends up being kind of a win-win-win for everybody when we can guarantee that quality.
Carol Vassar, podcast host/producer:
And how long has Handspring been around? Did it benefit also from, if there’s anything to be benefited, from COVID-19 and the advent of that?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Yeah, so it’s been around about three years at this point. To say benefited from the pandemic is a hard thing to say, but I think the silver lining of the pandemic is that it really pushed all of us towards considering telehealth in a much, I think, broader and faster way than we might have otherwise. Although there certainly were groups thinking about it beforehand. It forced us all to be more flexible in thinking about this as a real option for increasing access to care.
Carol Vassar, podcast host/producer:
So I bring my child to the screen, and I start a telehealth session with Handspring. What does that look like? What does it sound like? I personally take my therapy online. Is it different for kids than it is for adults?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
It’s a great question. So, for the most part, a telehealth session is going to sound and look very similar to an in-person session. So at the beginning of therapy, it’s going to sound a lot like the therapist getting to know the child, asking questions, understanding whatever the challenges might be. As they progress in treatment, it’s going to look a lot more like identifying goals, learning skills to work towards those goals, thinking about how they can implement those in their lives. I think where in person, there might be kind of live games to help a kid get comfortable, via telehealth, we have to get a lot more creative in how we engage kids, help them stay focused, have fun in the session. I think that’s one of the differences between child and adult sessions, certainly. But, in general, at Handspring, one of our central beliefs is that pediatric care is specialized care. And so that developmental approach really permeates every session, starting at the assessment and all the way through an entire course of treatment.
Carol Vassar, podcast host/producer:
I’m curious as to what some of those icebreakers are if games are not an option.
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
So I would say games are an option. They just have to look different. We tend to try and play games that are simultaneously teaching the skills that we’re working on. So a great example is, for example, a feelings wheel. So that’s just a really low-threatening way. It’s an electronic tool that you can use that kind of spins and lands on a feeling, and it’s just a fun way to talk about different emotions when a person might feel them, what it might feel like in your body when you’re experiencing different emotions, and again, just kind of normalizes, depathologizes and adds a little bit of fun to that process.
Carol Vassar, podcast host/producer:
Now it sounds to me like telehealth for mental health concerns for children would not quite solve the access issue, but go a long way towards solving it. Does the telehealth approach improve access to mental health care for children, say, in rural areas or underserved areas?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Absolutely. In rural areas, you have families who might have to drive an hour or several hours to get to the nearest mental health clinic, and that’s a real barrier. And we see that in study after study, transportation is one of the biggest barriers. Besides, for distance, you also have to have a caregiver available at the time of the session who’s not involved in work or caring for other siblings who’s able to get you to that session. So that has historically been one of the biggest barriers to kids accessing mental health care. And what telehealth does is it allows kids to access care right from their home. And so it doesn’t matter where the closest clinic is. And, to take it one step further, even when you kind of get to that clinic, that close clinic may not have the specialized care a family needs, whether that’s pediatric therapists or it’s therapists that specialize in the specific presentation, like OCD or PTSD. There’s many presentations that really require specialized knowledge.
So what telehealth does is allows kids to access the right care, the care they need, from wherever they are and from their home, which has been a really huge deal in increasing access. And the other piece I’ll add about access that I think is important is it also helps overcome that stigma barrier. So, we’re seeing just such a wonderful trend towards increasingly kids talk about therapy. They love talking about the fact that they go to therapy, what they talk about with their therapist, and we now have tons of teens coming in, who they’ve asked their parents to come to therapy because they’ve heard about it from their friends. So that’s just one of these really wonderful trends, and still, stigma is there and remains a barrier for some families. And so the other really nice thing about telehealth is that, where that is still a barrier, it helps a family overcome it, so that you can really just access it from your home.
Carol Vassar, podcast host/producer:
You raise a really good point about certain mental health conditions. Specialists might become more available through the telehealth platforms. Are there particular mental health conditions in children that telehealth is particularly effective in either giving them access or in treatment for them?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Yeah, so one of my favorite examples is OCD. The gold standard treatment for OCD is exposure and response prevention. Not all therapists have the training they need to be able to provide that and certainly to provide it within the pediatric space. And so that’s something that we train all of our therapists in, and they’re then able to provide that very specialized treatment to patients across the state, in whatever state they’re licensed in.
The other thing that I’ll add that I think you mentioned is the other piece that I think telehealth has been transformative is this idea of ecological validity, or the extent to which treatment is actually making an impact in a kid’s life where it matters. And so what can happen sometimes when you’re doing an exposure-based treatment is, a kid is coming to the clinic, and they’re facing their fear there, and they get really good at facing their fear in their therapist’s office, and it’s a lot harder for them to translate those gains into their actual life where it matters. And the beauty of telehealth is that a kid can be doing the exposures in their home or in their life, or where it actually matters. And for some presentations, what that means is that we’re actually seeing it translate into real gains in a child’s life in a much more significant way.
Carol Vassar, podcast host/producer:
We’re talking also about access here, and I’m curious as to whether the digital divide, the so-called digital divide, where some folks have access to the internet, some folks don’t, some folks have high speed, some folks don’t. Does that come into play at all?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
It does. So, telehealth promotes equitable access to care. It’s really helping level the playing field there, and we still have these barriers, as you’re mentioning. So, in order to access telehealth, a family has to have access to fast enough internet speed. They need a working electronic device that’s available to the child, that’s not being used by someone else. And I’ll add that the child needs to have a private space that they can actually engage in the session, and the family needs to have the digital literacy to really follow the link and engage in the session. So all of that kind of remains as barriers. Again, the trends are very positive in this particular way. So we’re really seeing that the last study was over 92% of families have access to Wi-Fi that does support these kinds of sessions.
In terms of digital literacy, this is where we have a little bit of advantage working with kids, where children and adolescents really tend to be increasingly digitally savvy, and we’re seeing less of the digital divide there. But the other thing that I’ll say is that our team is working very carefully to try and limit some of these barriers. So we have an entire intake team that’s devoted to helping a family walk through every single step of this process so that it’s really as simple as possible.
Carol Vassar, podcast host/producer:
You talked about the child needing to be in a room where privacy is secure. How do privacy and confidentiality concerns differ in the telehealth setting, especially for kids and adolescents?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
So that is one of the biggest challenges. When a kid comes in, in person, you have a mental health clinic that is built with sort of an entire infrastructure devoted to privacy, to confidentiality. So you wait in a waiting room, but then you go to a private room that is built with this idea that the entire conversation is confidential, stays in that room. Besides for being its own room, many clinics have white noise machines. So there’s really sort of a full infrastructure built to guarantee privacy and confidentiality.
When a child’s at home, the therapist has much less control over that. And what we do at Handspring is we have really transparent conversations with families at the beginning of every course of treatment. We explain why confidentiality is so important, that it’s so central to therapy, is a child knowing that anything I say here sort of remains private. Without that, it’s very hard for them to really engage in the work. And then we work with the family to use whatever resources they can to ensure that. So we try and problem-solve. How can the child have a private space? How can we make sure siblings aren’t walking in the middle, pets aren’t walking in the middle, whenever possible, there’s a white noise machine? How can we work with each family to sort of recreate that privacy?
Carol Vassar, podcast host/producer:
It sounds like the family has a role here, too, don’t they?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Absolutely. Absolutely.
Carol Vassar, podcast host/producer:
Talk about other barriers. I would think from the state licensure perspective, each state having its own licensure structure requirements. How does that work across state lines when you’re trying to do treatment in the telehealth space?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
That’s a real challenge. What telehealth allows is that a therapist and a patient don’t have to be in the same space, but a therapist does still need to be licensed in the state that the child is located in at the time of the session. What we’re doing at Handspring is, as we hire therapists, we are also cross-licensing them into different states, but it is a cumbersome process. Every state has its own process. It takes time. And so, one of the exciting things that has been happening is sort of new regulation that have been making that process easier. So for psychologists, PSYPACT already exists. The social work licensure compact has been kind of coming down the pipe. And what these regulations are doing is making it easier for therapists to gain licensure across multiple of the states, and we’re hoping that we’ll see that continue to make access easier.
Carol Vassar, podcast host/producer:
I want to return to the parental and caregiver role for just a moment if I could. Aside from making sure their child or children have a private room where the session is secure, how can they best support their children during a telehealth mental health session?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
One of the most important things that parents can do is just help minimize distractions. In the office, a therapist can really build an infrastructure that supports focusing. At home, we really look to the parents to think about how can they minimize distractions in the room, whether that’s other electronic devices or pets coming through or siblings coming through, really setting up a space, making sure kids are ready on time in that space, fed, prepared for the session. And the other really important piece is making sure that the caregiver is available at least for a portion of the session.
So when they come in, in person, just by virtue of the logistics, a parent is there for the whole session. They’re usually waiting in the waiting room to be able to drive their child back. When you’re working with telehealth, it’s tempting for a parent to just start getting involved in something else and not be available. But we know, when it comes to child mental health, having a caregiver involved in some portion of the session is really important so that they know what their child’s learning, what their child’s working on, and they can help generalize those skills at home and in the child’s life.
Carol Vassar, podcast host/producer:
I’m kind of working backwards here, but how does a parent or caregiver help a child get ready for a telehealth appointment? Is it different than getting ready for an in-person appointment?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
So largely similar. I think in the beginning, it can be really helpful for parents to just have very transparent conversations with kids. What therapy is, right? So just across the board, what is therapy, why you’re going, really important that it not be presented in a way that’s sort of shaming or a punishment, but as sort of an opportunity for support and help towards their goals. And then, in the context of telehealth, just further explaining to a kid what they can expect in terms of seeing their therapist on the screen, that they’ll see their own face, expectations around not using the device in other ways and really just making space to answer any questions that their child might have about what they can expect.
Carol Vassar, podcast host/producer:
I’m curious, from your perspective, your organization is three years old, the adoption of telehealth, which is much more widespread these days, how has it changed the landscape of mental health care for children and adolescents here in the U.S.?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
I think we’ve hit on some of the big ones. To me, the biggest impacts have been on access, and that extends beyond just more kids being able to access, but also kids that are already in therapy, being able to be engaged more consistently. So, barriers like inclement weather or a parent’s kind of work meeting or travel are no longer meaning that needs to be a missed session. So, not just the ability to engage consistently for more kids. To me, that’s really the huge impact. And the second piece is really on that ecological validity, where we’re able to actually do the care in the context of a child’s life, where it matters, and see those gains. And the third piece that I’ll just add is, for some kids, the idea of going to an unfamiliar building and then talking to an unfamiliar person about some of the most vulnerable things they’re feeling and thinking can just feel like too much. And so, for those kids, it’s just another way that telehealth can increase access by just reducing that one barrier and allowing them to access care from home where they’re comfortable.
Carol Vassar, podcast host/producer:
Off the top of your head, and without revealing anything that might be HIPAA private, do you know of any kids who have really benefited from the work that you are doing in the field and have really risen to the challenge of mental health telehealth therapy?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Yeah, it’s hard to pick one because we are just here, family after family, who, in their intake call with us, are saying, “I have been looking for care for my child for months, and we have not been able to find anyone,” or, “We have not been able to find anyone who’s willing to see us.” We just saw a family with Functional Neurological Disorder, which is a very sort of specific presentation. And what they were saying is nobody was willing to work with us. And again, our therapists have the training, have the space in their caseloads, and that we were able to provide really effective and helpful care for this family and really family after family we’re hearing primarily, we have been looking for months, and we have not been able to find a therapist with a specialization to treat our child.
Carol Vassar, podcast host/producer:
So a success story right there, and many others, I’m sure.
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
Yeah. Yeah.
Carol Vassar, podcast host/producer:
What’s the future of telehealth in the child and adolescent mental health space, do you think?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
To me, the future is just continuing to increase access. So, telehealth has helped mitigate some of the challenges when it comes to access, but the need continues to far outpace access to therapists. And so, in my mind, the goal becomes that every child who needs care is able to access that care when they need it. And so, we know that now about 20% of kids have a diagnosable mental health disorder and 50% of them do not get access to the right care. So that’s a very high number. And to me, the future is that we are able to provide care in a way that every child is able to access the right care when they need it, and we know that improves outcomes. In my mind, the future, again, is that telehealth is one of several options, that it does not come to replace in-person care. At Handspring, we’re really committed to a hybrid model, but that the goal is that every child has access to high-quality, affordable mental health care. Every family knows that they have access to high-quality, affordable mental health care when they need it.
Carol Vassar, podcast host/producer:
Do you do medication management?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
We are starting in a few states and then with Plan to Grow, and our goal is really to be a one-stop shop for families. So therapy is at the center of what we do, but what we’re finding is that many of our families say, “Well, this is great. You’ve solved the access problem for us in terms of therapy, but we are still just as stuck trying to find medication for our child.” And so we are planning to expand to help families cover that problem as well.
Carol Vassar, podcast host/producer:
Excellent. For parents who are listening who might be considering telehealth for their children for mental health care, what would you recommend as the first step?
Amy Kranzler, PhD, Chief Clinical Officer, Handspring Health:
The first step is really to get clear on your goals. Why am I looking for therapy? What am I looking for? And then to research the right care. So not all telehealth is created equal, and you want to make sure that you’re looking for the right care for evidence-based care that specializes in children, and then just reach out. I think sometimes that first step is the most anxiety-provoking, can be really difficult for parents. It’s why we have such a dedicated intake team who can answer all your questions. What’s been most exciting to us is to see our care working. So we’re hearing from family after family, not only that symptoms have reduced, but that their child’s life has been expanded. They’re able to get back into the things they’re excited about, succeed in school again, engage with friends, and that’s really been exciting for us to see. So, would end with, if you are hesitating as a parent, to reach out and ask us any questions that you might have.
Carol Vassar, podcast host/producer:
Dr. Amy Kranzler is the Chief Clinical Officer for Handspring Health.
MUSIC:
Well beyond medicine.
Carol Vassar, podcast host/producer:
Thanks so much to Dr. Kranzler for sharing with us the Handspring Health Model of Care. And thanks to you for listening. Topics of mental health are on the agenda for the Well Beyond Medicine podcast during this month of mental health awareness. Yet there is so much more that happens outside the doctor’s office and affects children’s health. Maybe you know of such a topic and would like to hear more about it. Your suggestions for episodes are always welcome. Reach out to us via email at [email protected] or visit our website nemourswellbeyond.org. Leave us a voicemail with your suggestion.
Previous podcast episodes are also found there, plus you can subscribe to the podcast there and our new monthly e-newsletter. That’s nemourswellbeyond.org. You can also find our podcast on your favorite podcast app and on the Nemours YouTube channel. Thanks to our production team for this episode: Cheryl Munn, Susan Masucci, Lauren Teta, and Steve Savino. Our next episode continues the theme of mental health with a look at how eliminating stigma in clinical settings can better support patients and families affected by substance-use disorders.
I’m Carol Vassar. Until then, remember, we can change children’s health for good, well beyond medicine.
MUSIC:
Let’s go-oh-oh, well beyond medicine.
