Expanded Outreach Improves Rural Adolescent Mental Health Outcomes

Expanded outreach to adolescents in a rural setting contributes to improved mental health outcomes.

During the COVID-19 pandemic, 1 rural area experienced a significant increase in adolescent emergency department (ED) visits for mental health-related crises, including suicidality and intentional medication overdose. A nurse practitioner (NP)-led initiative expanded mental health outreach and improved outcomes for youth experiencing a mental health crisis, according to a care innovation poster presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Tampa, Florida.

“Routinely asking about mental health normalizes the conversation, much like asking about digestive health or any other body system you discuss with your primary care provider,” said study coauthor Jessica Jurasin, MSN, FNP-C, ARN. “It serves as an invitation to start the discussion, which can be an enormous hurdle when stigma is involved.”

Through consistent early identification, treatment, and follow-up, Jurasin and coauthor Heather Youmans, NCMA, reduced the negative outcomes for adolescents at Summit Pacific Medical Center, Rural Health Clinic in Elma, Washington. “Many of the youth treated at our local ED had been seen by their primary care provider for various reasons in the preceding days, weeks, and months. This trend highlighted an opportunity to provide meaningful intervention,” the authors said.

As part of the expanded screening process, all patients aged 10 years and older were screened for mental health conditions regardless of whether their visit was related to mental health. Clinicians asked a simple question to initiate a conversation with the youth such as “how is your mental health these days?” Additionally, all youth aged 11 years and older completed a Patient Health Questionnaire modified for adolescents (PHQ-A) at routine well-child checks and for any visit related to mental health.

Collaborating with the patient or caregiver on their preference, while inviting them to call back sooner if needed, generally yielded positive results.

For adolescents who were deemed at risk, clinicians worked with the patient and their family to develop individualized care plans, including formal safety plans when indicated. Clinicians also arranged mental health referrals, wrote letters to the adolescent’s school, and prescribed medication as needed. Clinicians distributed 49 medication lockboxes during the study period — these were to be used to lock away all potentially dangerous medication. For adolescents identified as at risk for a new or exacerbated mental health condition, permission was obtained from the patient for follow-up calls to be made either directly to the youth, the parent, or both.

Follow-Up Calls Made to At-Risk Teens

Medical assistants (MAs) followed up with the guardians of patients whom clinicians deemed were at risk for mental health crises 1 to 2 weeks after their initial visit. In these follow-ups, MAs inquired about any questions the patient or guardian may have, medications started, referrals, and necessary follow-up visits.

Leading up to the adolescent’s follow-up appointment, MAs continued to check in on the patient and their family every 1 to 2 weeks unless the patient established care with a community behavioral health provider or declined further calls.

“We quickly discovered that the ideal call-back time frame varied depending on a multitude of factors,” Jurasin explained. “Collaborating with the patient or caregiver on their preference, while inviting them to call back sooner if needed, generally yielded positive results. These discussions are well suited between the primary care team and families since rapport is already established. I imagine this would be a more challenging nuance for a third-party caller.

Program Receives Positive Feedback From Patients, Parents

The enhanced screening and follow-up process was beneficial to both patients and clinicians; while patients reported feeling more empowered and respected, MAs and NPs reported increased job satisfaction and a better sense of camaraderie with the health care team. Parents reported feeling less isolated and patients said they appreciated being contacted directly.

“Among the primary care nurse practitioner and MA involved, there is a sense of camaraderie, reassurance, and increased job satisfaction,” the study authors noted.

Anecdotal outcomes regarding a decreased number of emergency department visits for suicide attempts and overdoses are reassuring,” Jurasin said. “While collecting quantitative data would formally strengthen our results, we feel positive about the impact we made by acting quickly on this acute need while using the resources available to us.”

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This article originally appeared on Clinical Advisor


Jurasin J, Youmans H. Adolescent Mental Health Outreach in Rural Primary Care. Presented at: NAPNAP National Conference; March 15-18, 2023; Tampa, FL.