YCSC Eating Disorder Care

August 01, 2023

Information

August 2023

In this informational webinar, YCSC Assistant Professor Rebecca Kamody provides an overview and prevalence of various presentations of disordered eating that are found in patients across levels of care at the YCSC and YNHCH. She also provides some sobering statistics related to eating disorders and risk factors and discusses some of the work being done to address related critical needs.

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00:09Hello everyone. My name is Rebecca Cammady,
00:11I'm a clinical psychologist and assistant
00:13professor with the Yale Child Study Center.
00:16And I'll be speaking in today's
00:18webinar on eating disorder care
00:19at the Child Study Center,
00:21focusing quite a bit initially on kind of
00:25the presentations of disordered eating
00:26that we see across levels of care.
00:29And then what the center has done to address
00:32that and what kind of hopes for things are.
00:35So whenever giving a talk on this topic,
00:38I start with this image of the silos
00:40of care and especially pediatric
00:42eating disorder care with other
00:44mental health comorbidities.
00:46Unfortunately,
00:46what's happened is receiving treatment
00:49and the research and program
00:51development that's often associated
00:53with eating disorder care becomes
00:56quite siloed from other child and
00:58adolescent mental health services and
01:00kind of thinking about those other
01:03presentations that we often see.
01:05Why is this the case that
01:07it's become so siloed?
01:09Eating disorders in the mental health,
01:11medical,
01:11social work kind of across different fields
01:14have become a a niche area throughout
01:17training and program development.
01:19And despite we often see the significant
01:22comorbidities that we often see,
01:24we still see it kind of separated out
01:27that makes providing the most kind of
01:30holistic and cohesive care quite challenging.
01:34So when thinking about how we
01:36really have to move that forward,
01:38I always invite folks to think about
01:40what images come to mind when you hear
01:42the term eating disorder and they think
01:43that the system of what perpetuates
01:45this more kind of siloed mentality of it.
01:48When you Google search it,
01:50the similar kind of images come up of slim,
01:53white young adult females.
01:55And in reality,
01:56we know that feeding,
01:58eating and weight disorders are
02:00actually very complex heterogeneous
02:02presentations that don't fit one mold.
02:04So when we actually think about what
02:07constitutes a feeding or eating disorder
02:08based on the DSM or a manual that we
02:11used to diagnose psychiatric diagnosis,
02:13it's characterized by a persistent
02:15disturbance of eating or eating
02:17related behavior results in an
02:19altered consumption of food and
02:21that significantly impairs physical
02:23health or psychosocial functioning.
02:24So in essence,
02:26it's disturbance with food that's
02:28clinically significant impacts relationship
02:29with food and how much we're eating
02:31and then impacts are functioning.
02:33And as you can imagine that that's
02:35quite broad in the range of youth,
02:37young adults who are requiring care
02:39for these kind of presentations.
02:44So I highlight here some of the issues
02:46related to diversity in disordered
02:48eating presentations that are often
02:50kind of not conceptualized in a lot of
02:53our more traditional models of care.
02:55So we actually know that Bipoc youth and
02:57young adults are less likely than their
02:59white counterparts to be asked by doctors
03:02about their eating disorder symptoms.
03:04Even when they're self reporting
03:06disordered eating symptoms,
03:08Bipoc individuals are half as likely
03:10to be diagnosed or receive treatment
03:12than their counterparts with it,
03:14the white counterparts with
03:16an eating disorder.
03:17Black individuals are less likely
03:19to be diagnosed with anorexia,
03:21but may experience the OR do experience
03:23the condition for a longer period of time.
03:26In some ways related to these difficulties
03:29accessing the appropriate care,
03:32black teenagers and adolescents
03:34are more likely than white teeners
03:37to exhibit binge purge eating.
03:39Similarly,
03:39Hispanic youth are more likely
03:42to experience bulimia and nervosa
03:44than their non Hispanic peers.
03:46And we know that Asian Americans experience,
03:49based on some nationally representative data,
03:52higher rates of restriction
03:53compared to their white peers,
03:54as well as some higher levels
03:57of body dissatisfaction.
04:00We see diversity in presentations based
04:04on gender and sexual minority identity.
04:07So we see higher rates of binge
04:09purging in gay men and adolescents,
04:11as well as increased likelihood of
04:14experiencing compensatory behavior.
04:16So fasting, vomiting, using laxatives,
04:19we see transgender college students
04:22reporting higher experiences of
04:24disordered eating as well as this
04:27really important component among
04:29individuals who identify as the gender
04:31minority of the role that disordered
04:33eating can play in a way of affirming
04:36one's body as a gender affirming tool.
04:39And that is where we see then often a
04:42tie in with more gender dysphoria and
04:45body dissatisfaction overlap and and
04:47impact disordered eating in this population.
04:53Among youth with eating disorders,
04:55we see a particularly high
04:58risk population among trans
05:00and gender diverse adolescents,
05:02so we know similarly.
05:05Based on prevalence data and a
05:07nationally representative sample
05:09of young adult of adolescents,
05:11we see that in trans use with
05:13youth with eating disorders,
05:15they're more than 20 times as likely
05:17to have attempted suicide in the
05:19past year than either cisgender
05:21female with the history of an eating
05:24disorder or trans use without a
05:26history of an eating disorder.
05:28And approximately 3/4 of trans use
05:31with an eating disorder have endorsed
05:34suicidal ideation or engaging in non
05:36suicidal self injury in the past year.
05:39So very high risk population.
05:42We also see diversity in terms
05:45of disabilities in individuals
05:46with disordered eating.
05:48So among with physical disabilities
05:50and young girls being more likely
05:52to develop disordered eating,
05:54we see high rates of disordered
05:56eating among individuals with
05:58neurodiversity or on autism spectrum.
06:01We see high rates of autism and a SD
06:04traits among individuals with eating
06:06disorders and high rates of EDHD as well.
06:13And despite the fact that we
06:14often think about these as
06:15presentations affecting young adults,
06:17we see much higher rates in
06:19children than adolescents Now.
06:20So in similarly some large national
06:23survey data and looking at school age,
06:25children see 42% of 1st to 3rd grade
06:29girls with a desire to be thin or thinner.
06:33Over 80% of 10 year old children in the
06:36survey reporting a fear of being fat.
06:39close to 50% of 9 to 11 year
06:42olds reporting being on a diet
06:44some of the time for themselves.
06:47And we see 35 to 57% of adolescents
06:50engaging in unhealth unhealthy disordered
06:53eating behaviors to control their weight.
06:56And over 90% of women,
06:58once they reach college,
06:59then trying to control their weight
07:01through different dieting behaviors.
07:03A really important piece too that I
07:05want to highlight here as you here.
07:07We're talking about just some of what
07:08may be developing at a younger age.
07:10But since the start of the pandemic,
07:12we've seen actually much higher
07:14rates of hospitalizations for
07:16medical complications associated
07:17with restrictive eating,
07:19especially in the younger skew to
07:21to being younger children who are
07:23requiring the highest level of care.
07:27So you know, important to consider despite
07:29the fact that we have this this kind of
07:32stereotyped idea of what it looks like
07:34to have an eating disorder that less
07:36than 6% of people with an eating disorder
07:39are actually diagnosed as underweight.
07:41Now this is with any clinically
07:44significant eating disorder, so not just
07:46anorexia where of course we do see much,
07:48much higher rates of being underweight
07:50given that's part of the diagnostic criteria.
07:52We think about clinically
07:54significant disordered eating that
07:56impacts somebody's functioning.
07:57We have this kind of as a society
08:01misrepresented idea of what that looks like.
08:05And yet there is a SWAG stereotype that
08:07exists that we talked about in the field
08:09of if you have an eating disorder,
08:11you're skinny, white,
08:13affluent girl when.
08:14And it's very problematic of not
08:16just societal views of it,
08:18but that current treatment models are
08:20based often on samples of affluent,
08:22young adult, cisgender,
08:24neurotypical white women,
08:25when there's quite a range of presentations
08:28of individuals who and youth who
08:31can experience these presentations,
08:32as Google Images shows us.
08:37So as I was saying there,
08:38there's a wide range of
08:40disordered eating presentations.
08:42Pika and rumination disorder are ones
08:44that I'll talk about in a moment that
08:47mostly affiliated or associated with
08:49neurodevelopmental disabilities in
08:51younger children avoidant restricted
08:53food intake disorder and anorexia,
08:55both resulting in lower weight bulimia
08:57nervosa and binge eating disorder,
08:59both associated with episodes
09:01of binge eating and bulimia
09:02with associated purge episodes.
09:07The challenge here,
09:08especially for children and adolescents,
09:10is, as anybody who has kids of their
09:12own or works of kids knows that things
09:15don't often nicely kind of fit into one box.
09:17And that happens with psychiatric
09:19presentations as well.
09:19We often see symptoms or elements of
09:22different presentations that are what
09:24we'd call trans diagnostic kind of
09:26crossing in and out of these boxes
09:28and to meet diagnosis for an eating
09:30disorder based on our DSM criteria.
09:32It's mutually exclusive.
09:34So having experiences with of
09:38symptoms of multiple presentations
09:39results in a lump sum diagnosis
09:41of something that we call Osfed or
09:43other specified feeding and eating
09:45disorder which is often what we
09:47see with children and adolescents.
09:52So here's a list of the types of
09:54eating disorders those that will
09:55be talking about requiring kind of
09:57our our highest level of care are
09:59most frequently anorexia nervosa,
10:01which is going to be having an unrealistic
10:03idea about body image and overvaluation
10:05of how important that is, right.
10:08It's one of the most fundamental
10:10important things to to an adolescent
10:12sense of self and this intense fear
10:14of gaining weight that results
10:16in significantly low body weight.
10:18The Lumia Nervosa are episodes
10:20of binge eating,
10:22so eating significantly large amounts
10:24of food with an experience of loss of
10:26control in a short amount of time,
10:28following by purging episodes or some
10:30other type of compensatory behavior.
10:33Sometimes excessive exercise,
10:35fasting, use of laxatives,
10:38binge eating disorder is bulimia without
10:40the compensatory behaviors are perching.
10:42So having those significant binge episodes,
10:46larger amount of food than somebody
10:48would typically eat in a short
10:49amount of time and experiencing a
10:51sense of loss of control and then
10:53an associated feeling of disgust or
10:56guilt with oneself after the fact.
10:58Rumination disorder is an experience when
11:01somebody swallows in the regurgitates
11:04the food and the re swallows and and
11:07pica is consuming non food objects.
11:10These two,
11:11as I mentioned are are often highly
11:14cooccurring with a number of other
11:18developmental presentations.
11:19Avoidant and restrictive food
11:21intake disorder is,
11:22as I mentioned previously,
11:24one of our other restrictive presentations.
11:27Whereas anorexia is focused on a
11:30body image concern or fed or another
11:33name for avoidant and restrictive
11:35food intake disorder is when a youth
11:38or an adolescent or a young adult
11:40forever is experiencing it severely
11:43restricts what they're eating for
11:45a non body image related reasons.
11:47So sometimes it's a sensitivity
11:50to to the experience of eating,
11:52sometimes not being aware of hunger cues,
11:55sometimes of a fear of pain,
11:57right of if they've had some type of
11:59medical complication that often leads
12:00to then significantly low weight.
12:05So with these different presentations,
12:07we can lump them together into
12:09these boxes that again don't quite
12:11fit nicely away from one another,
12:13but but do have some overlap.
12:15We have these presentations of
12:17restriction or overcontrol,
12:18which is what we would
12:19think about with anorexia,
12:21this regulation and loss of control
12:23with bulimia and binge eating
12:24and those related to anxiety,
12:26pain or sensory sensitivities.
12:28This is where we put our food or the pika.
12:31The challenge is that as we
12:34conceptualize these things different,
12:36what therapeutic treatment looks
12:37like is going to be different,
12:40but they don't fit nicely in those
12:42boxes and and so that's really where
12:44kind of providing the most effective
12:46treatment can be a challenge.
12:50So with regard to eating disorder prevalence,
12:53unfortunately their data overall
12:54is quite is a little outdated.
12:56So this is from the nationally representative
12:59prevalence data from NIMH looking at
13:02the lifetime prevalence of eating
13:04disorders by the time of reaching mature
13:07adolescence from about 20 years ago.
13:09And this was where we see close to
13:124% of females and 1.5% of cisgender
13:15males meeting criteria for an eating
13:18disorder by the time that they turn 18.
13:22This is as as is clear from the
13:25dates of it you know very,
13:27very much pre pandemic.
13:28And so we already saw an increase
13:30happening over those those years of kind
13:32of the the early 2000s and 2000 tens
13:35when we see continue to see increase on
13:37body image pressures by society that
13:40have been really exacerbated by the
13:42pandemic and a very important piece
13:44to hit on as we're thinking about
13:46care for this patient population.
13:48So beginning at the at the beginning
13:51of the pandemic there was anticipation
13:53of kind of the impact on eating
13:56disorders that was significantly I
13:58think underestimated what we would
14:00actually see that the,
14:02the first publication was now two years
14:05ago of how medical admissions related
14:07to restrictive eating disorders among
14:09youth had increased significantly.
14:11Looking at pre pandemic to during
14:13the pandemic rates of youth requiring
14:15medical hospitalization to be stabilized
14:17and this has been replicated throughout
14:20the country and throughout Europe
14:21and at our own Children's Hospital
14:24seeing that significant increase.
14:27So what's exacerbated the prevalence
14:29and severity,
14:30There's a number of factors that
14:32we can contribute to it,
14:34a greater susceptibility to
14:36illness during the pandemic,
14:38psychological distress with a pandemic
14:40happening and then the uncertainty
14:42and social isolation that happens.
14:44We do know especially things like
14:46anorexia is a very isolating disease
14:47and so social connection is one
14:49of the most protective things.
14:51And so taking, you know,
14:52as was needed,
14:53but taking kids away from one another
14:56really increased kind of risk factor.
14:58There was almost nothing but virtual
15:00interaction staring at one another on
15:02the screen and then a lot more time
15:04spent on social media and the dangers
15:06that we know associated with that,
15:08with what youth are exposed to in terms
15:10of content and unrealistic body image ideals.
15:15So then thinking specifically at
15:17our Children's Hospital at Yale,
15:19what we saw in the couple of years before
15:21the pandemic to the first year and a half,
15:24we saw a significant increase where
15:26even in half of the time we saw more
15:29cases in that first year and a half
15:31of the pandemic increasing from 48
15:33cases the year and a half before the
15:35pandemic or the three years before
15:36the start of the pandemic to just
15:38the first year and a half of 60.
15:40So as you can imagine and and our team
15:42still needed to comb through that data,
15:45we see more than a double increase
15:46anticipated of what we've seen
15:48in the similar time frame.
15:52So not only did we see an increase in
15:54the number of patients hospitalized,
15:56but an increase in the length of stay
15:59because of the severity of cases
16:00and the lack of appropriate kind of
16:03referral options for post discharge
16:04because of the crunch on the system,
16:07a much higher number of youth
16:10younger than the age of 13.
16:11This is consistent with now some
16:14recently published data that has come
16:16out kind of more nationally as well
16:18where we're continuing to see the the
16:21average age of hospitalization for
16:23restrictive eating concerns skewing
16:25younger and younger which unfortunately
16:27again are treatment care models.
16:29Kind of historically as a nation
16:31and as a society are not up to date
16:34with see a greater number of youth
16:37requiring medication intervention
16:39for psychiatric concerns because of
16:41the comorbidities and more patients
16:43requiring A discharge to a higher
16:45level of care.
16:46And this is consistent with other
16:48sites in Connecticut and then
16:49country and world more broadly.
16:53And so why are we worried, right,
16:55We're seeing this increase and
16:57we know of course that eating
16:59disorders can be significant,
17:00but really in terms of the severity,
17:01it's worth taking note just
17:03how severe they can be.
17:04So eating disorders are among
17:06the deadliest mental illnesses,
17:08second only to opioid overdoses.
17:11Relapse rate for anorexia,
17:13once somebody has experienced
17:15the disease approaches 50%.
17:19The standardized mortality ratio of
17:21somebody with anorexia is approximately 6,
17:24which means to somebody else there,
17:26same age, all other factors,
17:28they're six times as likely
17:30to have mortality of that age.
17:33Approximately one in five
17:35patients with anorexia develops
17:36a severe and protracted illness,
17:39which means we don't expect to
17:42necessarily experience any remission.
17:44And there is an estimated death
17:46almost every hour each each year
17:49attributed to eating disorders.
17:52Among individuals with anorexia specifically,
17:55we see 60% of the deaths attributed
17:57to the medical complications
17:59associated with it such as cardiac
18:01arrest and sudden organ failure,
18:04but as well as suicide.
18:06And we know that's overall suicide
18:07rates among individuals with eating
18:09disorders are are quite high.
18:12So not only is there the
18:14individual health costs,
18:15but we do see a significant
18:17health costs in our our medical
18:19and healthcare systems costing
18:21about close to $65 billion.
18:26Approximately 9% of people will
18:28experience some type of eating
18:30disorder in their lifetime.
18:32I think it's important to note here,
18:34this doesn't mean 9% people experiencing
18:37anorexia could be a number of those
18:39other presentations I mentioned.
18:40But that does mean clinically
18:42significant disordered eating where
18:44it's impacting somebody's daily
18:46life despite the prevalence and
18:48and kind of robustness that we
18:50see in society that therapeutic
18:52interventions have modest results and
18:54we actually don't have FDA approved
18:56medications except for an adults with
18:59binge eating disorder or bulimia.
19:02We often we also see high comorbidities
19:05in this patient population.
19:06So despite you know that that we imagine
19:09that these are the patients that need
19:12the the most cohesive and and holistic
19:15care because eating disorder care is
19:17often siloed out as when we started the
19:21presentation that it's difficult to to
19:23receive treatment for both at the same
19:26time and and having the psychiatric
19:28comorbidities are associated with
19:30greater negative longterm outcomes.
19:32We see over half of adolescence with
19:35anorexia display some type of mood disorder.
19:38The challenge here is it it's
19:40often hard to disentangle.
19:41Is that a result of the severe
19:44malnutrition or does the mood disorder
19:46predate the the eating disorder?
19:51One in four patients with
19:53anorexia have an anxiety disorder.
19:56We see one in four patients with anorexia
19:58experiencing a substance use disorder.
20:00Particularly cocaine and amphetamines are
20:02quite high and a high rate of comorbidity
20:06with OCD in individuals with anorexia.
20:09An important distinction here is that
20:11there are obsessive kind of tendencies
20:14associated with severe restrictive eating,
20:16and the cooccurrence of OCD requires
20:18the obsessions to be outside just the
20:21restrictive eating presentation themselves.
20:26Hitting further on the the importance
20:28of kind of conceptualizing that how high
20:31risk this patient publishing can be.
20:33In another nationally representative
20:35study that looked at prevalence rates
20:38among among adults with a diagnosis of
20:40an eating disorder in their lifetime,
20:42we saw elevated rates or we do see
20:45elevated rates of a lifetime and a
20:48suicide attempt that in individuals with
20:50a subtype of anorexia being over 40%.
20:52So despite the fact that we silo
20:54out and and separate eating disorder
20:56care from other psychiatric concerns,
20:59it it doesn't work as a treatment
21:01model because these things are so
21:02often Co occurring and leads to to
21:04poor care that can be delivered.
21:08So I painted this picture of the
21:11significance and severity of eating
21:13disorder presentations and the
21:14increase that we're continuing to see,
21:16that we're continuing to see it
21:18in younger and younger patients.
21:20And the reality is despite all this,
21:23our country continues to experience
21:24what we consider a crisis in care,
21:27in eating disorder care,
21:28especially in anorexia.
21:30And this is actually a paper from
21:32about two years ago now that was
21:33in some ways a call to action and
21:36it's published in Gym Psychiatry,
21:37the journal that highlights the
21:40number of reasons for that.
21:42So the major take home points is that
21:44really we continue to experience a
21:46crisis in care for patients with
21:49eating disorders and and especially
21:51anorexia that it's critical to
21:53improve eating disorder care.
21:55We continue to be in the systems
21:57where we are more kids,
21:59young adults requiring those higher
22:02levels of stabilization because
22:03there's not enough resources in
22:06the community and at lower levels
22:08of care that there's a need for
22:10more funding for research because
22:12eating disorders are significantly
22:14underfunded research field and
22:16the need to develop more effective
22:19interventions because both are are
22:21therapeutic and psychopharmological
22:23or medication based interventions
22:25do have modest success thus far.
22:28But it's critical to improve training
22:30as again where I'd started as it's
22:32been such a niche area of our fields
22:35that that's a much smaller percentage
22:37of our mental health and medical
22:39providers are trained in eating
22:41disorder care than we actually need.
22:43There need to be more resources for
22:45treatment for patients and families.
22:46There are often long wait lists
22:49that allow the the disorder to to
22:51exacerbate or get worse before
22:54receiving care and we have to develop
22:56higher standards of care which
22:57just aren't available currently.
23:01So highlighting the severity,
23:03highlighting the need,
23:05what are we doing about it at Yale,
23:08what's been done to address
23:09the problem is you know,
23:11really acknowledging the reality
23:12of of the severity and increase
23:15of cases that we've seen.
23:16I highlighted the,
23:17you know what has happened with the
23:19numbers overall in the pandemic.
23:21I would say we're continuing to see that
23:23escalation while while it ebbs and flows,
23:25I know just recently we had five
23:27patients in the Children's Hospital with
23:29being hospitalized on the Pediatrics
23:31floor for the medical complications
23:33associated with restrictive eating.
23:35So we don't see this
23:37slowing down anytime soon.
23:39What we've done to address that need
23:42kind of given given the state of the
23:44field and and those different issues
23:46with resources that we have talked
23:48about of just kind of as a a field
23:50generally is trying to be creative
23:52and innovative in the collaboration
23:54with the Children's Hospital.
23:56So collaborations with the
23:58Pediatrics team for these youth
24:00that are medically hospitalized.
24:02So these patients are managed by our
24:04consultation liaison team who serve or
24:06youth that are medically hospitalized
24:08requiring psychiatric supports.
24:10There's weekly case rounds where
24:11the youth with eating disorders
24:13are rounded on by both the medical
24:15and psychiatric team as well as
24:17other members caring for them,
24:19including nursing child life,
24:23doing trainings, teaching didactics
24:25with the Pediatrics team as well as
24:27the consultation liaison team and
24:29educating on eating disorder care.
24:31And trying to revisit our clinical
24:32pathway that we use to care for these
24:34patients to try to keep it as up to date
24:36as possible to provide the best care.
24:40We've also done is the necessity
24:41of providing bridging plans for
24:43patients due to wait list there.
24:44As I had kind of started to allude to,
24:48there is a significant kind of dearth
24:50of resources in the community for this
24:52patient population that is in a lot
24:54of ways you know largely connected
24:55to that niche area that it's become.
24:58So often we have patients that
25:00once medically stabilized,
25:01they're still not the right next
25:03treatment for them immediately available.
25:05And so we're having to create these
25:07bridging plans to not unnecessarily
25:08keep them in the hospital people
25:10either without kind of access to
25:13necessarily an eating disorder mill you.
25:16We're working to create innovative
25:18and responsive treatment care
25:19models for complex patients.
25:21So as I had you know already said
25:23that the eating disorder very
25:25infrequently happens in the vacuum.
25:27And so we've more and more frequently
25:29see youth coming in with those concerns,
25:31but also having suicidality
25:33or other mood concerns.
25:34And because treatment models
25:36are often very separate,
25:37we have to think about how do we bridge
25:39that and provide more appropriate care,
25:43finding ways to provide training
25:45education to clinicians within the Child
25:48Study Center across levels of care.
25:50And that who are often working with
25:52these patients whether it be outpatient
25:54or in home services who are also
25:57coordinating with their medical teams.
25:59And then thinking about the goals for eating
26:01disorder care at the Child Study Center.
26:02Building on this work
26:04that's already been done,
26:05we're working to build more robust
26:07eating disorder care in partnership
26:09between the Child Study Center and
26:11Neil New Haven Children's Hospital.
26:13This is something that in in kind of
26:15moving those efforts forward has been
26:17primarily led by the Child Study Center
26:19and with mental health lead and with
26:22the interdisciplinary partnership with
26:24Pediatrics and nutrition with really
26:27that goal again not to shy away from
26:30those high risk complex presentations,
26:33really another goal addressing the
26:35limited community referral options.
26:36So that can be done in a number of
26:39ways through both increasing those
26:41outpatient services affiliated
26:42directly with Yale or through
26:44community partnerships and trainings.
26:46So again training of community providers
26:49within the Yale system and developing
26:51more of those bridging services,
26:54trying to think about and other goals
26:56of developing that streamline pathway
26:58from those youth requiring that medical
27:00inpatient stabilization to outpatient care.
27:02So once somebody is brought into the system,
27:05what are the steps to getting them back out
27:08safely knowing that it's not, you know,
27:10kind of one stop and then back out.
27:12This includes that aim of utilizing
27:14sites within the Yale New Haven
27:17Children's Hospital Network,
27:18including the initiative to begin to
27:21utilize places like Bridgeport Hospital
27:23for stabilization of these patients and
27:25ensuring the most robust supports there
27:27available that are needed to support
27:29this patient population that has been
27:31built up at our York Street campus.
27:35Really another goal of maintaining that
27:37mindset of the multiple systems level
27:39approach that is needed in partnership with
27:42colleagues throughout our departments.
27:44So given such a complex high
27:47risk patient population,
27:49not just think about who is
27:50directly caring for this patient,
27:51but where will this patient be
27:53going next And and really thinking
27:56about helping it to be as fluid a
27:58process for families as possible.
28:01And this is where we start with the
28:03need and the goal of prioritizing an
28:05ambulatory program that can provide
28:07that interdisciplinary support to
28:08a patient and their family when
28:11those concerns are emerging.
28:14And then of course one of the other,
28:16you know really,
28:17really crucial and I would say
28:19critical goals and priorities being
28:21a prioritizing training of fellows
28:23throughout the departments including
28:25the child study center in Pediatrics.
28:27To get away from this idea,
28:28from it being a niche area of training
28:31and really trying to focus on kind
28:34of broadening the exposure for
28:35trainees and professionals working
28:37with this patient population,
28:38this as it's critically needed for care.
28:41And so well the the Child City
28:43Center and Children's Hospital has
28:45done a lot to to work through some
28:47of these challenges and to be able to
28:50address this continued increasing need.
28:51There continues to be a lot of goals
28:54for those next steps and and as you
28:56know it's been highlighted throughout
28:58the field is where we're continuing to
29:00see the increase in need and trying
29:03to evolve dynamically as a center
29:06and a hospital system to meet that
29:09need for this patient population.
29:11And figuring out how to to to best
29:14serve a patient population that does
29:15pull on on resources quite a bit and
29:17to be able to deliver the the best
29:20care for that patient population.
29:25Thank you very much for
29:26for attending the webinar.
29:27I hope that you know the note that I
29:30really do want to end on is with the
29:32hope of despite us seeing the dire
29:34need in the field on the increase
29:36in severity and presentations that
29:37somewhere like the child study
29:39center you know New Haven Children's
29:41Hospital has the infrastructure and
29:42the right sports in place to meet
29:44that need and and the right vision
29:47to continue to innovate and move
29:49those move that process forward.
29:52Thank you.