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State Approaches to Improve Comprehensive School Mental Health Systems
The COVID-19 pandemic has negatively impacted the mental health of many children and adolescents and reduced students’ access to comprehensive school mental health systems (CSMHS) as schools shifted to remote learning.
In recent years, states have implemented policies that have successfully expanded access to CSMHS. Lessons learned from these initiatives can help address students’ growing mental health needs and may help reduce states’ health care costs by decreasing mental health-related emergency department visits, which have escalated during the pandemic.
Background
The availability of a comprehensive behavioral health system is critical to a child’s health and well-being. Nearly 17 percent of children and adolescents have a mental health condition, yet almost half of these children do not receive needed treatment. This is more pronounced among children and youth who are Black, Latinx, and come from other racial and ethnic minority groups, which disproportionately face barriers to accessing quality mental health care. These disparities have been amplified by the COVID-19 pandemic. A lack of regular, accessible mental health programs, services, and supports may lead to greater use of emergency departments, which are costlier and often lack appropriate policies to serve children with mental health needs, such as how to transition children and adolescents to other services and provide appropriate care coordination.
Schools are a primary source of mental health services for children and have been shown to improve students’ access to mental health programs, services, and supports. This is true for an increasing number of students, as the percentage of adolescents receiving mental health services and supports in educational settings has grown from 12 percent in 2011 to 15 percent in 2019.
A CSMHS approach is a best practice identified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS). Schools can use this approach to support:
- Prevention of mental health needs among all students;
- Early identification of students and intervention for those who are at risk; and
- Services and treatment for those who have mental health needs.
A CSMHS also supports adherence to treatment, decreased stigma, and improved educational attainment. Implementing and expanding a CSMHS may also help to reduce racial and ethnic disparities in school responses to students’ behavior by encouraging mental health services over punishment. Children and youth with mental health needs who are Black and Latinx are more likely to receive punishment instead of mental health care services in comparison to White children.
A CSMHS is one component of a system of care for children and youth with special health care needs (CYSHCN) and behavioral health needs, and can be considered within a broader framework of policies to support mental health of children and adults.
Federal Policy
There are a variety of federal initiatives that support state efforts to develop and expand these critical school programs, including:
- The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) provides funding at state and local levels to promote health and well-being through schools, including programs and services to support students’ mental health;
- SAMHSA’s Project Advancing Wellness and Resilience in Education (AWARE) provides funding to state education agencies to partner with state mental health agencies to increase awareness of mental health in schools, provide training to school staff, and connect students with behavioral health needs to services; and
- The School-Based Mental Health Services Grant Program, authorized by the 2020 Department of Education budget, provides $10 million to six states to increase the number of mental health service providers in schools.
The Biden Administration has underscored the importance of behavioral health services for students by setting a goal to double the number of mental health professionals in schools. The day after his inauguration, President Biden issued an executive order stating that the federal government will support states in promoting mental health and social-well-being in schools, and the American Rescue Plan Act of 2021 that was signed into law in March 2021 allocates more than $120 billion in grants to states through the Elementary and Secondary School Emergency Relief Fund. The majority of this funding will be distributed to local education agencies, which could use these subgrants to provide mental health services and supports and to implement interventions that address learning loss while responding to students’ emotional needs, among other purposes.
State Policy Considerations
Schools have adapted to shifting priorities over the past year and continue to implement innovative strategies to meet students’ growing mental health needs. During the pandemic, several states have introduced legislation to support schools in various ways to enhance their mental health programs during and after the pandemic.
- Implementing statewide task forces. Schools face a variety of barriers to developing CSMHSs for students, including allocating adequate funding, adhering to data privacy regulations, and identifying and implementing best practices. To support school districts’ diverse needs, states are forming committees to review existing approaches and make recommendations to improve mental health programs. This process may be particularly helpful to identify and address emerging challenges and strategies during and after COVID-19.
In 2017, North Carolina created the Superintendent’s Working Group on Student Health and Well-Being to produce recommendations to support students’ mental health, which were released in a report in May 2018. In October 2020, Illinois introduced legislation that would create a similar mental health task force consisting of mental health providers, school nurses, state General Assembly members, school board members, principals, parents, and students to produce recommendations in 2021.
- Developing mental health policies in schools. Clear policies at the state and local level can support comprehensive, consistent, and appropriate approaches to addressing students’ mental health needs in schools. State policies can provide guidance for local school districts regarding expectations and best practices, while allowing flexibility for schools to meet their students’ specific needs while considering the local context.
On June 8, 2020, North Carolina enacted SL 2020-7 S476, which implemented recommendations from the state task force. This law requires the Department of Public Instruction to adopt a statewide, school-based mental health policy, and requires each school to adopt its own policy following task force recommendations.
- Supporting universal screening practices. Widespread screening for children’s behavioral health needs is a recommended best practice. While schools have a unique opportunity to screen a high proportion of their students for behavioral health needs, less than 15 percent of schools have implemented a universal screening process. States are supporting schools by issuing recommendations for schools to increase mental health screening among students and guidance for funding for these services.
New Mexico requires in its administrative code that schools screen all students for health and well-being, including behavioral health needs. The state has developed guidance on funding sources for screening services, which may include operational funds, Title I and Title III funds, and Coordinated Early Intervening Services funding through the Individuals with Disabilities Education Act. In January 2020, New Jersey introduced legislation that would require schools to provide annual depression screening for students in grades seven through twelve.
- Expanding the availability of mental health services in schools. Few schools meet the recommended student-to-staff ratios for counselors, psychologists, nurses, and social workers due to a lack of funding and workforce shortages. States are enhancing CSMHSs through policies that provide funding to increase the availability of mental health professionals in schools and support partnerships with community-based behavioral health agencies.
Washington, D.C. has made significant efforts to support the expansion of behavioral health services to all students by earmarking local and federal funding and increasing funding over time for schools to develop partnerships with community-based mental health services. In October 2020, New Jersey introduced legislation that would require all public school districts to have at least one school counselor and to meet a maximum student-to-school counselor ratio of 250 to 1 – the national recommended ratio.
- Improving mental health training and education. School staff who are frequently in contact with students are an important resource to support students’ mental health. States are providing guidance and support to train these staff to identify indicators of mental health needs among students and facilitate appropriate referrals. States also advise on school curricula and education that support mental health awareness among students.
North Carolina’s SL 2020-7 S476 requires the state’s mental health policy to include a model mental health training program for school staff that local school districts must adopt. All school staff who work with students in grades K-12 must be trained in youth mental health, suicide prevention, and other mental health-related topics. Pennsylvania introduced similar legislation in September 2020 that requires schools to train school staff in identifying signs of depression and referring students and their families to mental health services.
Conclusion
Comprehensive school mental health systems are an important component of systems of care for CYSHCN and behavioral health needs. The National Standards for Systems of Care for CYSHCN, which were developed by a national work group of state and national health policy leaders, is a valuable resource that states can use to guide improvements to systems of care for CYSHCN, including considerations for mental health systems. States can implement systems based on the following standards to improve care for CYSHCN during and after COVID-19, including:
- Improve mental health care access, especially for marginalized communities;
- Increase the use of medical homes serving individuals with chronic and complex conditions;
- Improve coordination of care across behavioral health, social and health systems; and
- Improve access to CSMHS.
Schools have played an important role in supporting students’ mental health, but often face challenges in implementing CSMHS. Mental health needs among children and adolescents have been rising for several years, and this trend has been exacerbated by the pandemic. One way that states can address this is through policies that strengthen CSMHS to support students during and after the pandemic. The National Academy for State Health Policy will continue to track state policies that support CSMHSs during and after the COVID-19 pandemic.
State Strategies to Support the Health Needs of Children with Special Needs in Schools during COVID-19
Children and youth with special health care needs (CYSHCN) and their families face unique hardships in accessing school-based health services during COVID-19, especially children of color, those experiencing poverty, and those living in rural areas who have limited access to technology and acute socioeconomic needs.
States are developing unique strategies to support the health needs of CYSHCN who lack access to their usual school-based physical, developmental, and mental health supports.
These approaches include:
- Upholding requirements mandated by the Individuals with Disabilities Education Act (IDEA) and in particular, Individualized Education Plans (IEP);
- Holding or prioritizing in-person learning for specific populations of children (e.g., CYSHCN, children experiencing homelessness);
- Expanding Medicaid coverage of telehealth in schools; and
- Expanding Medicaid coverage of home health services.
How COVID-19 Impacts CYSHCN
CYSHCN require health care services and supports beyond what children normally require and account for about 20 percent (14.6 million) of US children and youth. Rates are higher across racial and ethnic demographics, with about 25 percent of non-Latinx Black children and youth reporting special health care needs, for example. This inequity is driven by a combination of systemic issues, including factors such as lower rates of access to robust medical homes and lower quality of received care among Black and Latinx CYSHCN.
Recent data from the Centers for Disease Control and Prevention (CDC) shows that children who self-identified as Hispanic, non-Hispanic Black, and Native American/Alaska Native with underlying medical conditions make up nearly 80 percent of children who died from COVID-19. These racial and ethnic inequities are a result of a range of socioeconomic issues including: systemic racism; lack of access to healthcare; education, income, and wealth gaps; and crowded housing conditions. Inequities among CYSHCN have been heightened by the loss of school-based services that provide physical, behavioral, and developmental services and supports.
A May 2020 survey conducted by ParentsTogether found that just one in five parents reported that their children received all the school support services required by their IEP as schools moved to virtual instruction. As school opening policies (in-person, virtual, hybrid) are changing on a weekly basis, it is important for states to closely monitor and improve the accessibility of school-based health services for CYSHCN both in-person and virtual settings.
The US Department of Education released guidance early on in the pandemic requiring local education agencies (LEAs) to provide students with disabilities access to the same educational opportunities provided to the general student population, including the provision of free appropriate public education (FAPE) during the COVID-19 outbreak. The guidance requires schools to uphold the services in a student’s IEP – a tailored education plan designed to meet the unique needs of children with special needs – and requirements under IDEA during any school changes, as a result of the pandemic.
To support districts in their transition to virtual learning during COVID-19, the Georgia Department of Education was awarded $6 million in federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and IDEA funding. The Georgia State Board of Education allocated $3 million to supplement the state’s special education program, including the delivery of IEP plans. Pennsylvania is taking a similar approach, allocating $20 million from the Governor’s Emergency Education Relief Fund and the state’s federal IDEA funding to bolster remote services and supports for students with complex needs and provide services to students with disabilities who experienced a loss in skills or a lack of progress due to school closures.
State Strategies
States have prioritized children with special needs for in-person learning due to their unique needs for access to services and supports, and the current challenges they face in accessing in-person learning. In late August, the California Department of Public Health issued rules to allow for opening of schools to small cohorts of students with “acute needs.” The guidance encourages LEAs to prioritize students with disabilities who receive specialized services, such as occupational therapy, speech and language services, and other medical, behavioral, and educational support services. These cohorts are limited to 14 students and two supervising adults.
Oregon is taking a similar approach by allowing schools to bring a limited number of students (up to 10 per cohort) for up to two hours of in-person instruction daily. Students who receive special education services, are learning English, or lack reliable internet access, are prioritized for in-person learning. It is important for states that have already transitioned students back to in-person instruction to design and implement policies to protect the health of CYSHCN and other vulnerable students. A recent National Academy for State Health Policy (NASHP) blog, State Strategies to Safely Transition Children with Special Health Care Needs Back to School, highlighted additional state strategies to safely transition CYSHCN back to physical school settings.
States are also using telehealth and home health services to increase accessibility to care for CYSHCN that previously received these services in a school-based environment. Since the onset of the pandemic, 31 states have released guidance allowing Medicaid reimbursement of school-based telehealth services and nine are allowing reimbursement of school telehealth services for the first time.
Pennsylvania, South Dakota, and Texas are newly allowing Medicaid reimbursement for school-based audiology, counseling, and occupational, physical, and speech therapy telehealth services. Other states, such as Ohio and Wisconsin, are working on making their telehealth-in-school Medicaid policies permanent post-COVID-19. Additionally, most states are allowing telehealth services to be delivered via audio-only format and with widely available tools, such as Zoom and FaceTime, to make services more accessible.
States are also updating their Medicaid waiver rules to meet the health and educational needs of CYSHCN during remote learning sessions. The North Carolina Department of Health and Human Services recently worked with the Centers for Medicare & Medicaid Services (CMS) to allow families to use Medicaid waivers for home health services delivered at the same time that students are engaged in virtual learning. Families were previously prohibited from doing so because of restrictions on the use of federal funds from different programs (health and educational), as both home health and virtual school services rely on federal funding. North Carolina’s new Appendix K Waiver increases in-person physical health and therapeutic supports for CYSHCN who lost access to these services due to remote learning.
As states consider new policies to better support the health needs of CYSHCN in virtual and in-person educational settings, it is important to consider:
- What specific policies can be developed to support the unique needs of Hispanic, non-Hispanic Black, and Native American/Alaska Native CYSHCN who are disproportionately affected by COVID-19 and school closures?
- Can policies such as expanding Medicaid coverage of telehealth in schools and increasing funding for special education services be leveraged beyond the COVID-19 public health emergency to strengthen care for CYSHCN?
- What role will federal funding play in alleviating state budget pressures as they navigate COVID-19-related shortfalls?
- Can states continue to finance Medicaid-reimbursed home health services in supporting CYSHCN during remote instruction?
NASHP will continue to monitor school-based health policies during the COVID-19 pandemic and the implications for CYSHCN and their families.
State Approaches to Family Caregiver Education, Training, and Counseling
State Medicaid home- and community-based waivers and state plan amendments can provide critical information, counseling, and training to family caregivers. Recently, the National Academy for State Health Policy (NASHP) reviewed states’ Medicaid 1915(c) and 1115 waivers, and 1915(i) and 1915(j) state plan amendments (SPAs) that focuses on waivers and state plan amendments covering older adults and adults with physical disabilities, to highlight their unique approaches to training and supporting caregivers.
Family caregivers provide increasingly intense and complex care that requires them to learn how to perform difficult medical and nursing tasks. Training and other supportive services offered through Medicaid waivers and state plan options can be important tools to assist the caregivers of Medicaid enrollees with long-term needs, promote better care, and potentially delay admission to higher levels of care. As many individuals are confined to their homes due to the COVID-19 pandemic, reliance on these services and supports provided by family caregivers is greater than ever.
Findings
Twenty-four states include education, training and counseling for family caregivers in their 1915c and/or 1115 waivers. Fifteen states use their 1915c waivers to provide these services; six states provide services through a 1115 waiver; and three (Minnesota, South Carolina, and Washington State) include services in both 1915c and 1115 waivers. While states often include these services (particularly within 1915c waivers), states varied greatly in identifying which caregivers were eligible for training, education, and/or counseling services and which services were provided. States also varied in their requirements for how the need for these services was documented.
States define informal or unpaid caregivers using a range of familial relationships. Florida, Rhode Island, and Utah define unpaid caregivers in their states’ waivers as “any person, family member, neighbor, friend, companion, or coworker who provides uncompensated care, training, guidance, companionship or support to a person served.” Georgia is the only state to specify that spouses, in particular, currently are not eligible for specific waiver caregiver education and training services. Georgia and Indiana specified in their waiver service definitions that caregivers had to live with care recipients to qualify as caregivers who could receive specific caregiver education and training services.
Several states make distinctions between paid and unpaid caregivers.
- Seven states (FL, CA, MD, OR, RI, UT, WA) provide education and training services for unpaid caregivers. For example, Washington State’s 1115 waiver includes education and training for unpaid caregivers through its Medicaid Alternative Care (MAC) program, and Rhode Island’s 1115 waiver includes unpaid caregiver training and counseling services.
- Four states (HI, PA, WI, MN) specify that both paid and unpaid caregivers may qualify for specific training services. Hawaii’s 1115 waiver and Pennsylvania’s and Wisconsin’s 1915c waivers specify that paid and unpaid caregivers can access specific services. Minnesota’s 1915c waiver specifies that only consumer-directed community supports services can be used to purchase training for paid or unpaid caregivers. Other waiver services are for informal or family caregivers, and its 1115 waiver mirrored the 1915c waiver.
States’ training and education includes a range of topics and modalities. Collectively, states list a range of different types of training related to medical care, including but not limited to education and training on:
- Specified medical equipment;
- Medical treatment;
- Personal care assistance;
- Medications;
- Performance of instrumental/activities of daily living (I/ADLs) or body movements; and
- Disease pathways or specific conditions.
Eight states (MA, MN, NJ, UT, TN, SC, WA, and WI) listed some kind of formalized training related to providing care. Collectively, states listed various types of services, including evidence-based programs, seminars, group training, or reimbursement for conference attendance. For example, Minnesota allows costs of training and conference registration fees to be included in training and education, but does not cover transportation, travel, meals, or lodging. One state, Maryland, explicitly excludes group or classroom training.
Several states also covered caregiver-specific services, such as:
- Financial support for attending caregiver-related training programs;
- Support groups;
- Non-psychiatric counseling services;
- Caregiver coping skills building; and
- Consultation services.
Hawaii, Iowa, Washington, Minnesota, and New Jersey specifically mention counseling or similar services aimed at caregivers. Iowa’s 1915c waiver includes counseling that could address adjusting to a care recipient’s disability or terminal condition. Two states, New Jersey and Washington State in their 1115 waivers, include training on coping skills as a caregiver support. New Jersey offers seminars, including a seminar on coping skills for caregivers of individuals with long-term care needs. Hawaii includes “supportive counseling” and family therapy in its waiver service list.
States require these services to be included in assessments and care plans.
All states with training, education, and/or counseling services for family caregivers include language in waivers that these services must be listed under a care or support plan, evaluation, service plan, therapeutic regimen, or some other type of identification or assessment in order to be reimbursed. Washington State’s 1115 waiver requires caregivers to complete a specified caregiver screening and, as needed, a specified caregiver assessment to determine qualification for specific tiers of services. Tennessee includes caregivers in its face-to-face assessment – assessing caregiver well-being and continued ability to provide care.
Conclusion
States have great flexibility with Medicaid waivers and state plan amendments to provide education, training, and counseling to family caregivers. Several states also incorporate flexibility into the types of training that can be provided to caregivers, often specifying a range of caregiver education, training, and/or counseling opportunities.
Recognizing that states depend on family caregivers to provide critical support to help relatives, friends, and neighbors, especially during the pandemic, NASHP will be publishing state resources on Medicaid policies supporting family caregivers through the RAISE Act Family Caregiver Resource and Dissemination Center with support from The John A. Hartford Foundation and in collaboration with the US Administration for Community Living. NASHP will analyze topics including respite services, reimbursement for caregivers, and paid leave in its future work.
Note: State-only funded programs as well as waivers and amendments for children and people with intellectual/developmental disabilities are not included in this analysis.
Information for Wyoming and Kentucky was not available for this analysis.
States Can Use CARES Act Funding to Support Health-Related Social Needs Exacerbated by COVID-19 Pandemic
State officials are working tirelessly, taking aggressive steps to flatten the curve to stop community spread of coronavirus (COVID-19); their responses are varied and based on evolving guidance from the US Centers for Disease Control and Prevention (CDC).
As schools and non-essential businesses close, access to services that support health and well-being become more challenging, especially for those who already experience health disparities, such as homelessness, housing insecurity, and poverty. Individuals, families, and communities at greatest risk may be least able to follow physical distancing recommendations.
To help stop the spread of COVID-19 and assist people with health-related social needs, states are addressing housing, food, transportation, education, and employment needs. The Coronavirus Aid, Relief, and Economic Security (CARES) Act will also provide support to states to help support health-related social needs.
Below are examples of how states can address new needs, including housing, food, transportation, education, and employment, and how the CARES Act can support and amplify their work.
Housing: Homeless or housing-insecure individuals are at unique risk and more susceptible to the spread of COVID-19 because they have limited places to self-quarantine or isolate. These individuals may not have access to running water to practice safe hand-washing techniques. Title XII of the CARES Act includes funding to help sustain and expand states’ investments in homeless services and other emergency measures to ensure those individuals are able to stay healthy and to lessen the risk of community spread. These funds are intended to prevent, prepare for, and respond to COVID-19 and include appropriations of:
- $4 billion in Homeless Assistance Grants, available until Sept. 30, 2022;
- $1.25 billion to the Tenant Based Rental Assistance program, available until expended;
- $1 billion to the Project Based Rental Assistance program, available until expended;
- $6.85 million to the Public Housing Operating Fund, available until Sept. 30, 2021; and
- $5 million to the Office of Public and Indian Housing, available until Sept. 30, 2021.
The CARES act also appropriates funds for communities at higher risk of infection from COVID-19, including, under Title X, a $14.4 billion investment for veterans who are homeless or at risk of becoming homeless and under Title XII, $50 million directed to Housing for the Elderly, and $15 million to housing for people with disabilities, with funds available through Sept. 30, 2023.
- Examples of states’ current investments in shelter and emergency housing:
- California has authorized $150 million to protect homeless Californians from the spread of COVID-19. About $100 million is directed towards local government for shelter support and emergency housing to address COVID-19 in the homeless population and $50 million is directed to purchase trailers and lease rooms in hotels, motels, and other facilities in partnership with cities and counties throughout the state for immediate isolation placements for homeless individuals.
- Washington State’s Department of Commerce announced it is making $30 million available to use to expand shelters, buy more cleaning supplies, and other strategies, such as leasing motel rooms.
- State and federal initiatives to halt eviction processes:
- States, including New York, California, Maryland, and North Carolina, have implemented differing versions of a moratorium on evictions of residential and commercial tenants to ensure rent-insecure individuals do not lose their housing during this crisis and become more at risk. California’s order instructs its Public Utilities Commission to oversee customer service protections for services such as water, Internet, gas, and cell phone services.
- The US Department of Housing and Urban Development announced on March 18, 2020, an immediate foreclosure and eviction moratorium for single family homeowners with FHA-insured mortgages until the end of April.
- The CARES Act (Title IV Sec. 4024) also requires a temporary (120-day) pause on evictions proceedings, for any covered housing program as defined in section 41411(a) in the Violence Against Women’s Act, any rural housing voucher program, or has a federally backed mortgage loan.
Education: Most states (48 states and Washington, DC as of March 29, 2020) have closed schools and many are working to implement distance learning to comply with the CDC’s guidelines restricting social interactions. Distance learning is a strategy to keep not only children safe, but also their families, teachers, and administrators. However, it is important to consider that not all children and families have the appropriate technology or Internet capabilities at home to continue their education. School shutdowns illuminate the country’s “digital divide” – those who have access to the Internet and technology and those who do not – and demonstrates the inequities between wealthy and poor school districts, which can perpetuate and possibly worsen socio-economic and other disparities for individuals who have faced discrimination and are already underserved.
The CARES Act (Title VIII Sec. 18001) appropriates $30.75 billion in grants to school systems and higher education institutions to remain available through Sept. 30, 2021 through the Education Stabilization Fund, which provides emergency funds to aid in the continuation of educational services and supports both domestically and abroad. The act directs 1 percent of these funds for grants to states with the highest COVID-19 burden.
- Using state and federal funds allocated through public-private partnerships and local jurisdictions, many school districts, including in Connecticut, Florida, and Montgomery County, Maryland are distributing laptops and other technology as well as information about Wi-Fi hotspots to students, and encouraging parents of students with disabilities to reach out for extra support. New York City is prioritizing iPad distribution for students in temporary housing. Every district is trying to address the challenge of the digital divide in their community, including making hard-copy resources available for students who do not have immediate access to the Internet, and providing free Wi-Fi hotspot services from buses.
- The US Department of Education (DOE) announced it will approve waivers for any state that is unable to assess their students through standardized tests and report cards for the remainder of the school year due to the ongoing COVID-19 emergency. This change was implemented to protect student’s health and safety. DOE has approved these waivers in several states, including Arkansas, Colorado, Florida, Georgia, Indiana, Michigan, Oklahoma, Pennsylvania, Tennessee, and Washington State, and more states are considering this option.
- Virginia and Kansas have already announced their schools will be closed for the remainder of the school year, and other states may also close schools.
Food: Assuring access to healthy food, a critical determinant of health, is a challenge during a pandemic. States have determined that grocery stores are essential businesses, and food store workers are considered part of the critical infrastructure. To ensure underserved individuals maintain their ability to access healthy food in a safe way consistent with CDC guidelines, states are implementing various strategies. Additionally, the largest anti-hunger federal initiative is the Supplemental Nutrition Assistance Program (SNAP), and to ensure continuation of SNAP funding, the CARES Act (Title VI Division B) directs $15.8 billion to remain available until Sept. 30, 2021. Of this amount, $15.5 billion must remain in a contingency reserve until the secretary deems the funds necessary. The CARES Act (Title VI Division B also appropriates $8.8 billion to Child Nutrition Programs, also available until Sept. 30, 2021. Several state and strategies to ensure at-risk populations have access to nutrition are listed.
- Providing meal delivery services:
- The school lunch program is the second-biggest anti-hunger initiative after SNAP. To ensure students who receive free or reduced-price lunches at schools do not go hungry while state-mandated school shutdowns are in place, at least 25 states were approved for US Department of Agriculture (USDA) waivers that authorize school meal distribution. Maryland and Florida have developed websites with interactive maps of the states’ locations for grab-and-go meals. Cities and counties are working in collaboration with states to ensure all students are able to get their meals, even if they are living with at-risk relatives. Loudoun County in Virginia, Wayne Township in Indiana, and Cambridge, Massachusetts are all using school buses to deliver meals to those students.
- Arizona, California, Ohio, and Texas governors all directed their National Guard units to be on alert to aid in food delivery for vulnerable populations, including elderly individuals.
- The CARES Act (Title VI Division B) appropriates $100 million for the USDA Food Distribution Program directly to Native American reservations.
- Arizona and Iowa’s approved 1135 waivers for Medicaid Emergency Authority both expand eligibility for home-delivered meals. Arizona’s waiver expands access to all eligible populations, and Iowa’s waiver expands eligibility to non-waiver members who are home-bound and waiver members even if the waiver does not have meals as an allowable service.
- Modifying restaurant services:
- Most states (42 states and Washington, DC as of March 25) have halted “dine-in” options for restaurants and bars to slow and limit the spread of the coronavirus. For example, the Colorado Department of Public Health, like many other states, issued a public health order to close bars, restaurants, and other establishments though they are still permitted to provide delivery service, window service, and drive-through services with precautions.
Transportation: Access to transportation services is an important determinant of health, but to aid in social distancing and limit spread, states are recommending people limit their use of public transportation by working remotely and using telemedicine services to reduce unnecessary travel so that public transportation can be safer for those who depend on it, such as transit operators, essential health care workers, and grocery store employees. The CARES act (Title XII) also appropriates $25 billion in funding, available until expended, to support this the infrastructure of operating expenses for transit agencies related to the response of to the coronavirus public health emergency.
- Modifying public transportation services:
- Several state and city transportation systems, including the Maryland Department of Transportation, Massachusetts Bay Transportation Authority, and Washington Metropolitan Area Transit Authority, are limiting service for essential travel only.
- Relaxing telehealth requirements
- States are rapidly relaxing telehealth requirements to address coronavirus symptoms. For example, the Massachusetts Department of Public Health issued guidance that all insurers are required to cover medically necessary telehealth services in the same manner they cover in-person services. Texas and Michigan have issued guidance that allows providers to establish patient-physician relationships via telemedicine, including phone calls. Other states, including Louisiana and West Virginia, are relaxing Medicaid requirements to allow emergency and non-emergency evaluation visits to be conducted via telemedicine. These changes are vital to ensure that everyone in the state can still access health services while taking precautions against unnecessary potential viral spread.
- The CARES Act (Part II Sec. 4213) reauthorizes Health Resources and Services Administration’s (HRSA) grant programs that promote telehealth services, which offers flexibility for Medicare patients at risk of contracting COVID-19, and aids in screening patients avoiding their exposure to others.
- The CARES Act (Part II Sec. 4214) also reauthorizes HRSA grant programs that strengthen rural community health through quality improvement, increased access to care, and improvement in coordination to care. This is especially important because rural residents are disproportionately older and more likely to have a chronic disease, which increases their risk for coronavirus.
Employment benefits: Many states, including Maryland, New Jersey, and North Carolina, have implemented telework policies and are encouraging all employers to allow telework opportunities to aid in social distancing. However, many state employees, including sanitation workers, health workers, and retail workers do not have the ability to work remotely, and require protection and benefits to ensure they stay healthy and able to do their jobs. Many retail workers are part-time hourly employees and do not have access to sick leave so states are taking initiatives to create equitable policies for their more vulnerable residents who are providing critical services during this pandemic. The federal government is following states’ lead in developing policies to support individuals with benefits and supports that are essential to respond to the pandemic.
- Classifying emergency workers:
- Minnesota and Vermont have classified grocery store workers and food distribution workers as essential personnel. This change classifies grocery and food distribution workers as first responders, critical to their states’ response to coronavirus. This classification qualifies them for special child care provisions. This is especially important because these workers tend to be paid hourly, and often do not have access to comprehensive benefits.
- The CARES Act (Title VIII) proposes an additional $3.5 billion in funding to states and territories, available through Sept. 31, 2021, through the Child Care and Development Block Grant to provide childcare assistance to low-income families. The funds may also be used for continued payment and assistance to child care providers to health care employees, emergency responders, sanitation workers, and other employees deemed essential to the response to coronavirus.
- Paid sick leave:
- Several states have paid sick leave policies in place. When Colorado declared a state of emergency on March 10, 2020, the declaration allowed workers in certain covered industries, including hospitality, food services, child care, education, transportation, and home health, up to four days of sick leave when experiencing flu-like symptoms and awaiting test results for COVID-19.
- The CARES Act (Subtitle C Sec. 3602) authorizes paid sick leave benefits for employers with employees who are sick or seeking care for coronavirus or need to take leave to care for quarantined individuals, including their children. The payments are capped at $511 per day per employee who is sick or seeking care, and $200 a day for employees who are caring for a sick family member.
- Unemployment benefits:
- States are creating unemployment compensation benefit plans. For example, Alabama and Pennsylvania have implemented a policy to allow individuals who are employed but unable to work because of COVID-19 to file for unemployment benefits.
- The CARES ACT (Title II Sec. 2102) creates a temporary Pandemic Unemployment Assistance program to provide payment to individuals who are not eligible for traditional unemployment benefits (e.g., self-employed, independent contractors, those with limited work history, and others) and are unable to work as a direct result of the coronavirus public health emergency for reasons including:
- They are seeking a COVID-19 diagnosis;
- Are providing care for someone sick with COVID-19;
- Are providing care to a child or someone in their household who is unable to attend school or another facility that has been closed because of c COVID-19;
- Are unable to get to work because of a COVID-19-related quarantine. Individuals who have the ability to telework with pay or are receiving paid sick leave or other paid leave benefits do not qualify for these funds.
- These funds are available to those who experienced unemployment, partial unemployment, or inability to work from Jan. 27 through Dec. 31, 2020.
State policymakers have led the way in taking aggressive steps to address the impact and stop the spread of COVID-19. They have recognized that vulnerable populations need special attention and protections and have launched efforts to address a myriad of health-related social needs. The federal government is adding needed support through the CARES Act, which will allow states to invest in their residents’ social and medical needs. Many of these efforts are stop-gap measures in a time of crises and raise questions about how policies will continue to address the health and social disparities that the crisis exacerbates after the immediate emergency period is over.
In a Washington Post op-ed, Richard Besser, president of the Robert Wood Johnson Foundation, notes, “Every long-term solution must be viewed through the health equity lens, for if they are not, we’ll be setting the stage for our next public health failure.” States are working hard to address both health and health-related social needs emerging from COVID-19, and the National Academy for State Health Policy will continue to track implementation of state’s critical policies to assist states with replication.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
The State of States: How Governors Plan to Address Health-Related Social and Economic Factors in 2019
View a chart comparing the issues each governor addressed.
Governors’ state of the state and inaugural addresses provide critical insights into their policy proposals that impact the health of their residents. Last week, the National Academy for State Health Policy (NASHP) highlighted the health care issues governors raised in their 2019 addresses. This week, NASHP examines the social and economic issues raised – such as poverty, violence, housing, education, and addiction — that heavily impact the health and well-being of Americans.
By early February, 2019, 48 governors, including 20 newly elected, had outlined policy priorities in their speeches.* Of the health-related social and economic factors identified in their speeches, governors most commonly mentioned plans to address education, jobs, and infrastructure, followed by opioids and the environment. Other topics included violence prevention, child welfare, justice, equity, and cannabis. Ten governors discussed plans to develop new government structures to coordinate services efficiently.
Given that health is shaped by myriad conditions in which people live, work, and age, it is not surprising that many topics interrelate and cross sectors. For example, governors who mentioned plans to address workforce training and job readiness touched on both education and employment as key issues.
Of the 40 governors who addressed education, many highlighted early education, student health and mental health, student debt relief, and increased resources for schools:
- New Mexico Gov. Michelle Lujan Grisham: “I reject the false choice of today’s children or tomorrow’s budget. We must dramatically increase our Pre-K and educational investments today and provide sustainable revenue for the long term. I have also proposed an expansion of the Working Families Tax Credit, which we know creates a ladder out of poverty, providing child care programs so parents can continue to get meaningful support even as they do the hard work to transform themselves and their family’s fortunes for the better.”
- Ohio Gov. Mike Dewine: “Our plans to intervene early in the lives of at-risk kids, to address their physical and emotional needs, and to give them better, higher-quality educational opportunities — all will be undertaken in the faith and hope and confidence that these children will flourish and grow and that their lives will be forever changed by the things that we do. Education is the key to equality and to opportunity.”
Of the 37 governors who addressed jobs, many focused on workforce readiness, public employee and teacher wages, and minimum wage:
- Nebraska Gov. Pete Ricketts: “The first pillar is making sure we’re connecting Nebraskans to great paying jobs and that they’ve got the skills to be able to take those jobs. … As previously announced, I am recommending the creation of the Nebraska Talent Scholarships program to help our community colleges, state colleges, and the university system attract even more students in targeted programs from engineering to health care with over 2,100 new scholarships. Additionally, I am recommending the expansion of the Developing Youth Talent Initiative to connect more middle school students to opportunities in manufacturing and IT with an additional $1.25 million annually. This program has already impacted 7,000 students, and this expansion will help reach even more.”
- New Hampshire Gov. Chris Sununu: “I will be proposing the state’s single largest ever investment into workforce training — a $24 million one-time investment — to grow our state’s nursing and health care workforce and double the number of those graduates in New Hampshire schools.”
Twenty-two governors mentioned plans to address the opioid epidemic. This analysis specifically focuses on the preventive aspects of their plans, including efforts to address mental health:
- Vermont Gov. Phil Scott: “In my first budget address, I talked about the most undeserving victims of our opioid crisis: the children born to addiction. That day — two years ago — I vowed we would not fail them. This budget continues to support our investments in prevention, treatment, recovery, and enforcement. And with an increased investment of $2 million to the Family Services Division, we can give these children more of the support, hope and opportunity they deserve.”
- South Carolina Gov. Henry McMaster: “Last year, I declared a statewide public health emergency, mobilizing the full power of the state’s emergency infrastructure in response to the growth of opioid addiction and abuse. And I signed what must be the most comprehensive set of laws in the country addressing this crisis across the spectrum of law enforcement, education, and health care…. For instance, our doctors are now required to educate minors and their families on the dangers of opioids before prescribing them; the Department of Health and Environmental Control is issuing tamper-proof prescription pads; the anti-overdose drug Narcan is more readily available; and initial prescriptions are now limited to seven days. I also established the Opioid Emergency Response Team, which in June released a plan consisting of recommendations on physical and public education, prevention and response, treatment and recovery, and law enforcement approaches.
Twenty-eight governors mentioned infrastructure issues, from high-speed internet to active transportation, to bridge and road repairs. Georgia Gov. Brian Kemp promised to bring high-speed internet to rural areas and Kansas Gov. Laura Kelly promised, “In the coming days, we will build an interconnected, strategic plan for rural economic development that leverages our communities’ unique assets. That means developing infrastructure.”
Twenty-five governors mentioned environment goals, including clean water, clean and renewable energy, climate change, and environmental protection:
- Maine Gov. Janet Mills: “The Gulf of Maine is warming faster than almost any other saltwater body in the world, driving our lobsters up the coast. Our coastal waters are growing acidic, temperatures are fluctuating, and sea levels are rising, endangering our shellfish industry. Our forests are less suitable for spruce and fir and more suitable for ticks. Climate change is threatening our jobs, damaging our health and attacking our historic relationship to the land and sea.”
- Florida Gov. Ron DeSantis: “Our economic potential will be jeopardized if we do not solve the problems afflicting our environment and water resources. …We will fight toxic blue-green algae, we will fight discharges from Lake Okeechobee, we will fight red tide, we will fight for our fishermen, we will fight for our beaches, we will fight to restore our Everglades and we will never ever quit, we won’t be cowed and we won’t let the foot draggers stand in our way.”
Sixteen governors called for increased access to affordable housing and/or reductions in homelessness:
- Nevada Gov. Steve Sisolak: “I will be supporting the recommendation to create a new program which will offer $10 million of state tax credits per year for the creation and preservation of affordable housing.”
- Oregon Gov. Kate Brown: “[W]e can speed up construction of 200 units of permanent housing for the chronically homeless. We also need to help Oregonians who have homes but are struggling with the high cost of rent. When problems arise, they need technical assistance to stay in their homes and not end up on the streets. We can help landlords and tenants navigate this tight housing market.”
Eighteen governors identified a need to prevent gun violence and improve school safety:
- Delaware Gov. John Carney: “[W]e provided schools with new resources to make them safer, and passed responsible gun safety legislation. This included the Beau Biden Gun Violence Prevention Act.”
- Mississippi Gov. Phil Bryant: “A problem exists in our schools today that threatens children of all ages. It has become commonly known as the active shooter… I will ask you to pass a comprehensive plan to keep our school children safe. …If you will pass and fund the Mississippi Safe School Act, our parents, teachers and administrators will be allowed to care for our children in a safe and protected environment.”
Thirteen governors mentioned the need for equity in educational, employment, and other opportunities:
- Texas Gov. Greg Abbott: “We must ensure destiny is not determined by zip code. Students from the most challenging circumstances can perform at the highest levels. But we have to give them the opportunity to succeed.”
- Washington Gov. Jay Inslee: “We’re the state that’s going to tear down the systemic barriers to work and education faced by people of color, people with disabilities, veterans and women. …We’re the state that embraces our differences and diversity… We’re the state making sure our government looks like the people it serves.”
Other topics that impact health include efforts to improve the justice system, enhance child welfare, and structure state government more efficiently:
- Indiana Gov. Eric Holcomb: “We’ll continue to be transparent and accountable on pressing issues like child welfare…. A year ago we had just started a top-to-bottom review of the Department of Child Services (DCS). Now, we are moving full speed ahead on addressing all those 20 recommendations that not only protect children but recognize the difficult work of those who protect them. It’s still early, but the investments we’ve made to increase caseworker salaries and improve the workforce culture are making a difference. The ratio of supervisors to case managers has improved, so there is more time for supportive supervision and coaching. Turnover among frontline staff is down and retention is up, which means more stability between caseworkers and the families they work with. And, fewer children are reentering the DCS system after their cases close.”
- North Dakota Gov. Doug Burgum: “We’re creating a unified IT Shared Service organization. Already, we have aligned the backend systems of 31 state agencies, saving more than half a million dollars… We created the Office of Recovery Reinvented to promote these [behavioral health] efforts with help from behavioral health professionals and community and tribal leaders.”
- Pennsylvania Gov. Tom Wolf: “Our differences haven’t stopped us from putting a down payment on criminal justice reform with the Clean Slate bill… I want us to be ambitious in imagining the Pennsylvania we can build together… Where we reform a criminal justice system that treats African Americans and the poor unjustly.”
Governors’ plans to address these social and economic issues have clear implications for their residents’ health. NASHP will continue to track these proposals and other, related state initiatives in the coming year.
* For some states, information from both a governor’s inaugural address and a state of the state address was included in this review. For others, information from only one speech is incorporated due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred, the inaugural address served as the governor’s primary policy speech and no state of the state address is planned, or the governor did not have an inauguration and delivered only a state of the state address. As of Feb. 5, 2019, Louisiana and North Carolina governors had not made speeches.
Produced in partnership with the de Beaumont Foundation and the Robert Wood Johnson Foundation.
A Class Act: Coming Together to Improve School-Based Health Services
Thursday, August 16th
10:00am – 11:30am
Integrating health services in school settings can promote student health and readiness to learn. This session focuses on cross-agency collaboration between Medicaid and schools to improve coordination and delivery of school-based health services. The session includes a national overview of school health services delivery models, and Ohio and South Carolina officials share best practices of effective health-education state partnerships, including successes, challenges, and lessons learned.
Moderator
Colleen Sonosky, Associate Director, DC Department of Health Care Finance
Colleen Sonosky, JD is the Associate Director of the Division of Children’s Health Services in the Health Care Delivery Management Administration in the District of Columbia’s Department of Health Care Finance (DHCF). DHCF is the agency responsible for the administration of the Medicaid program and the Division of Children’s Health Services oversees policies and procedures for Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services benefit—the pediatric component of the Medicaid program for children under 21. Ms. Sonosky serves as the District’s EPSDT Coordinator as well as the CHIP Director for the Medicaid-expansion program. In addition, Ms. Sonosky represents DHCF on the District-wide Child Fatality Review Committee, Interagency Coordinating Committee for Early Intervention, and the State Early Child Development Coordinating Committee (SECDCC) where she co-chairs the Health/Wellbeing Subcommittee. She has also served on many national work groups concerning maternal and child health.
Speakers
Anne De Biasi, Director of Policy Development, Trust for America's Health
Anne Ekedahl De Biasi is Director of Policy Development at the Trust for America’s Health (TFAH), a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority. She is responsible for defining the agenda and general strategy associated with the organization’s goal to create a modernized, accountable public health system and to integrate prevention into a reforming health care delivery and financing system. Previously Anne served as the first Director of Child Health Policy and Advocacy at Nemours, Director of Public Policy at the National Breast Cancer Coalition and Director of the Children’s Dental Health Project. She was President/CEO of the Oak Orchard Community Health Center and came to Washington, D.C. as a Robert Wood Johnson Health Policy Fellow, working as health care staff for U.S. Senate Majority Leader Tom Daschle.
Lesley Scott-Charlton, Ohio Department of Medicaid, Medicaid Health Systems Administrator
Lesley Scott-Charlton currently serves as a Policy Administrator with the Ohio Department of Medicaid. She has over 20 years of experience in public service, policy development, and systems administration. Mrs. Scott-Charlton spends a great portion of her time presenting on initiatives that serve Ohio’s children and families. Her Collaborative efforts include partnerships with the Centers for Medicare and Medicaid Services; the US Department of Health and Human Services; the US Department of Education; State and Local Government agencies; Managed Care Plans; Hospital Associations; and Community organizations. Ms. Scott-Charlton’s Associate Degree training was in the field of Mental Health/Chemical Dependency/and Developmental Disabilities. Her confirmed bachelor degree training is in the field of Social Work, and subsequently dual Graduate degree training in School Counseling and Clinical Counseling from Capital University in Columbus, Ohio.
Pete Liggett, Deputy Director, SC Dept of Health and Human Services
Pete Liggett, Ph.D., licensed psychologist, serves as the Deputy Director of Long Term Care and Behavioral Health for the South Carolina Department of Health and Human Services. His focus is guiding long term care and behavioral health policies as SCDHHS transforms these critical services and explores ways to better integrate long term care and behavioral health with primary care services. He joined SCDHHS in August 2012 as Director of Behavioral Health.
Mark Smith, Agency Lead, Medicaid School Program, Ohio Department of Education
Mark H. Smith MPA, BA, QIDP, CPM, Agency Lead, Medicaid in Schools Program, Ohio Department of Education, is currently an administrator with the Ohio Department of Education (ODE), serving as the agency’s Medicaid lead as well as its lead health services administrator. Mark also currently serves on the National Alliance for Medicaid in Education’s Board of Directors and has served as NAME’s Past President.
In his work, Mark has presented nationally on topics related to school-based health, data sharing between education and health arenas, parental consent, HCBS waivers, intellectual disabilities program design, electronic signatures protocol, and telepractice service delivery.
NASHP Identifies State Strategies to Address Mental Health and Education Inequities
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.[1]
| Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students. |
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
Notes
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
