Behavioral/Mental Health and SUD – Page 2 – The National Academy for State Health Policy

In November 2021, the Centers for Medicare and Medicaid Services (CMS) announced a series of new policies aimed at enabling access to behavioral health services via telehealth. The announcement comes as utilization of behavioral health services via telehealth has been on the rise, which is attributable to a couple of factors:

New flexibilities to use telehealth for both providers and patients to support access to health care throughout the COVID-19 pandemic; and
Increased behavioral health needs resulting from social isolation, economic challenges, grief, and other challenges spurred by the pandemic.

With increased access to, demand for, and utilization of behavioral health via telehealth, states are grappling with a number of challenges to ensure adequate yet quality access to remote behavioral services.

With Patient-Centered Outcomes Research Institute (PCORI) support, NASHP convened a call series with state health officials representing diverse agencies and programs, including Medicaid/CHIP, State Employee Health Plans (SEHPs), State-Based Exchanges, and Departments of Insurance, to discuss telehealth. Throughout these conversations, behavioral health emerged as a persistent theme and area of focus, as states seek to maintain robust yet appropriate access to these critical services.

Rapid state actions bolstered remote behavioral health access

Toward the beginning of the COVID-19 pandemic, state and federal officials worked quickly to enable the utilization of telemedicine across healthcare services. Some of these changes were untested, such as allowing a telehealth visit to prescribe medication and induction of controlled substances, as well as delivery of healthcare services over non-HIPAA compliant platforms such as Google Hangouts or Zoom. States also worked to support infrastructure needs, enabling some providers, including behavioral health practitioners, to practice remotely for the first time. Significant investments in broadband extended access to remote behavioral health services to communities that may not have an adequate network of local in-person providers.

States also worked to bolster their workforce, taking action to waive in-state licensure requirements or by joining interstate licensure compacts such as PSYPACT which allows for out-of-state providers and those with lapsed or in-progress licenses to provide behavioral health services. To entice providers to deliver remote care, states mandated or encouraged parity in reimbursement and/or cost-sharing between in-person and telehealth services. States also allowed for more flexibility in health plans’ network definitions so that more provider types, including behavioral health professionals, could engage in telehealth delivery when clinically appropriate.

These changes incentivized the use of telemedicine services, with state coverage officials reporting that behavioral health service use via telehealth remains high, even as more patients are seeking in-person medical care again. A recent Commonwealth Fund analysis found that at the end of 2020, over half of all behavioral health visits nationally were being conducted via telehealth. Another analysis of behavioral claims data noted that over 60% of behavioral health patients now use virtual services, and 97% of the people that accessed behavioral health services between March and May 2020 did not have a behavioral telehealth claim before March 2020 when COVID-19 required closures. State officials speculate that the increased demand for behavioral health services could be indicative of both previously unmet needs and needs exacerbated by the effects of the COVID-19 pandemic.

Looking ahead, state officials balance practical concerns with emerging needs in behavioral health

As reported in a prior blog, policymakers are now grappling with many questions as they look to the future of telehealth. States seek to balance appropriate access to and coverage of both in-person and remote behavioral health services, accounting for changes in behavioral health use observed during the pandemic. States are also being funded to build out mental health and SUD service capacity and in so doing are considering the role of telehealth to support the behavioral health needs of their populations.

Policymakers flagged a few emerging issues as they consider decisions over telehealth delivery of behavioral health services.

Assessing appropriate modalities of care delivery

While flexible telehealth policies increased access to remote care and new modalities of service delivery, policymakers must consider whether these modalities are appropriate and safe to use in all circumstances. Patient needs could differ based upon specific circumstances or diagnoses that should perhaps be weighed in determining whether telehealth services will lead to optimal health outcomes. For instance, given the particularly sensitive nature of many behavioral health concerns, policymakers want to ensure appropriate measures are in place across all allowed technologies to ensure that privacy concerns are met.

In some cases, more flexible use of technology and increased capacity to receive care in an “at-home” environment, may help enable access for some, including for those with complex needs. However, certain technologies can also be prohibitive for some, especially if patients lack technological literacy, cognitive functionality, or adaptive or other resources to use them effectively. More information is needed to understand where technologies are, at minimum, adequately serving patients, and where continued flexibility does succeed at (or potentially inhibit) delivery of optimal care.

Ensuring equity in behavioral health accessed via telehealth

Despite increased investment in technological infrastructure by both states and the federal government, access to broadband remains an issue across many communities. In addition, the adoption of new technologies is limited for patients by both economic disparities, as well as disparities in tech literacy. In particular, communities of color, and low-income populations present lower rates of technology literacy. In tandem, these populations experience worse mental health outcommes, which may be further exacerbated if states shift to advance telehealth delivery without coordinated efforts to also address technological disparities across their populations.

Addressing behavioral health stigma while not fostering isolation

Some patients may have different comfort levels with receiving behavioral health services in person. This is driven in part by stigmatization around behavioral health that prevents some patients from seeking care at all. Individuals discussing sensitive or stigmatized topics such as substance use disorder or mental illness may feel more comfortable disclosing information in the privacy and comfort of their own homes. Additionally, Black and Hispanic communities experience higher levels of mistrust in health institutions and may feel less comfortable interacting with practitioners’ in their offices versus in a familiar space. Officials speculated that access to care from a safe, “at-home” environment, may be fueling some of the increased utilization of behavioral health services. However, others expressed concerns over the importance of community and relationship building to treating many behavioral health concerns and uncertainty over whether that could not be replicated in a virtual space.

State officials have many issues still to consider as they continue to debate the future of telehealth policy. Stay tuned for more NASHP resources to support states interested in exploring emerging telehealth and behavioral health policies.

Webinar: State Strategies to Support Telehealth Infrastructure

February 28, 2022/in Policy Webinars Behavioral/Mental Health and SUD, COVID-19 /by NASHP Staff

Moving Toward Prevention: Oregon Launches Kindergarten Readiness Metric

February 22, 2022/in Behavioral/Mental Health and SUD, Policy Oregon Blogs, Featured News Home Back to School, Behavioral/Mental Health and SUD, COVID-19, Maternal, Child, and Adolescent Health, Relief and Recovery /by Elinor Higgins

Oregon has launched a new kindergarten readiness metric in its Medicaid program. Early childhood is a critical time for growth and development, and the services and supports children and their families receive early on can have a large impact on health outcomes later in life. Because COVID-19 has exacerbated existing health disparities, including for young children, state officials are looking for new ways to support healthy child development and advance health equity. Oregon has promoted healthy child development for decades, with a particular focus on the social-emotional health of young children. The state’s new kindergarten readiness incentive metric focused on social-emotional health renews that commitment and helps solidify the connection between a child’s health and their success in school and beyond.

In the 2000s, Oregon worked with the National Academy for State Health Policy (NASHP) in the Assuring Better Child Health and Development (ABCD) Program. One of the state’s major goals at the time was to increase developmental screening for young children. One of the levers Oregon used to achieve this goal was to include developmental screening as an incentive measure for coordinated care organizations (CCOs)—a successful approach that led to one of the best developmental screening rates in the country. At that time, there was also interest in outcome-based kindergarten readiness metrics and a sense that CCOs could help ensure that children have their health-related needs met before entering the school system. NASHP staff recently interviewed state officials in Oregon about how the state has progressed from incentivizing developmental screening to creating a kindergarten readiness incentive measure that prioritizes children’s social-emotional health.

Kindergarten Readiness and Social-Emotional Health

For many children, kindergarten is their first contact with the education system. Those who arrive in the classroom with the skills and supports they need are more likely to have a positive experience, to succeed in school, and to have a healthy life. With the leadership of the Children’s Institute in collaboration with the Oregon Health Authority and Oregon Pediatric Improvement Partnership, Oregon formed the Health Aspects of Kindergarten Readiness Technical Workgroup in 2018 to identify the health aspects of kindergarten readiness and to offer recommendations about how to measure them. The workgroup, which was made up of pediatricians, early learning partners, families, and others, identified physical, oral, developmental, and social-emotional health as key aspects of kindergarten readiness in a 2019 report. The workgroup identified a need for systems-level change with social-emotional health as a priority focus area.

In conversations with NASHP, stakeholders in Oregon described unidentified or untreated social-emotional health delays as a factor that contributes to long-term educational inequities by increasing both the likelihood of classroom behaviors that are viewed as difficult and the likelihood of disciplinary action. Additionally, national data shows that children of color, particularly those who are Black or Indigenous, are more likely to have one or more adverse childhood experiences (ACEs) than white children—which can negatively impact social-emotional development. An Oregon health official shared that when children have ACEs and also experience racism, the supports available are often not matched to cultural needs and the response to social-emotional delays can further perpetuate health inequities.

In Oregon, children with social-emotional delays are not as likely to receive follow-up care as children who screen positive for other health needs. The Oregon Pediatric Improvement Partnership (OPIP) has led improvement work in 13 counties to focus on follow-up to developmental screening and consistently found that children with social-emotional delays rarely received follow-up services and a contributing factor is the lack of services available for children birth to age five.

Development of a CCO Incentive Measure for Kindergarten Readiness

In Oregon, the Medicaid CCOs, the state’s version of an “accountable care organization,” share financial and medical responsibility for physical, behavioral, and oral care with the state for providing coordinated care in order to limit unnecessary spending. The Oregon Health Authority (OHA) provides CCOs with a fixed global budget that allows them the flexibility to implement new ways of paying for and delivering care, using strategies that are best suited for their members. In addition to standard performance measures, a set of incentive measures is linked to a CCO quality pool fund. CCOs must meet benchmarks for performance on these measures to be eligible for incentive payments from the quality pool.

The Health Aspects of Kindergarten Readiness Technical Workgroup was tasked with identifying and assessing existing kindergarten readiness metrics to identify gaps and ultimately recommending metrics that could address health and be part of the CCO incentive measure set. After the 2019 measure recommendations were unanimously endorsed by state measurement committees, in 2020, Oregon began implementing readily available incentive metrics for children’s preventive dental and well-child visits. Then, informed in part by the OPIP pilot programs and the lack of services to address children’s social-emotional needs, the group recommended that CCOs work to incorporate a child-focused social-emotional kindergarten readiness incentive metric. The group recommended a strategy for building capacity to provide follow-up services and care: the suggested incentive measure would first require CCOs to do the community outreach and planning to develop needed resources and strengthen connections to services.

A team made up of individuals from the Children’s Institute and OPIP developed the novel metric, which was supported by the Oregon Health Authority. The team presented a proposal to Oregon’s Metrics and Scoring Committee in November 2020 and then carried out pilot activities with the CCOs in early 2021. The resulting Health Aspects of Kindergarten Readiness Measure: System-Level Social-Emotional Health Metric was endorsed a metric and is included in the 2022 incentive measure set. As the CCO Metrics 2020 Final Report shows, distribution of quality pool funds is based on the number of total incentive measures a CCO meets and the CCO’s size.

Implementation and Next Steps

The kindergarten readiness metric is transformative and anchored to community engagement, stakeholder input, and hearing from marginalized communities in order for the CCO to attest to completing specific activities. Over the four years that the system-level incentive metric is in place, the CCOs will be asked to complete activities that fall into four specific components that require:

Social-Emotional Health Reach Metric Data Review and Assessment
Development of an Asset Map of Existing Social-Emotional Health Services and Resources
CCO-Led Cross-Sector Community Engagement
Development of an Action Plan to Improve Social-Emotional Health Service Capacity and Access

The CCOs will engage communities, create asset maps to identify what services are available, and review data for populations with historical inequities—breaking out the data by ACEs, medical complexities, race and ethnicity, zip codes, and more. At the end of the first year, the CCOs will design an action plan with community input about where to focus improvements. Over the remaining years the CCOs will continue to track and analyze the data to identify barriers and facilitators and to inform the transition to a child-focused social-emotional kindergarten readiness incentive metric at the end of the fourth year.

A key focus is assessing how the data, asset map, community engagement, and action plans can be informed by and address the specific needs of historically marginalized populations. Oregon has adopted the strategic goal to end health inequities in the state of Oregon by 2030. Implementing strategies among young children that promote health equity and equitable educational achievement is one way that Oregon is working toward a more equitable future for all inhabitants. As children’s health, mental health, and development opportunities continue to be a primary focus of COVID-19 recovery efforts, incentive-based approaches hold great promise to eliminate disparities experienced by children from historically marginalized communities.

States Take Action to Address Children’s Mental Health in Schools

February 14, 2022/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Back to School, Behavioral/Mental Health and SUD, COVID-19 /by Olivia Randi and Zack Gould

The COVID-19 pandemic has exacerbated rising mental health needs among children and youth. In addition to experiencing the human cost and social isolation brought upon by COVID-19, many children have lacked consistent time in classrooms. School closures and shifts to online learning have limited access to educational and social opportunities as well as mental health services. Since the onset of the pandemic, 38 states have enacted nearly 100 laws focused on supporting schools in their role as one of the primary access points for pediatric behavioral health care. These laws provide funding for school-based mental health services, strategic planning to improve school mental health systems, training and resources for school staff and students, and guidance for school policies. As children navigate the lasting impacts of the pandemic and policymakers prioritize youth mental health, states are certain to continue investing in and strengthening school-based mental health systems.

Background

In 2019, 16.5 percent of US children were estimated to have at least one mental health disorder, and the rates of adolescents who experienced persistent sadness or considered suicide both rose substantially from 10 years prior. The COVID-19 pandemic has only amplified these decade-long trends. The Centers for Disease Control and Prevention (CDC) has reported sharp increases in the proportion of children’s emergency department visits that are related to mental health. At the same time, youth utilization of mental health services has decreased, which may reflect families’ concerns in seeking non-emergency, in-person care given the risk of COVID-19 and shortages of available health care professionals working in children’s mental health.

The Biden Administration and key national organizations representing providers have intensified their focus on children’s behavioral health. In December 2021, U.S. Surgeon General Vivek H. Murthy issued a youth mental health advisory and released guidance for states in elevating policies to improve children’s behavioral health. The advisory included allocating more resources and technical assistance to school mental health systems as a key recommendation for state officials. In addition, in October 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association released a joint statement declaring a national emergency of child and adolescent mental health, calling upon federal and state policymakers to address key priorities for improving the state of children’s mental health.

School-based mental health care can improve access to mental health services, reduce risk, and improve mental health and academic outcomes for students. Additionally, when effectively designed, school mental health services may help to reduce racial and ethnic disparities in access to mental health care. Ideally, these services are delivered through a comprehensive school mental health system (CSMHS) which supportsprevention, early identification, and provision of services and treatment for students with mental health needs. These systems are increasingly important to help address children’s mental health needs, particularly during the pandemic.

Federal initiatives that support CSMHSs include the Health Resources & Services Administration’s School-Based Health Centers, the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Project Advancing Wellness and Resilience in Education (AWARE), and the Department of Education’s School-Based Mental Health Services Grant Program. Additionally, SAMHSA and the Centers for Medicare and Medicaid Services (CMS) have developed joint guidance to support states in implementing effective payment and delivery models for school-based behavioral health services.

State Laws Enacted During the Pandemic to Support School Mental Health Systems

Based on a national scan of state legislation introduced during the pandemic (March 2020 to December 2021), NASHP identified 92 state laws that were enacted to support children’s mental health through schools. States have pursued a range of approaches including 26 states allocating federal and state funding to increase school-based mental health services, 12 states supporting strategic planning to improve school mental health systems, 24 states providing education and resources for school staff and students, and 10 states guiding school mental health policies. See the table below for a list of states that have enacted laws to support these strategies.

Supporting strategic planning to improve school mental health systems

Schools often face a range of challenges in supporting students’ mental health, including identifying and implementing best practices and coordinating across agencies. During the pandemic, 12 states enacted laws that support strategic planning to identify barriers and approaches to increase access to school-based mental health services.

Arkansas’s HB 1689 (Act 802) established the Arkansas Legislative Study on Mental Health and Behavioral Health, which is required to study and develop a report on mental health screening and suicide prevention policies for children in schools. (Enacted October 1, 2021)
Connecticut’s HB 6621 (Public Act No. 21-95) established requirements for the School Emotional Learning and School Climate Advisory Collaborative, which will develop a strategy to initiate collaborations with community-based mental health providers and support school staff in mental health and social-emotional learning. (Enacted June 24, 2021)

Allocating funding to increase school-based mental health services

Schools report that the most common limitation to providing mental health services for students is inadequate funding. Relatedly, many schools face challenges in engaging mental health providers, and few meet the recommended ratios of students to counselors, psychologists, and social workers. To alleviate this barrier, 26 states enacted laws to increase financial support for school-based mental health services. These measures include funding to reimburse and support school telemental health services and to hire school-based mental health providers.

California’s AB 133 (Chapter 143) established the Children’s Behavioral Health Initiative, which includes grant funding for school-linked behavioral health services. (Enacted July 27, 2021)
Massachusetts’ H 4002 (Chapter 24) appropriated funding for a pilot program for telebehavioral health services through schools. (Enacted July 29, 2021)
North Carolina’s SB 105 (SL 2021-180) allocated funding from the American Rescue Plan Act to establish a grant program for schools to hire psychologists in response to COVID-19. (Enacted November 18, 2021)

Providing mental health education and resources for school staff and students

Teachers and school staff can often be more effective in supporting students’ mental health when equipped with information on mental health and best practices for prevention and early identification. Seventeen states enacted laws to provide mental health training and resources for school staff.

Rhode Island’s SB 31/HB 5353 (Chapter 131) requires that school staff and students receive education on suicide awareness and prevention. (Enacted April 22, 2021)
Virginia’s SB 1288/2299 (Chapter 452) requires that school counselors receive training in mental health, including mental health disorders, depression, trauma, and youth suicide, in order to be licensed and to renew their license. (Enacted March 30, 2021)

States have also supported schools in providing mental health education and resources directly to students and their families. Thirteen states enacted laws to support schools in providing mental health education and resources for students.

Illinois’ SB 818 (Public Act 102-0522) requires that health education courses for students include information on mental health. (Enacted August 21, 2021) Illinois also adopted HJR 1, which encourages schools to provide mental health training and education for students. (Adopted June 1, 2021)
Texas’ SB 279 requires schools to include crisis line contact information on all identification cards for students in grades six through twelve. (Enacted May 28, 2021)
Washington’s HB 1373 (Chapter 167) requires all school websites to provide access to information and resources on behavioral health, including mental health. (Enacted May 3, 2021)

Guiding school mental health policies

While local school districts often have autonomy in implementing and administering policies and programs, states can provide guidance for these policies by issuing requirements and recommendations. Ten states have enacted laws to support schools in adopting innovative policies to address many of the unmet needs and gaps in youth mental health services exposed during the pandemic. These include requiring that schools allow mental health days or excused absences related to students’ mental health needs, delineate protocols around providing mental health services, and develop plans for responding to a student experiencing a mental health crisis.

Connecticut’s SB 2 (Public Act No. 21-46) requires local boards of education to allow students to take up to four mental health days per school year. (Enacted June 16, 2021)
Florida’s SB 590 (Chapter 2021-176) requires that school health services plans, which are jointly developed by county health departments and local school boards, indicate that school and law enforcement staff must attempt to contact a mental health professional for a student in crisis, and that behavioral health providers and school resource officers must attempt to verbally de-escalate crises. (Enacted July 6, 2021)

Conclusion

Children’s mental health has been and will continue to be a top priority for state leaders across both legislative and executive branches of state government. With COVID-19 exacerbating the challenges children are facing, there is much more work to be done. This blog summarizes the actions many states have taken from March 2020 through December 2021. However, many more states continue to consider legislation during the 2022 session. The National Academy for State Health Policy will continue to track state policies to support children’s mental health during and beyond the pandemic.

Summary of State Laws Enacted During the COVID-19 Pandemic to Support School Mental Health Systems (March 2020-December 2021)

Approach	States
Supporting strategic planning
Work group/task force	AR, CA, CT, HI, MA, MI, TX, VA
Data/assessment of needs	AR, CA, CT, MN, TX
Recommendations and standards	AK, CA, CT, HI, LA, ME, VA
Allocating funding to support school-based mental health services
Mental health services*	AZ, CA, CO, CT, DE, IN, KS, MA, MD, ME, MI, MN, MT, ND, NJ, NY, OH, OR, PA, TN, VA, WA
Telemental health	CO, FL, IL, MA, MN
Providers	AZ, DE, KY, MI, NC
Providing mental health education and resources
School staff	AK, AR, CA, CO, DC, IL, IN, KY, LA, MA, MN, ND, NY, OK, OR, RI, VA
Students**	CA, CT, IL, KY, RI, UT, WA
Crisis hotline printed on student IDs	AR, IL, IN, NJ, NV, SC, TX
Guiding school mental health policies
Mental health days/excused absence	AZ, CA, CT, IL, NV, UT
Crisis response policies	FL, MA, NE, NV, OR

Note: The states listed here have enacted laws during the COVID-19 pandemic that support these approaches. These laws may be sustaining existing programs/policies, or enacting new ones, and states may vary in their implementation progress. Other state laws may have been enacted that support school-based mental health, but the language of the act did not specify as such. Additionally, other states may have implemented these approaches through other policy mechanisms.

*This category does not include state laws that specifically fund telemental health services (these laws are included separately in the row below).

**This category does not include state laws that require crisis hotlines to be printed on student IDs (these laws are included separately in the row below).

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California Bridge: Considerations for State Financing of OUD Treatment in Emergency Departments

Utah’s Crisis Worker Certification: Successes and Lessons Learned

Map: State Medicaid Managed Care and Access to Rural Behavioral Health Services

Webinar: Sustaining Emergency Department Buprenorphine Services: Panel Discussion with California Leaders

How States Are Leveraging Payment to Improve the Delivery of SUD Services

States Focus on Behavioral Health as They Consider the Future of Telehealth