State Strategies to Mitigate Adverse Childhood Experiences during the COVID-19 Pandemic and Beyond
The COVID-19 pandemic has exacerbated adverse childhood experiences (ACEs), and children could be facing a surge of poor physical and mental health outcomes without adequate investment and focus to reduce the effects of ACEs. This is especially important because Black, Latinx, and Native American children, who already disproportionately experience higher levels of ACEs, have also been impacted by the COVID-19 pandemic, in part due to longstanding inequities. A number of states are taking action. States like California and New Jersey have launched statewide initiatives to mitigate the long-term effect of traumatic events, and several state legislatures have introduced bills to identify and address ACEs in partnership with systems such as Medicaid and education.
State Initiatives to Address ACEs
In California, the ACEs Aware Initiative focuses on screening children for ACEs and working to address the impact of toxic stress, as NASHP has previously highlighted. California set a goal of reducing ACEs by one half in a generation and is working towards this goal in a multi-faceted, community-oriented approach. Through the ACEs Aware Initiative, and in collaboration with the California Department of Health Care Services, the state has distributed nearly $45 million in grants to more than 120 communities. Grantees work to educate providers and community members to recognize exposure to racism as a risk factor for toxic stress and ACEs. Grantees also highlight the importance of prevention, treatment, and healing. For example, several grantee sites assess children for resilience as well as trauma. Individuals who are racially marginalized (Black, Latinx, Native American, or multi-racial) are more likely to experience confounding ACEs and toxic stress in childhood, including lack of access to quality health care or education, or disproportionate involvement in the criminal justice or welfare systems. Because new crises like COVID-19 are more likely to disproportionately affect racially marginalized populations, the ACEs Aware Initiative centers equity as a core component of the program.
In New Jersey, the Department of Children and Families’ (DCF) Office of Resilience released a statewide action plan in 2021 with a goal of helping children and families in New Jersey reach their full potential by focusing on prevention and reduction of childhood trauma and adversity in future generations. The DCF Office of Resilience was created in June 2020 during the pandemic, to host, coordinate, and facilitate statewide initiatives with the purpose of raising awareness of and creating opportunities to eradicate ACEs through grassroots and community-led efforts. Key components to implementing the new action plan include:
- Conducting a statewide literature and programmatic review to assess current efforts to address ACEs in the state,
- Meeting with non-governmental organizations to ensure actions are community-led and centered, and collaboration to highlight and promote an online community, and;
- Making data from the New Jersey Population Health Cohort study publicly available.
Both state strategies center community voices and highlight resilience as a protective factor against trauma, and both plans work in stages by first identifying the breadth and depth of trauma in children through screenings, and then using this information to create appropriate resilience-focused programs. Both California and New Jersey strive to proactively address the impact of ACEs, especially as children are exposed to compounding trauma living through a pandemic and help build a healthier future.
Proposed State Legislative Strategies
COVID-19 has exacerbated existing stressors and the trauma from the pandemic has created new ones, and states have been having active discussions about how best to serve the needs of children during the pandemic. Against this backdrop, legislators across states are considering new strategies to address ACEs. Most states’ legislative cycles are reaching their end and bills are at various point in the legislative cycle, but common themes in proposed legislation include:
- Publicly acknowledging the impact of trauma and importance of trauma-informed care. Illinois SR 212 declared May 25, 2021 “Trauma-Informed Awareness Day,” to, among other things, encourage all employees of the State to become informed regarding the generational impacts of ACEs, toxic stress, and systemic racism.
- Creating entities to identify areas of need and recommendations. A bill in Georgia seeks to create a House Study Committee on ACEs to improve the health of women and children. The bill was introduced after data from the U.S. Health Resources and Services Administration showed that in 2019, 23.6% of Georgia children lived in economic hardship, that economic insecurity is the most common ACE, and non-Hispanic Black children are nearly twice as likely to experience one or more ACEs. Similarly, a Maryland bill proposes establishing a “Workgroup on Screening Related to Adverse Childhood Experiences,” tasked with updating and developing screening tools, submitting the screening tools to the Department of Health, studying best practices, and making recommendations to the Governor and General Assembly.
- Increasing ACE and social determinant of health screening for children by Medicaid and education agency stakeholders. State legislatures are exploring:
- Requiring home health care professionals to use ACE questionnaires to assess patient health risk with reimbursement by Medicaid (NY).
- Requiring school district board of directors to conduct ACEs screenings for any child before taking disciplinary action and including the results in any reports explaining the disciplinary results (AR).
- Screening students for ACEs or traumatic events (CT, MD, PA). Pennsylvania’s bill requests a comprehensive analysis to identify an age-appropriate measuring tool that can be used by school districts to measure childhood trauma. Maryland’s bill requires the Secretary of Health to approve ACE training programs that providers can complete, to be reimbursed by Medicaid.
Next Steps
Unfortunately, nearly 40,000 children lost parents to COVID-19, and sustained investments will be critical to mitigate the effects of the trauma experienced during the pandemic. States are at different stages of promoting ACE awareness and addressing the effects of ACEs–identification and screenings are just the first steps toward improving long term health outcomes. Ongoing efforts to shine a light on this issue are moving ACEs towards mainstream consciousness at a critical juncture. As strategies in California, New Jersey, and other states demonstrate, awareness, community engagement, provider training, and critical partnerships are the first steps toward ensuring that children’s needs are considered and met. NASHP will continue to monitor state action including use of American Rescue Plan Act Funds to address ACEs. See related NASHP resources.
State and National Strategies to Increase COVID-19 Vaccine Confidence
With vaccine supply outpacing demand, boosting public awareness and confidence in COVID-19 vaccines remains critical. Federal, state, and local governments are identifying and employing strategies to improve vaccine confidence across different populations. In NASHP’s recent webinar, “State Strategies to Improve Vaccine Confidence,” speakers from the Centers for Disease Control and Prevention (CDC), the Oregon Health Authority, and AM TRACE discussed strategies and shared tools policymakers can employ to achieve this goal.
As more than half of all American adults are fully vaccinated, and children 12 years and older continue to receive their vaccinations, states are working to further increase access, removing barriers, and providing incentives for those who are yet to be vaccinated. Recent polling shows that up to 40 percent of adults fall into one of several camps: those who will “wait and see”, those who will only get the vaccine if required, and those who will definitely not get the vaccine, and strategies to reach these different groups vary. Vaccination rates also vary by state: 14 jurisdictions have vaccinated 70 percent of all adults with at least one dose of a COVID-19 vaccine, while in other states, less than 40 percent of the adult population has received one dose. Experts believe that many individuals can be persuaded to receive a COVID-19 vaccine if approached with appropriately targeted strategies, and that outreach efforts should be focused on these populations, rather than those who report that they will definitely not get the vaccine.
Building vaccine confidence requires multi-pronged, tailored strategies to engage with and listen to communities to help build trust in the COVID-19 vaccines and the policies and processes that led to their production. State health officials have found that those with concerns about the vaccines are more receptive to messaging from familiar individuals, like their physicians, clergy, and other community leaders. Partnerships with trusted individuals and local institutions, like schools, universities, and employers, are also key to building confidence, especially among those who are more hesitant.
National Approaches to Building Trust
AM TRACE shared research findings during the webinar that mass marketing campaigns have less effect on individuals in the “wait and see” and “probably not” groups – those typically considered to be in the “movable middle”. AM TRACE recommends conducting refined analyses to better understand each target audience’s hesitations and using this information to create localized and personalized messaging campaigns to tailor to these needs.
Federal, state, and local government agencies also underscore the importance of tailoring messages to specific populations and localities to ensure that the vaccine information provided best addresses each community’s needs and concerns. CDC’s Vaccinate with Confidence program gives strategies to help build trust in a variety of key public health and medical tools, including the COVID-19 vaccines, the vaccine-administrating providers, and more generally, the processes and policies that lead to the vaccine development, licensure, authorization, manufacturing, and recommendations for use. For example, CDC developed a rapid community assessment guide to help health departments understand drivers of low vaccine uptake and identify potential interventions. And, CDC’s Confidence Consults1 provide one-on-one support and technical assistance for building COVID-19 vaccine confidence and are available to state, territorial, and tribal immunization programs. The CDC continues to emphasize building trust among individuals and communities and using that trust to promote vaccine confidence among health care providers, who in turn, will recommend the COVID-19 vaccines to their patients.
AM TRACE’s campaign planning tool is another resource that states can consider using to promote vaccine confidence. This tool supports agencies in developing and implementing localized campaigns with personalized messaging, including a micro-targeting, tailored approach, intended to address a variety of factors that influence hesitancy by using a target audience analysis framework. These tools, in collaboration with a strong state and federal emphasis on data collection and analysis to identify vaccination trends and gaps, can help prioritize priority populations and tailor strategies to improve vaccination rates.
State Strategies: Featuring Oregon
The Oregon Health Authority (OHA) and Oregon Department of Human Services presented a variety of tailored approaches to identify populations and reach out to encourage vaccination in effective ways. For instance, OHA identified challenges in reaching Oregon’s Latinx populations, and subsequently developed a coordinated state response that included: a statewide communication strategy, close partnership with community-based organizations and local health departments, connections with trusted Migrant and Community Health Centers, and a radio talk show where Latinx community members can connect and share their experiences.
Other efforts to provide tailored communication approaches in Oregon include:
- The Oregon Youth Authority (OYA) created resources and vaccine messages in multiple languages for various populations, including youth in OYA custody, and Latinx, Black, and Native American youth and families. OYA’s flyers include messaging around the importance of vaccination from high-profile and trusted messengers, including Vice President Kamala Harris, United States Representative Alexandria Ocasio-Cortez, and physicians of color.
- OHA developed a weekly series, Vaccine Voices, to help address vaccine hesitancy, during which people from a variety of communities who have gotten their vaccine can share their stories and experiences with the process to help alleviate concerns.
Other states officials have shared with NASHP various new strategies to reach specific populations in culturally appropriate ways. For example, some states are organizing community vaccination clinics in popular venues. Kentucky organized a “Derby Day” campaign, which included vaccinating individuals at Churchill Downs, the site of the Kentucky Derby, Alabama set up a vaccine site at the Talladega Superspeedway, and Wyoming has set up sites to vaccinate young people and families at drive-in movie theaters.
Additionally, to promote vaccine confidence among parents and adolescents, many states are partnering with school districts, including working with superintendents and teachers. In some instances, states are locating vaccine clinics on school grounds, which allow people to get vaccinated in a familiar and easily accessible setting. Some health departments are also working with schools to send out targeted educational materials. For example, the Louisiana Department of Health teamed up with the Louisiana Department of Education to distribute flyers to students with FAQs about vaccines for adolescents. New York City is launching a pilot program with four schools in the Bronx as a site for children 12 years and older to get vaccinated, and will be hosting community conversations with parents, educators, and youth. Many states are using these school-based sites as an opportunity to encourage entire families to get vaccinated together.
Experts during the NASHP webinar noted that building trust and vaccine confidence requires patience, time, and trusted messengers. It requires identifying the differences between the need to build vaccine confidence, provide education, and reduce barriers to access. It also requires identifying that these needs differ based on the state and community, and that data is a critical component for states to accurately identify pockets of need and target successful strategies. As states roll out new vaccination strategies and build on existing best practices, NASHP will continue to analyze distribution efforts and support states in identifying effective and successful approaches.
This blog is sponsored by AM TRACE with content development at the sole discretion of NASHP.
Endnotes
- For a CDC Confidence Consult, state and/or jurisdictional health departments can email requests to confidenceconsults@cdc.gov
State Opportunities to Strengthen Home and Community-Based Services through the American Rescue Plan
The American Rescue Plan of 2021 (ARP) – signed into law on March 11, 2021 – provides states with a one-year, 10 percentage-point increase to the federal medical assistance percentage (FMAP) for Medicaid expenditures on home and community-based services (HCBS) for children and adults. This increase provides states with a critical opportunity to address both emerging and long-standing challenges in state long term care systems – systems that have been heavily impacted by the COVID-19 pandemic in the last 14 months. The Center for Medicare & Medicaid Services (CMS) issued a letter to State Medicaid Directors on May 13, providing additional guidance to states on how they can use this new funding.
Highlights from CMS guidance:
- The increased FMAP must be used to supplement, not replace, existing state funds spent on Medicaid HCBS in effect as of April 1, 2021.
- State funds equivalent to the amount of the increased FMAP can be used to facilitate activities that enhance, expand, or strengthen Medicaid HCBS.
- States are prohibited from imposing stricter eligibility requirements for HCBS programs and services than were in place on April 1, 2021, and may not eliminate covered services or reduce the amount, duration, or scope of those services during this period.
- CMS will not apply penalties or non-compliance restrictions to states once the authority for temporary changes to HCBS eligibility, coverage and/or payment rates (e.g., Appendix K waivers and disaster relief state plan amendments) has expired or if the state needs to implement changes to comply with federal requirements
- CMS will work with states making programmatic changes to revise cost effectiveness projections appropriately and determine the feasibility of their budget neutrality models.
While the enhanced FMAP increases federal funding for specific services, the impact of the 10% bump could have broader implications for state HCBS systems. States may use state dollars freed up by the enhanced match to “enhance, expand, or strengthen” Medicaid HCBS in myriad ways. State context and specific priorities will drive these investments, which could include:
- Bolstering workforce: COVID-19 has highlighted the need to better support the long-term care workforce. States can target resources to increase wages and benefits, facilitate vaccinations and other COVID protections, and invest in training and career pathway strategies to grow and sustain a diverse LTC workforce, including peers and community health workers.
- Addressing equity: Expanding access to HCBS services in underserved communities and communities of color is a critical priority across states: policy makers may choose to enhance cultural and linguistic capacity, assess and address equity through existing No Wrong Door Systems, and invest in community-based organizations that are located in and serve communities especially hard hit by the COVID pandemic.
- Supporting family caregivers: Families can be critical to keeping adults and children and youth with special health care needs (CYSHCN) at home or in community settings. States may want to increase services and supports for families, including respite; establish or strengthen family caregiver assessment and outreach; build greater cultural and linguistic capacity; enhance Medicaid self-direction programs that pay families and others to provide Medicaid services, and facilitate wider use of innovative technology.
- Investing in behavioral health recovery: The higher match rate is also available for services to support people in recovery from mental illness and substance use disorders. Enhancements could include strengthening community-based interventions that help people remain in housing or stay employed; building cross-system reentry capacity with state prisons or local jails; developing diverse peer support capacity for people with behavioral health disorders; improving transitions for youth with behavioral health needs, and promoting access to recovery options for children, youth, and adults in underserved areas.
Additional considerations for states
States will have to quickly identify priorities and focus areas, identify services available for the enhanced FMAP, and submit plans and budgets within a very narrow timetable. Other issues to consider:
Sustainability: The enhanced FMAP is only available for one year; additional state funds that result from the enhanced match are available to support HCBS activities through March 31, 2024. States that opt to expand access to HCBS will want to plan for sustainability of services, both after the initial one-year FMAP bump, and through 2024 when all additional resources need to be spent.
Waiver/SPA rules still apply: States may add new services to maximize impact of the FMAP bump, but may need to submit a waiver or state plan amendment to do so. CMS will work with states to ensure state compliance with cost neutrality and budgeting rules.
State planning and initiatives: States may already have legislative and other state policy initiatives in the works that impact their HCBS systems. These ongoing or upcoming initiatives may benefit from ARP funding and can be incorporated into state submissions.
The American Rescue Plan funding represents an important opportunity for state policy makers to address long-standing challenges in HCBS systems related to access, rebalancing, health equity, workforce, and other issues. Initial state plans are due to CMS within 30 days of May 13th. CMS indicates it will publicly post state plans; NASHP will track these plans as they are posted and share information on emerging themes.
Two States’ Approaches to Leveraging Data for Equitable COVID-19 Vaccine Distribution
Federal and state governments are continuing to vaccinate residents as quickly as possible, while working to ensure they reach populations experiencing barriers to vaccination. Access to high-quality data to track and identify under-vaccinated areas and populations is critical to this goal. States have a variety of data systems at their disposal, with vaccine registries at the center.
The National Academy for State Health Policy (NASHP) spoke to state officials in Minnesota and North Carolina, two states who took different approaches to developing COVID-19 immunization data systems, to learn about their experiences, including data challenges, successes, and implications for ensuring an equitable vaccine roll out now and in the future.
Tracking and reporting of COVID-19 vaccine distribution and administration data requires collaboration and integration across various systems that are administering and distributing the vaccine. To collect and track data for the COVID-19 vaccine, states are using their existing immunization information systems (IIS), adopting the CDC’s newly developed Vaccine Administration Management System (VAMS), creating a new system specifically designed for the COVID-19 vaccine, or some combination of these different approaches. The ability to connect IIS with other data sources, like Medicaid claims, and hospitals’ and health systems’ electronic health records (EHRs), is critical to identifying gaps and opportunities for improvement.
In addition to aggregating data across data systems, the completeness of patient records affects efforts to address the gaps. Because Black and LatinX communities have been disproportionately affected by the pandemic, complete patient data, including race and ethnicity data, can help target vaccination outreach to vulnerable communities.
Can you give an overview of the system you use to track and collect COVID-19 specific immunization data?
Minnesota: Minnesota uses an immunization information system (IIS), called Minnesota Immunization Information Connection (MIIC). MIIC-enrolled pharmacists are the only providers who are mandated to collect or upload data into the system. However, all health care staff at provider’s offices can access MIIC, so they have flexibility to input data. And, our health systems are excellent partners that share high quality data to MIIC via the electronic health record (EHR). Additionally, MIIC can capture patients’ vaccine refusal comments and has a reminder/recall function that allows providers to assess which patients are overdue for which vaccine. Minnesota also has data sharing laws that allow schools, childcare providers, purchasers, and community health boards to access MIIC. The ability for schools and childcare providers to review data in the system will be important as children get vaccinated. Our IIS has been working well during the pandemic; we can track and enter data into the system, and it can handle the volume of data without issue. We have been able to onboard new providers expediently and have created a more consolidated process that has been extremely useful.
North Carolina: North Carolina developed the COVID-19 Vaccine Management System (CVMS) instead of using our state’s IIS to create a single end-to-end system for COVID-19 vaccinations. CVMS gives us the ability to add or subtract fields at our discretion. For example, we were able to incorporate North Carolina’s vaccine eligibility determinations and include provider enrollment directly into the system. The system also has the ability to configure to meet provider’s needs, It does not have a reminder/recall system like North Carolina’s Immunization Registry (NCIR). However, CVMS does send proactive e-mail reminders to recipients to get their second doses. CVMS is Version 1 of an iterative software, so all enhancements can be developed in an agile manner.
How are you using data to track areas in need of targeted vaccination approaches?
Minnesota: We have pinpointed a growing list of individuals who have not yet received their second dose. We created this list using our data but have been grappling with how we ensure they actually get vaccinated. One solution we are working to implement is a pilot texting reminder/recall program through a partnership with one of our large health systems and are hoping to make this available more broadly across the state. We have also implemented a change in the data system to allow providers to set parameters to see who in a population needs a vaccine. They will be able to define age parameters and see who in that age bracket has not been vaccinated yet (such as seniors). They can also set product-specific parameters to see who in a county needs a second dose of a specific vaccine and do targeted outreach.
North Carolina: We have geospatial and demographic data for everyone who has received the vaccine, and demographic data and Social Vulnerability Index (SVI) data for all census tracts across the state, so we are able to see where vaccination rates are keeping up with the state average, and which regions are in need of more proactive engagement and partnership.
We are building equity into every aspect of vaccine distribution in order to close the vaccination gap between white populations and Black/African American, Hispanic/Latinx, and American Indian populations in North Carolina, including prioritizing data transparency. We require all vaccine providers to collect and report race and ethnicity data; provide a bi-weekly report to each vaccine provider on their vaccination rates by race and ethnicity; update a public dashboard daily that shows vaccine rates by race and ethnicity at the state and county level, and use this data to inform strategies.
How do COVID-19 immunization data systems interact with EHRs?
Minnesota: MIIC created a unique partnership with the state’s 10 largest EHRs through the EHR consortium. Through partner phone calls, we realized EHR systems collected race/ethnicity and other demographic and comorbidity data while MIIC collected individual patients’ full vaccine history. We partnered to share information across systems to create a full data set. MIIC also gets immunization data directly from the EHRs, which avoids double data entry. And, providers can also query MIIC to get vaccine history and forecast recommendations.
North Carolina: CVMS does not conform with HL7 message structure to exchange immunization information with health systems’ electronic health records and IIS but the platform enables imports of data from EHRs using a standardized file format, which prevents the need for double data entry. We are developing a system that will be able to push the COVID-19 vaccine data into the state IIS, which is critical to having one source of vaccine data for providers, schools, etc. The state IIS is also connected to EHRs, and allows providers that have been onboarded to check for vaccine status through the EHRs.
What are some challenges you have seen in accurately identifying areas of need?
Minnesota: Previously, vaccine supply and inconsistency with delivery had been an external factor that created challenges to accurately identify areas of need, though this is less of an issue now given more consistent supply. In terms of data, because we do not have a mandate to enter data into the IIS, we accept many different types of data, and we have heard from individuals that it has been a barrier to use full-scale EHRs in vaccine clinics because of the technology hurdles.
North Carolina: When supply was more limited, we set aside doses for vaccine providers and events focused on historically marginalized populations (HMP) and relied upon provider data of vaccinating these populations to determine allocation strategy. We track equity gaps – i.e., the difference between HMP vaccination rates and proportion of population – at the provider type, county, and individual provider level, and we share this information back with vaccine providers. We found that equity gaps have steadily declined across geographies as a result of this and other equity-focused vaccination strategies. External barriers like internet access, limited interpretation services, and transportation have also created challenges in ensuring access to vaccinations. We have invested in strategies for people to access information without having to go online – i.e., set up a call center with English- and Spanish-speaking agents who can answer common vaccine questions and help people find vaccine providers near them. We also have had to make it clear up front that identification and insurance are not required, and that data collection relies on self-attestation.
What are some “best data practices” you have found to ensure an equitable distribution of the vaccine?
Minnesota: We use data from MIIC to look at vaccine uptake by SVI. A Federal Emergency Management Agency (FEMA) site was placed in St. Paul which targets zip codes with high SVI. FEMA sites can distribute a small percentage of their allocated vaccine doses off-site, and have utilized some mobile vaccinations for the distribution processes.
North Carolina: We regularly review provider race and ethnicity data internally to evaluate progress and share externally. We promote accountability through data transparency and use of data; we share bi-weekly reports to vaccine providers on their race/ethnicity and publish public dashboards that are updated daily with vaccine rates by race/ethnicity at the state and county levels. We use the data to identify census tracts with high SVI and low vaccination coverage to recruit and allocate to new providers and inform micro-targeting of related resources, such as public communications/media or the support of community health workers. Our data platform is also flexible; it is able to handle new requirements over time.
How have you used federal funding to enhance your data capabilities and ensure full vaccination coverage?
Minnesota: We have a cooperative agreement through the CDC on the business and operational side of the IIS and technical funding comes from the HITECH 90/10 match. We used our previous funding to implement the reminder/recall function, as well as other IIS enhancements, like a COVID-19 assessment report, that will be available soon, improvements to geocoding, implementing COVID-19 vaccine ordering in MIIC, and automating our reporting to the CDC.
North Carolina: We fund CVMS through a variety of funding sources, but primarily through the CARES Act Coronavirus Relief funds. We plan to use American Rescue Plan Act (ARPA) funding to support continued vaccine implementation efforts, including strategies that ensure greater equity and access to the COVID-19 vaccine by those disproportionately affected by COVID-19. The new ARPA funding will also be used to support local communities through local health departments, community-based organizations, and current community vendors to provide mobile vaccination. In addition, we are planning to sponsor vendors to go into neighborhoods to provide vaccine education and administer vaccines to historically marginalized populations that have had challenges accessing vaccines.
What lessons have you learned from the pandemic that you will be able to use to improve vaccination rates (both for COVID-19 and for routine immunizations) moving forward?
Minnesota: There continues to be concern around the gap in childhood immunization rates that has developed as the result of children missing primary care visits, and the MN Immunization program is in the process of determing the best method to help close those gaps. In general, we’ve had new funding conversations that could not have happened without our strong partnerships with health systems and are hoping these partnerships will have built a foundation for immunizations that we can continue past the pandemic.
North Carolina: As we move from very limited supply to increased volume, our approach to using data to achieve vaccine equity is evolving. Moving forward, we are focusing even more intently on census tracts with low vaccination rates and high social vulnerability to determine tailored strategies for identifying providers (including state-sponsored vendors) who can vaccinate in those census tracts, paired with trusted community partners and community health workers to optimally establish mobile or fixed vaccination sites. It can be tricky to balance data sharing and transparency with the critical requirement (and value) of preserving privacy, but it is possible. Overall, our team has learned to be flexible and to openly communicate within the team and with partners.
Acknowledgements: This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
States Adapt COVID-19 Vaccination Strategies for Adolescents Ages 12-15
Following the May 10, 2021 approval from the Food and Drug Administration (FDA) authorizing the Pfizer COVID-19 vaccine for adolescents aged 12-15, approximately 17 million adolescents are now able to get vaccinated, about half of whom are adolescents of color. States are using lessons learned from earlier vaccination efforts and adapting the planning and implementation process of vaccinating individuals aged 16 and older against COVID-19 to inform the process for those 12 and older and ensure an equitable and efficient approach.
This authorization raises new considerations for states as they work to increase vaccination rates among their populations, including where children and adolescents will get vaccinated, how to build vaccine confidence among parents and adolescents, what the consent process looks like, and appropriate messaging strategies.
Vaccination Locations
To reach adolescents ages 12-15, states are both drawing on existing vaccination locations, from mass vaccination clinics and pharmacies to medical offices, as well as setting up new vaccine sites in a variety of settings. For example, Alaska changed its vaccine allocation for evening drive-thru sites to Pfizer to increase access for adolescents after school and work hours. Some states are also newly engaging pediatricians. Washington State is working to get the Pfizer vaccine into pediatricians’ and primary care providers’ offices so trusted and familiar providers can educate children and their parents about the vaccine together, and family members can receive their vaccinations at the same time.
Many states are also leveraging schools as a critical vaccination setting and are developing plans for pop-up vaccination sites at summer camps and other recreational programs. In Virginia, the Department of Health began reaching out to school systems and meeting with superintendents prior to the FDA’s authorization. The state was able to help educate and prepare the schools to hit the ground running so that they could immediately schedule vaccine clinics upon FDA approval. This process was especially important given the short window of time before the school year ends. Earlier in May, South Carolina announced plans to hold vaccination events at schools intended for both students and their parents, with an added incentive of school supply giveaways for those who receive the vaccine. Additionally, some high schools in Maine are hosting vaccine clinics at the end of May, which provides just enough time to administer second doses before the school year ends. Oregon state officials are encouraging schools to provide the venue and help with outreach and scheduling, while facilitating partnerships with federally qualified health centers, pharmacies, and local public health authorities to provide the vaccination services on campus.
As states roll out the vaccine to new providers and locations, providers are also identifying a need for smaller vaccine packaging to avoid any potential vaccine waste. Vaccine waste has varied among states. Some state officials noted that they removed previous requirements for providers to use a certain percentage of doses within a given timeframe to ensure all opportunities to administer the vaccine are taken and to reduce barriers to vaccination, especially in areas with lower vaccination rates.
Consent Requirements
Requirements for parental consent to vaccinate minors vary among states, and even across vaccination sites. In Maine, parents or guardians do not have to be on site to provide consent. Rather, Maine allows parents to sign a form and either mail or email the form to the provider in advance, or have the child bring a hard copy to the vaccine site. Maine parents can also provide verbal consent over the phone. A small number of youth in Maine may provide their own consent for the vaccine, including those who are living separately from their parent/legal guardian, are legally married, are a member of the armed forces, or have been emancipated by the court. The state has already used this process for 16- and 17-year-olds.
In Alabama, adolescents aged 14 and older can consent for themselves in clinics, like mass vaccination sites or provider offices, but require parental consent for vaccinations in school. The state has existing processes in place to obtain consent for children to receive other routine childhood immunizations through the school; it is using the same process for the COVID-19 vaccine. Other states, like Kentucky, are also using existing processes for obtaining consent for routine immunizations and adapting them for the COVID-19 vaccine.
Vaccine Outreach and Messaging
Because studies have shown children have a lower risk of serious illness and death from COVID-19, polling has indicated that parents are confused about the benefits and risks of vaccination and hesitant to vaccinate themselves and their children. However, over the first two weeks of May, there was a 3 percent increase in the total number of COVID-19 cases in children, and a jump of over 20 percent of new cases in children under 19. The CDC is emphasizing that vaccinating eligible children is of the utmost importance to help protect both children and families, and move towards the goal of herd immunity to protect vulnerable community members who cannot get vaccinated.
Vaccinating children and adolescents brings an additional challenge for states and providers, who are tasked with building vaccine confidence among both parents/guardians and their children. State officials note that one important strategy is providing the vaccine in familiar settings with trusted providers, who can engage in conversations with families to understand their concerns and educate about the vaccine’s safety and efficacy. State officials also note the importance of messaging to both youth and adults, because children can be effective health advocates for their parents as well.
States are using trusted messengers and venues to communicate with adolescents. For example, the Louisiana Department of Health circulated flyers to the Department of Education encouraging vaccinations for adolescents 12 and above and providing relevant information. Some health departments are capitalizing on parents’ motivation to ensure their children can continue to play sports by messaging through sports teams that getting vaccinated eliminates the need for students to quarantine (thereby missing practices and games) if there is a school exposure. Other states are using football games that draw large crowds of teens as an opportunity to educate about the benefits of vaccination.
The Oregon Youth Authority (OYA) created resources in different languages tailored to adolescents from different populations and those in OYA custody. The flyers include first-hand accounts of COVID-19 vaccination experiences from individuals who identify as Latino, Black, and Native American, and information about the Indian Health Services’ involvement in the vaccine planning and development process. The Michigan Department of Health & Human Services is using social media advertising designed for parents and children, including Snapchat, Instagram, and TikTok. The Alaska Department of Health and Human Services has created opportunities to ensure adolescents can communicate with each other using peer-to-peer platforms to give unvaccinated teens the opportunity to ask questions of vaccinated teens and share why they chose to get vaccinated.
As states vaccinate more adolescents and adults against COVID-19, they continue to use multi-pronged strategies in order to reach the greatest number of people in the most efficient and equitable way. With more populations now eligible, states are figuring out how to tailor vaccination strategies developed for adults to younger children and adolescents. As the vaccine distribution progresses, NASHP will continue to share promising strategies and support states in these efforts.
Acknowledgements: This blog is supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $250,000 with 100 percent funded by CDC/HHS. The contents are those of the author and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS or the US government. CDC General Terms and Conditions for Non-research Awards, Revised: February 2021.
Webinar: State Strategies to Build Vaccine Confidence
This webinar explored state strategies to improve COVID-19 vaccine confidence and reach more communities in an equitable and efficient manner.
As of May 2021, all individuals ages 12 and older are eligible for COVID-19 immunizations. As states continue to design and roll out targeted vaccination campaigns, they are considering:
- The reasons why individuals are hesitant to get the COVID-19 vaccine;
- Current efforts to undermine confidence in the vaccine; and
- Solutions to address vaccine hesitancy.
Speakers from the US Centers for Disease Control and Prevention, the Oregon Health Authority, and AM TRACE discussed various types of vaccine hesitancy, practical issues around vaccination, emerging issues of misinformation, and places where interventions can improve vaccine confidence in order to support pandemic recovery.
Participants included:
- Moderator: Trish Riley, NASHP Executive Director
- Richard Quartarone, Communication Co-Deputy, Centers for Disease Control and Prevention
- Douglas Raymond Lyon, MD, Senior Health Advisor, Oregon Health Authority
- Jens Dakin, Managing Director, Information Operations/Strategic Communications, AM TRACE
This webinar is sponsored by AM TRACE with content development at the sole discretion of NASHP.
Through Coordination and Investment, Arizona Substantially Increases Access to School-Based Behavioral Health Services
By leveraging federal Medicaid funding and state investment while simultaneously clarifying complex billing procedures and enhancing engagement with providers, Arizona has made remarkable progress in increasing student access to critical school-based behavioral health services.
Arizona’s efforts to improve school behavioral health services began in 2018 when its state legislature allocated $3 million from the state’s general fund to expand these services. The state’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of Education (DOE) used $1 million of this funding to provide schools with mental health training, and the remaining $2 million was matched with federal Medicaid funds, resulting in a total $10 million in Medicaid funding to increase the number of behavioral health providers in schools.
To obtain Medicaid reimbursement for school-based services under the Medicaid School-Based Claiming (MSBC) program, Arizona’s local education agencies (LEAs) use two school-based claiming programs, the Direct Service Claiming (DSC) program and the Medicaid Administrative Claiming (MAC) program. LEAs seek Medicaid reimbursement through the DSC program to cover the cost of providing medical and behavioral health services to Medicaid-eligible students with an Individualized Education Program (IEP). The MAC program provides LEAs with reimbursement for administrative outreach services for Medicaid that are conducted in school settings. The state contracts with a third-party administrator, Public Consulting Group (PCG), to process Medicaid school-based claims.
In addition to claims processed through the MSBC program for students with IEPs, Medicaid services delivered by behavioral health providers contracted through one of AHCCCS’ managed care organizations can be reimbursed by Medicaid regardless of whether the student has an IEP.
Challenges and Solutions
Improving partnerships and coordination between schools and providers: While Arizona provided school behavioral health services before 2018, the additional state funding helped prioritize these services and facilitated the development of new relationships between behavioral health providers and schools. State officials reported that prior to the initiative to promote school-based behavioral health services, there were some challenges related to establishing relationships between schools and providers.
For example, some school administrators were skeptical if they could bill for school-based services or were concerned about the logistics of providing appropriate space to conduct behavioral health services without interrupting usual school activities. Many of these issues have been addressed through extensive and ongoing training sessions with both school administrators and provider groups. State officials also credited the cross-sector workgroup meetings that are held on a regular basis with helping improve interagency relationships.
Another key factor in Arizona’s success was incentivizing partnerships between schools and behavioral health provider agencies to create a differential adjusted payment for behavioral health providers. The enhanced payment became effective in October 2019, and provides a 1 percent rate increase for providers that have a memorandum of understanding with three or more schools to provide behavioral health services, and a 3 percent rate increase for providers that are autism Centers of Excellence.
State officials at AHCCCS also are in the process of improving data sharing with the DOE. By matching school identifier numbers on claims for services provided on a school campus, or as the result of a referral from an educational entity, the state will be able to obtain a better understanding of where and which services are delivered. Improving these data-matching processes will also provide information about where students are being referred for additional services and help identify where future focus should be directed within the state to enhance school-based behavioral health services.
Another key partnership to support students’ behavioral health needs is AHCCCS’ collaboration with the Arizona DOE on several grants, including Project Aware, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Project AWARE works with three school districts to provide suicide prevention and behavioral health resources.
Addressing lack of behavioral health providers and service delivery challenges: Arizona state officials identified the lack of behavioral health providers, particularly in rural regions, as an issue faced by many states. However, Arizona officials are pleased and encouraged by the number of providers who are participating in the state’s expansion of school-based behavioral health services. One factor that likely incentivized greater provider engagement was the implementation of the differential adjusted payment, although state officials indicated that there had already been a growing interest among behavioral health providers to develop new school partnerships to reach more students due to the statewide focus on the issue.
School districts in Arizona have also developed creative solutions to connect their students to behavioral health services. One school district in Arizona responded to provider shortages and space limitations by setting up a dedicated mobile unit in the school parking lot for behavioral health services. Prior to bringing in the mobile clinic, providers did not have financial incentives to travel to the school because it was difficult to secure an appropriate office during the school day. With the mobile unit, the district can provide consistency for their providers as well as a private space for students to receive behavioral health care. However, because the care is not technically provided in the school building, the district needed to work with the state Medicaid agency to find a way to appropriately bill under school-based behavioral health services.
Clarifying qualifying services and billing procedures: The state’s increased focus on the provision of behavioral health services in schools also helped to improve the accuracy of billing code processes. When efforts to expand school-based behavioral health services were initially launched, state officials at AHCCCS actively worked to address some of the existing misunderstandings about the allowability for those services to be provided at a school campus outside of the MSBC program. State officials recognized that due to errors in coding related to where services are provided, some school-based behavioral health services were not being correctly captured, resulting in the state not having a clear picture of the scope of services being provided to students.
To address these issues, AHCCCS coordinated and led many informational learning sessions throughout the state for both educators and provider agencies, including trainings about billing procedures. Once providers learned how to assign the correct place of service code, state officials reported a notable increase in the quantity of behavioral health services provided. State officials attributed the increase not only to the coding improvements that more accurately captured completed work, but also due to new services provided as a result of the state’s overall emphasis and investment in school behavioral health services.
Like many states, Arizona uses a Random Moment Time Study (RMTS) to assess the amount of time providers spend engaged in Medicaid-reimbursable activities. Each LEA has a RMTS coordinator who facilitates the administration of the program. As the third-party administrator, PCG manages the overall RMTS process, and provides program-specific introductory trainings for new coordinators and LEAs as well as recurring trainings to provide program updates and address areas of concern. AHCCCS coordinates with PCG to improve the RMTS process, and at present, AHCCCS consistently meets RMTS compliance standards, despite having to transition to virtual trainings during the COVID-19 pandemic.
Effect of COVID-19: The transition to mobile learning due to COVID-19-related school closures has presented an opportunity for schools to provide behavioral health services through virtual platforms. State officials report there has been a reduction in the number of claims that use place-of-service codes, which indicate when services are provided at an educational institution, most likely due to the decrease in the number of students attending school in person because of the pandemic. However, officials indicated that they have observed a dramatic increase in the amount of behavioral health services currently delivered through telehealth as more students have had to operate within a remote learning environment.
For districts without local providers, the ability to work with students without travel has helped connect more children to care. According to one Arizona state official, many behavioral health providers have gone above and beyond to connect with children whose need for care has been exacerbated by stress and isolation resulting from the pandemic.
State officials said there is anecdotal evidence that the pandemic has caused an increase in the number of parents expressing concern that their children are exhibiting depression and/or suicidal tendencies. However, officials also noted they have observed a greater willingness among parents to discuss issues concerning mental health, which could result in parents more actively advocating to ensure that schools continue to offer behavioral health services.
Overall Success
Since the start of the state’s efforts to expand behavioral health services in schools in 2018, officials report progress has been remarkably successful throughout 2019 and into early 2020, and there has been a substantial increase in the number of students who have received behavioral health services from an educational entity or institution. While declines in the number of youth suicides cannot be directly correlated with the state’s expansion of behavioral health services — and data from the effect of the pandemic is not yet available — there was a 41 percent decrease in youth suicides from 2018 through 2019.
State officials report their efforts have been so successful that in 2020 the state legislature passed SB 1523, which established and allocated $8 million to a new Children’s Behavioral Health Services Fund that will further enhance school-based behavioral health services. The fund will be administered by AHCCCS and provides behavioral health services to students who are not Medicaid-eligible but are uninsured or under-insured and who receive a referral for services from an educational institution.
In reflecting on lessons from Arizona’s expansion of school-based behavioral health services that might be used by other states, officials explained that determining how to handle nuanced billing situations, such as telehealth and the state’s mobile unit, was an important factor in ensuring that all provided services were accurately captured and reimbursed. They commented, “If Arizona can do it, anyone can do it — we are ranked 51st in [the nation for] education funding, and we have the poorest counselor-to-student ratio in the nation…that said, we have this great state Medicaid agency, and we’ve been able to figure out how to reach more kids with the dollars given to us. And so, if Arizona can figure out how to do this sort of work and get these partners on school campuses, then any other state can do this.”
The National Academy for State Health Policy (NASHP) would like to thank state officials from Arizona for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
New Federal Resources Can Support States’ Affordable and Supportive Housing Programs
Across the nation, COVID-19 has exacerbated the dual challenges of housing affordability and homelessness. As states address these issues, there are new federal resources available through the American Rescue Plan Act (ARPA) and proposed American Jobs Plan that states can deploy efficiently and equitably.
The economic impact from COVID-19 has left 30 to 40 million Americans at risk of eviction with a disproportionate impact on low-income communities of color. To avoid homelessness, many individuals and families have sought housing with friends and family, leading to crowding and increased coronavirus transmission. The pandemic has also greatly impacted individuals currently experiencing homelessness and living in congregate shelters. In New York City, the age-adjusted mortality rate from COVID-19 among sheltered people experiencing homelessness was 50 percent higher than the rest of the population’s cumulative rate as of February 2021.
The National Academy for State Health Policy (NASHP) is launching its Second Health and Housing Institute. The goal of the institute is to help states break down inter-agency silos and strengthen services and supports to help low-income and vulnerable populations become and remain successfully housed. Permanent supportive housing programs require affordable housing and housing-related services financed by Medicaid. Importantly, the new institute will focus on state deployment and execution of newly available federal resources.
With the passage of ARPA and the proposed American Jobs Plan, the following are new programs, policy, and funding opportunities:
Eviction Prevention and Affordable Housing:
- In late March, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky extended the temporary halt in residential evictions until June 30, 2021. Under the eviction moratorium, individuals must declare their inability to pay rent due to the loss of income or employment to avoid eviction.
- ARPA allocated $21.5 billion for the Emergency Rental Assistance Program (ERAP). ERAP funds will be released by early May 2021 to support eligible households in which one or more individuals are experiencing unemployment or housing instability. Financial assistance is limited to 18 months.
- $100 million in grants to organizations approved by the Department of Housing and Urban Development (HUD) that provide housing counseling services to households experiencing housing instability. Housing counseling includes information on renting, mortgage defaults, foreclosures, and credit issues.
- $5 billion allocated in ARPA for emergency housing vouchers. Vouchers serve as emergency rental assistance and voucher renewals for people experiencing homelessness, at risk of homelessness, experiencing housing instability, or fleeing intimate partner violence.
Supportive Housing and Homelessness Assistance:
- $5 billion in federal funding to states for the Homelessness Assistance and Supportive Services Program. This funding will be distributed to states to acquire and develop properties for supportive housing programs, tenant-based rental assistance, and supportive services, including housing counseling and homeless prevention services. Funding can also be used for the supportive housing workforce and service providers.
Home- and Community-Based Services:
- President Biden’s proposed American Jobs Plan includes $400 billion to strengthen home- and community-based services for seniors and people with disabilities. This funding will also raise wages for home health care workers and support the Money Follows the Person program to provide services for individuals in communities rather than nursing homes. Both home-and community-based services and the Money Follows the Person program are essential components of supportive housing.
These newly available resources provide states with opportunities to support, expand, and develop programs for those experiencing homelessness, housing instability, and populations that benefit from supportive housing. States will play an important role in determining how resources are distributed equitably to communities that have historically been denied federal housing resources and those most in need. In addition, some funding will go directly to local governments, public housing authorities and HUD-approved nonprofits. States can work collaboratively with these partners on shared agendas around housing stability and homelessness to strengthen health outcomes.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government. The author would also like to thank the Corporation for Supportive Housing for their analysis of the American Rescue Plan Act.
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. 
