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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.

Transparency Regulations and the Consolidated Appropriations Act: A Checklist for SEHPs

February 18, 2022/in Health System Costs Featured News Home, Reports Health System Costs /by Marilyn Bartlett

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).

Massachusetts Health Policy Commission Takes Steps to Hold High-Cost Health System Accountable

February 14, 2022/in Health System Costs Massachusetts Blogs, Featured News Home Cost, Payment, and Delivery Reform, Health System Costs /by Johanna Butler

In January, for the first time in its history, the Massachusetts Health Policy Commission (HPC)’s Board voted to require the Mass General Brigham (MGB) health system to submit a Performance Improvement Plan (PIP) because of the system’s substantial contributions to the state’s health care cost increases. The HPC’s comprehensive analysis of MGB cost data and decision to require the PIP comes at the same time as MGB is seeking approval from the state’s Department of Public Health to expand its hospitals and create new ambulatory facilities throughout the state. In taking this action, the HPC is addressing an identified cost trend with the PIP as well as raising concerns aboutMGB’s proposed expansions currently being reviewed through the state’s certificate of need process.

HPC to Require First Performance Improvement Plan for Large Health System

The HPC is an independent state agency charged with monitoring health care spending growth in Massachusetts and providing policy recommendations regarding health care delivery and payment reform. Among other activities, the HPC oversees the state’s cost-growth benchmark program and conducts cost and market impact reviews (CMIRs) to understand how significant transactions between providers may impact the health care market. If the HPC identifies a referred provider that has total health status-adjusted medical expenses that exceed the established benchmark for health care cost growth, the HPC may require that provider to complete a Performance Improvement Plan (PIP).

In January 2022, for the first time in its history, the HPC Board voted to require a PIP from MGB, which will require MGB to identify the causes of the health system’s spending growth, a savings goal, and specific action steps that MGB can take to achieve the goal. In making this decision, the HPC Board found that MGB’s spending performance has likely impacted the state’s ability to meet its health care cost growth benchmark, which has been exceeded in 2018 and 2019. The Board determined that if not addressed, spending at MGB will likely result in the health care costs continuing to exceed the state’s benchmark target. From 2014 to 2019, MGB had more cumulative commercial spending in excess of the benchmark than any other provider, totaling $293 million. The largest provider group within the MGB system has spending levels substantially higher than insurer network averages and is consistently among the highest in the state for the top three commercial payers.

Through the HPC’s review process, MGB had opportunities to provide its own data and present factors that may be contributing to high costs. For example, MGB stated that pharmacy costs are a consistent driver of medical expenditures. However, through reviewing medical expenditure data from 2017 – 2018, the HPC found that pharmacy was not a top driver of costs.

MGB now has 45 days to file a proposed PIP with the HPC, request a waiver, or request an extension. Once the HPC receives the proposed PIP, the Board will vote on whether to approve it based on a variety of factors. If approved, MGB is subject to ongoing monitoring during an 18-month implementation period. After those 18 months, if the HPC Board finds the PIP is unsuccessful, it may require further action from MGB and can also levy a fine up to $500,000 for non-compliance.

Other states will be watching how the PIP process unfolds in Massachusetts. Following the Commonwealth’s lead, a number of other states have begun to implement cost-growth benchmark programs, including most recently in Nevada and New Jersey, where Gov. Steve Sisolak and Gov. Phil Murphy signed executive orders to establish benchmarks at the end of 2021. In 2021, Oregon’s cost-growth benchmark program was enhanced to include more enforcement mechanisms including the ability to require performance improvement plans like Massachusetts and fine payer or provider organizations that exceed the benchmark for three out of five years.

HPC Reports that Proposed Health System Expansions Will Raise Costs

In addition to requiring a performance improvement plan, the HPC board also voted in January to submit a public comment on three pending Mass General Brigham Determination of Need (DoN) applications, Massachusetts’ version of certificate of need.

In early 2021, MGB filed DoN applications for three substantial capital expenditures, totaling $2.3 Billion, including the expansion and renovation of Massachusetts General Hospital (MGH) and Brigham and Women’s Faulkner Hospital (Faulkner), as well as the creation of three new ambulatory sites across the state.

In determining whether to grant a DoN, the Department of Public Health (DPH) considers, among other factors, if an applicant has “sufficiently demonstrated that a proposed project will meaningfully contribute to the Commonwealth’s goals for cost containment, improved public health outcomes, and delivery system transformation.” DPH required an Independent Cost Analysis (ICA) to be conducted on each of the three applications, funded by MGB, which were released at the end of December.

While the HPC does not have formal authority over the DoN process, it can produce expenditure analysis and submit public comments. Leveraging its data analysis capacities and types of data similar to that used in its Cost and Market Impact Reviews, the HPC conducted its own analysis of the proposed MGB projects and ultimately concluded that the that the expansions are not in line with state’s cost containment goals.

The HPC found that in total, the proposed expansions would increase inpatient beds at MGH by 16.6% to 18.9% and beds at Faulkner by 45.6%. Based on conservative projections, the projects are likely to increase yearly commercial health insurance spending in Massachusetts by $46 million to $90.1 million.

This evidence will be considered in the state’s DoN review. Massachusetts DPH has four months to review the MGB’s application, with the option of a two-month extension (the clock was paused during the independent cost-analyses). A final decision on MGB’s proposed expansion is expected sometime this Spring or early Summer.

Impact of HPC’s Actions for Other States

Other states that are implementing cost-growth benchmark programs may consider Massachusetts a model for applying the benchmark infrastructure to examine proposed mergers and use collected data to bolster existing Certificate of Need (CON) programs. Across the country, 35 states have CON programs in place, although they vary dramatically based on which facilities are subject to CON, the range of activities that trigger a CON review, and the information considered during review. A primary challenge to state CON programs is having access to relevant cost data and analysis capacity to properly study the impact on care delivery and the expense of proposed expansions.

Massachusetts offers an example for other states interested in creating infrastructure that allows cost-growth benchmarks and CON programs to work with one another. While cost-growth benchmark programs are successful at studying spending growth, they provide a retrospective rather than prospective look at health care costs in a state. CON programs continue to be one of the few, albeit limited, tools to control future expansions, consolidation, and growth in costs. Leveraging data and analysis from cost-growth benchmark programs, may allow for more in-depth CON review processes.

Community Health Workers Twitter Chat — Thursday, February 24

February 14, 2022/in Community Health Workers Featured News Home Community Health Workers, Population Health /by NASHP Staff

The National Academy for State Health Policy (NASHP) is hosting a Twitter chat on Thursday, February 24^th at noon ET to continue the conversation around states’ best practices for sustainably financing the community health worker (CHW) workforce, and strategies to partner with these essential workers throughout and beyond the pandemic.

To join the conversation, make sure you follow @NASHPhealth  on Twitter and use the hashtag #CHWChat.

How to Participate 

Follow @NASHPhealth on Twitter.
Join us on February 24^th at noon EST and follow the conversation using #CHWtalk.
Share your thoughts and ideas on policies and support resources.
Use links to your website, programs, initiatives, and partners in your tweets to promote the good work you, your organization, and/or state are doing!
Include #CHWtalk in all of your tweets so chat participants can easily follow you and others during this event.

How it Works 

Each question will be numbered Q1, Q2, Q3, etc.
Start your responses with A1, A2, A3 etc. to correspond with the question.
You only have 280 characters per tweet but you’re not limited to only one tweet per question. Use A1a, A1b, A1c, etc. to indicate either a multi-part answer or multiple responses to a given question.

The Questions

Q1. What role have CHWs played during the pandemic?
Q2. How do CHWs help increase access to public health / health care for historically marginalized populations?
Q3. What are some innovative ways that CHWs work in the community to promote community health?
Q4. How can CHWs collaborate with other stakeholders to address social determinants of health and reduce health disparities?
Q5. How does your state or community work to support CHWs as a workforce?
Q6. What steps are states and communities taking to ensure that CHWs are sustainably financed and paid livable wages?
Q7. What are some creative efforts at the state, local, and community level to support CHWs?
Q8. What work can be done at the federal level to support CHWs?
Q9. What’s your #1 tip for state officials that want to support CHWs?

This chat is an excellent opportunity to highlight some of your exciting initiatives, innovations, and resources!

For questions, please contact Rebecca Cooper at rcooper@oldsite.nashp.org.

Educating the Public about Palliative Care

February 3, 2022/in Policy Featured News Home Chronic and Complex Populations, Featured Policy Home, Framing the Message, Palliative Care /by Salom Teshale, Mia Antezzo, Kitty Purington and Wendy Fox-Grage

Mobile Crisis: Maximizing New Medicaid Opportunities

January 24, 2022/in Behavioral/Mental Health and SUD Blogs, Featured News Home Behavioral/Mental Health and SUD /by Kitty Purington and Jodi Manz

The new national crisis line for behavioral health – 988 – will go online this summer, and state crisis systems will need to be ready. Current crisis call centers will need to handle an increase in the volume of calls, and the mobile crisis systems to which they refer will need to provide remote and in-person crisis services to people with a range of behavioral health needs across the state. To help build this capacity, the American Rescue Plan Act, among other resources to states, authorized a new Medicaid payment mechanism for Medicaid mobile crisis services, and awarded planning grants to twenty states to prepare for implementation. Through a state plan or within waiver authorities, states can draw down an enhanced 85% federal medical assistance percentage (FMAP) for mobile crisis services for 12 quarters, making this an attractive option for many states already facing overwhelmed mental health crisis systems.

CMS recently issued guidance to state health officials, outlining additional considerations on reimbursement for these new services. The guidance also calls out the Substance Abuse and Mental Health Services Administration’s National Guidelines for Behavioral Health Crisis Care, offering a good roadmap for states on clinical best practices for systems that incorporate:

Regional or statewide crisis call centers coordinating in real time;
Centrally deployed, 24/7 mobile crisis;
23-hour crisis receiving and stabilization programs; and
Essential crisis care principles and practices.

The following are some of the key factors and decision points states may want to consider as they build out services and systems that qualify for enhanced FMAP funding; engaging a cross-agency team and a broad range of external stakeholders can help ensure full consideration of diverse state crisis needs:

Describe the team structure for mobile crisis response: States can review their current crisis continuum and team structure to assess how/if it aligns with the newly authorized mobile crisis response service. Federal legislation and guidance emphasize that to qualify for Medicaid reimbursement, services must be delivered by a multi-disciplinary team that includes at least one licensed professional who can perform an assessment within the scope of their licensure. Other members of the team may be trained, non-licensed professionals and both CMS guidance and SAMHSA best practices underscore that peers can be an effective component of crisis teams. A number of states, such as Georgia, already embed peers throughout their crisis systems via warm lines, crisis intervention, and peer respite.

Review current training: Similarly, states may want to review the adequacy of current training for their state’s mobile crisis response teams. To qualify for Medicaid reimbursement, training must include trauma-informed care, de-escalation techniques, and harm reduction. In addition to ensuring that these core components are included in training crisis staff, states may want to look at how they can build or enhance key skills as part of the overall update to their crisis training. For instance, CMS guidance notes that crisis teams could be equipped with naloxone, fentanyl strips, and suboxone. Building on harm reduction requirements and acknowledging the significant spike in overdose deaths over the past year, states may want to work with behavioral health providers and other stakeholders to ensure that mobile crisis teams can more fully assess and address substance use disorder as a component of crises. Follow up can include systematic linkages and warm hand offs to SUD treatment as well as mental health care.

Review current transportation policies: CMS guidance notes that mobile teams may provide transportation for people in crisis to other settings, such as crisis stabilization centers. States can decide to include this function as a billable medical service or they can pay crisis teams an administrative fee for transport. The guidance indicates these expenses would be paid as Non-Emergency Medical Transportation, and not as a service eligible for the Mobile Crisis enhanced FMAP. Notwithstanding, crisis teams that have the ability to provide and be reimbursed for transportation – particularly in rural areas – may be especially effective in reducing engagement of and burden to local law enforcement.

Build on Telehealth: During the past two years of the COVID-19 pandemic, states have gained experience reimbursing for behavioral health services delivered via telehealth, and CMS guidance indicates that “screening, assessment and stabilization” offered via telehealth may be reimbursed as part of the new service. Given workforce shortages and gaps – especially in rural/frontier areas, telehealth offers states additional flexibility to build virtual teams and models that use laptops or tablets to augment in-person crisis response.

Define the crisis episode: CMS guidance references that near term follow up to support individuals after the initial crisis– delivered either in person or via telehealth – is also eligible for enhanced FMAP. States can consider how broadly to define this post-crisis period: some states currently tailor this to a 24- or 48-hour period or cap the amount of crisis units that may delivered without prior authorization. New York, through its 1115 waiver, defines the crisis period as 14 days, during which crisis providers may continue to deliver medically necessary follow-up care including outpatient services, coordination with primary care, and engagement or reengagement with a health home or peer support provider.

Maximize Medicaid: In addition to billing at an enhanced FMAP rate for medically necessary services, CMS guidance offers a number of options for states to use Medicaid to fund the full crisis continuum:

Leading states such as Georgia have developed payment strategies that allocate some costs related to call centers, mobile crisis, and peer respite to administrative claiming.
States may consider building out new technology infrastructure through the Medicaid Information Technology Architecture. Guidance released in 2018 specifically provides opportunities for states to enhance behavioral health care by creating capacity to share data across providers and systems (e.g., hospitals, criminal justice, and specialty mental health providers). That guidance also allows MITA funding to be used to build out the infrastructure needed to connect mobile crisis services to people in need.
Enhanced FMAP available under ARPA for home and community-based services may be used to improve crisis infrastructure. NASHP review of initial state spending plans for ARPA identified investments for behavioral health crisis systems, including support for 988 capacity, workforce training and reimbursement, and improving the data interface between key state agencies, such as corrections and behavioral health.

Conclusion: States right now have an unprecedented opportunity to enhance and modernize their behavioral health crisis systems by leveraging new Medicaid funding options. The COVID-19 crisis, coupled with skyrocketing overdose deaths and suicide risk, has put state crisis systems in the spotlight as never before. The roll out of a national 988 call number for behavioral health crisis will bring further attention and traffic. Leveraging Medicaid funding can help states build out sustainable crisis systems that can respond to growing challenges.

Acknowledgements: This blog was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank HRSA project officer Diba Rab and her colleagues for their guidance and helpful feedback.

NASHP’s Expanding Emerging Leaders of Color Fellowship

January 24, 2022/in Health Equity Blogs, Featured News Home Equity, Health Equity /by Hemi Tewarson

I am excited to welcome applications for the second year of NASHP’s Emerging Leaders of Color (ELC) Fellowship Program. NASHP is committed to addressing equity in our work across states and the ELC Fellowship is central to this commitment. We are looking for those who are inspired to learn more about state health policy and to work with us to ensure that our state governments can better reflect the communities that they serve.

In late 2020, NASHP launched the ELC Fellowship to help improve the accessibility of state health policy careers for people of color, particularly those from communities most impacted by health disparities.

Applications are due by 11:59 p.m. ET on Feb. 15, 2022. View more information here.

Through the ELC fellowship, NASHP equips emerging and aspiring state health policy leaders of color with the tools to enter state government and lead the development and administration of more equitable policy informed by their own lived experiences. These tools include guided learning opportunities and hands-on experiences as well as a community to share support and educational/ professional opportunities.

Central to this experience is the pairing of each fellow with a current state leader of color who can help them learn about, and navigate, the realm of state policy.

Last year, we were so pleased to have three fellows. The inaugural cohort of ELC Fellows meaningfully contributed to a diverse array of projects, particularly with health equity implications, alongside their state advisors, including:

Aligning early childhood health and Medicaid
Improving Medicaid coverage of fertility preservation services
Designing departmental diversity, equity, and inclusion efforts
Developing an agency health equity strategy
Implementing Medicaid coverage of doulas
Increasing follow-up for postpartum care
Improving provider and member messaging for contraceptive care

Given the success of last year’s program, this year NASHP is expanding the ELC Fellowship to accept up to ten fellows and each fellow will receive a stipend of $6,300. Fellows will be partnered with a state leader of color to take on a project of mutual interest. Fellows will also have the opportunity to engage in NASHP’s ongoing work, including a visit to Washington, DC and attending NASHP’s annual conference in Seattle, Washington.

The NASHP staff, corporate board and Academy members are looking forward to the launch of this year’s ELC Fellowship. I know we will have another impressive class of fellows this year and we are all excited to partner with them. We will announce the 2022 class of fellows by April 12, 2022.

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