On October 15, 2011, the Behavioral Health Subcommittee of Governor Andrew M. Cuomo’s Medicaid Redesign Team (MRT) gave its final report. For the adult behavioral health system, the report recommended an unprecedented investment into the housing needs of individuals with mental health and substance use disorders. For the children’s behavioral health system, there was also an unprecedented recommendation, that being: “The Children’s Behavioral Health System lacks capacity to best serve the needs of the state’s children and youth; community-based care should be targeted for planned investments and re-investments. This need for investment must be taken into account.”
The acknowledgement of lack of capacity is stunning because the status quo of too few services, with slots and caps on the number of youth and families accessing care perpetuated stable government spending and insurance actuarial projections that excluded the Medicaid population. In addition, access to care often relied upon a deficit-based care model, or the need to “fail first” at a lower level of care before accessing intensive services.
However, for over 75 years, there was credible, wide-spread support for the best methods of meeting the behavioral health needs of children.
- In 1941, Anna Freud, the youngest daughter of Sigmund Freud, formed the Hampstead Nursery in London. The nursery served as a psychoanalytic program and home for homeless children. Her experiences at the nursery provided the inspiration for books and findings that emphasized three needs of the growing child: the need for intimate exchange of affection with maternal figure; the need for ample and constant external stimulation of innate potentialities; and the need for unbroken continuity of care.
- In 1984, the Child and Adolescent Service System Program (CASSP) principles were initiated to encourage comprehensive, coordinated and culturally competent mental health services for children, adolescents and their families.
- Between 1995 and 1997 Kaiser Permanente, conducted a landmark Adverse Childhood Experiences Study that found that left untreated, a child’s adverse childhood experiences can result in chronic health conditions later in life.
Over generations, the debate around strong, family-and-community-focused care has dominated the child emotional development research, child health studies and child welfare policy debates. The recommendations often centered on accessing children’s mental health services earlier in a young child’s life, but somehow the debate never resulted in expanded capacity.
Therefore, it is extraordinary that less than a decade after the 2011 MRT revelation of the capacity shortcomings in child and family behavioral health care, a January 1, 2019 inauguration of behavioral health expansion and transformation will begin a hopeful new chapter in community capacity. Mechanics and economics aside, a better way to treat children and support families will greet the dawn of the New Year.
That better way is the addition of Child and Family Treatment and Support (CFTS) services to the New York State Medicaid State Plan under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) child health component of Medicaid. Federal statutes and regulations state that children under age 21 who are enrolled in Medicaid are entitled to EPSDT benefits and that States must cover a broad array of preventive and treatment services. New York’s capacity expansion adds children’s behavioral health services to join the existing array of health EPSDT entitlement services.
Better Services – Better Delivery Model
At the center of the CFTS service design is the foundation that the treatment goal or valued outcome for families and the youth is the desire to get better and lead a productive life. Families want that outcome regardless of which “service system” their child engages through, the child welfare system, the mental health system the DD system or the health system. The design of adding the behavioral health benefits as state plan services is that any child eligible or enrolled in Medicaid can access the services if a licensed professional determines medical necessity, regardless of what other Medicaid services they may need to address other challenges or disabilities.
The “better services” model includes family and youth support as funded services and an essential component of service delivery. Previously, those services were only available to the limited number of children who could access Home and Community Based Services (HCBS) through the state’s Waiver programs with a capped number of slots. Yet, they were rated among the most highly valued by families and children in the Waiver programs.
The “better services” model mirrors the family-friendly HCBS model in other ways too. CFTS Services are authorized to allow services and supports in settings that are preferable and readily accessible to children, youth, and their families. “Community-based care” was never more literal. The intent is that the majority of treatment and supports will be provided “offsite”, or in the home, school, and community. Once consent is provided, the services can be provided at the location that best meets the family needs and supports the restoration of the child’s functioning in a normal setting. For example, if a child’s biggest barrier to fully functioning in school is the lack of ability to establish non-confrontational communication, a community mental health worker can implement psychosocial rehabilitation services at a playground, park or sports team setting. The child learns, develops and practices his/her new skills in the setting where they will be most valuable.
The 6 new CFTS Services’ design will take family-driven and youth-guided services to scale by making them available to all Medicaid eligible children, based on their needs. The first 3 of the CFTS Services that will be implemented on January 1, 2019 are Other Licensed Professional (OLP), Community Psychiatric Treatment and Support (CPST) and Psychosocial Rehabilitation (PSR). These are also modeled after existing HCBS Waiver services. OLP will bring diagnostic, assessment and eligibility determination out of the clinic and doctor’s offices, allow licensed professionals to work to the top of their scope of practice and, hopefully, reduce waiting periods and erase some of the stigma families associate with having to bring their child to mental health outpatient settings. CPST is a service that will allow for reimbursement from counseling and crisis assistance to be provided by appropriately credentialed professionals and also allows for psychoeducation supports to be provided by BA level community health/mental health workers to family members to help them support their child’s treatment plan, medication adherence and to better understand how the services will support their child’s development. PSR is essentially a skill building supportive service provided by an unlicensed community mental health worker who helps the child implement the treatment plan one-goal-at-a-time.
Good Intentions – Great Design Better Results?
The growing populist belief is that behavioral health care is effective and commonly required. More and more, citizens motivated in part by their own family experiences, speak in favor of service expansion. These families are commonly accepted as the community’s voice about both the importance of behavioral health, and acceptance that the common definition of “health care” includes behavioral health. Policy makers should be aware that there exists something of a mandate to expand community capacity and respond to pervasive child and family need. They should understand that the CFTS services design is good. Most importantly, they should pay careful attention and join in an effort to dictate how the outcomes and results of such a creative expansion of new children’s behavioral health benefits will be measured.
One set of results, based on the Social determinants theory, might require us to wait until a child reaches age 27 (age of full emotional development for males). The Social Determinants Theory, extends the definition of health care beyond the limits of direct medical provision to include macro-factors that affect the health status of an entire population. The World Health Organization’s definition of social determinants is deceptively simple: The social determinants of health are the conditions in which people are born, grow, live, work, and age. The circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.
The assumptions that child health will be improved by a nurturing environment for children, better engagement with education, a socially supportive community will not send the insurance actuaries running to the bank to safeguard huge returns on their investment. Likewise, policy makers worried about re-election in 2 years may grow impatient with the slow pace of outcome data. However, the facts remain that early adverse experiences and missing developmental milestones become embedded in biology during the processes of development. The embedded biology forms the basis of the individual’s behavioral and human capital, which affects health throughout life. Only through earlier intervention and treatment can the adverse impacts be balanced with positive coping skills and appropriate development.
The complexity of these challenges may make it difficult for policymakers to remain constant and committed to the relatively slow return-on-investment represented by children’s mental health policy reform. Yet, by determining whether access to quality care is sufficient and whether the community-based design of CFTS services is practical MUST be the second phase of this children’s mental health reform; by securing and sustaining essential care for children. The commitment must last at least as long as a comprehensive review of how managed care organizations react to their new involvement with the “whole child’s” health care costs, now that previously carved out behavioral health costs are factored in and until we determine how the children’s mental health provider community fares in delivering more, high quality but less intensive, community-based services delivered by a mobile community mental health workforce.
Expanding the children’s behavioral services capacity won’t be easy. The positive outcomes may take five or more years to trickle in, but children and families who will benefit will understand immediately that the expansion, the way the new services will be delivered and the positive child development that results are worth the investment. The supporters of the redesign remain steadfastly unified behind the design, which embodies the fact that, children cannot be served alone. When we look at a child, we must never fail to see the two or five or ten caretakers around him, his community, the capability of his school to accommodate his needs and his access to social supports. Families are simply the first and best behavioral health asset that a child can have and the new Child and Family Treatment and Support Services were designed with that fact in mind.
The NYS Coalition for Children’s Behavioral Health website can be found online at: www.cbhny.org