The New York State children’s behavioral health community is in the last stages of redesigning the children’s behavioral health Medicaid benefits. Once approved by the Centers for Medicaid and Medicare (CMS), the new benefits will represent the most significant expansion of children’s services since the 1990’s when the Office of Mental Health (OMH) added the 1915c Home and Community Based Waiver services to the benefit package. The redesign includes an innovative array of new state plan services, the development of a Health Home (care coordination) infrastructure to support “care management for all,” and an effort to break down “silos” and align services across multiple child-serving systems including: health, substance use, mental health and foster care. Most importantly, the redesign revises the age eligibility for behavioral health services, which historically allowed serving children ages 5 to 17, to now encompassing all children and youth birth to 21 years of age. This change will enable a longer continuum of age-appropriate services, enable earlier identification of transition appropriate skill development and support young people more during the critical years of transition into adulthood. The goal is to facilitate more seamless “hand offs” when adult systems and supports are needed.
Based on the exciting opportunities this redesign affords our system of care, this article focuses on how the behavioral health provider community envisions using the new state plan benefits, care coordination and Home and Community Based services to better support the success of youth-in-transition (YIT). For the purposes of this article YIT are young adults needing behavioral health and substance use treatment between the ages of 15 and 21.
Youth with psychiatric and behavioral disabilities travel a daunting road into adulthood. The YIT research indicates consensus that this population has been neglected in public policy discussions and offers a history of identifying the obstacles to successfully serving YIT. The research offers few viable service solutions and even fewer have been developed widely or sustained. Common obstacles include cross systems eligibility contradictions, lack of accountability for the public system responding to the need of this age group, fragmentation in programs and funding streams, and differing eligibility requirements in terms of clinical eligibility and age appropriate service availability.
The statistics on this population drove the decision to expand the age of children’s services to 21 and the inclusion of treatment and support services that build skills needed by independent adults.
Among the Statistics
- There are over 2.4 million transition age youth (ages 18-26) who had serious mental illness in the United States in 2006. This is a low estimate given that institutionalized individuals were not included in the report. (Government Accountability Office [GAO] Study 2008)
- An estimated 20% of youth receiving treatment for emotional or behavioral problems have either contemplated suicide or attempted suicide. (Bazelon Center for Mental Health Law: Facts on Transitional Services for Youth with Mental Illnesses)
- Over 60% of young adults with a serious mental illness were unable to complete high school (Bazelon Center for Mental Health Law: Facts on Transitional Services for Youth with Mental Illnesses)
- Adolescents transitioning to adult hood with a serious mental illness are three times more likely to be involved in criminal justice activity then adolescents without an illness (Bazelon Center for Mental Health Law: Facts on Transitional Services for Youth with Mental Illnesses)
- Youth-in-Transition are four times less likely to be engaged in any gainful activities including employment, enrollment in college or trade school (Oregon White Paper)
Building a Better Lens and New Array of Services
When Governor Andrew Cuomo created the New York State Medicaid Redesign Team (MRT), a multi-agency, cross system stakeholder committee to guide the State’s efforts to transition to Medicaid Managed Care, a Subcommittee on Children’s Behavioral Health was appointed to focus on the unique needs of Medicaid-eligible children and youth. A strength of this “Kids MRT Subcommittee” was including cross-agency leadership, along with community-based providers and advocacy representatives from various child-serving systems. The cross-systems approach highlighted many of the “obstacles” and gaps identified earlier in this article for YIT and resulted in service solutions being part of the redesign.
A key example is the early decision to expand the age of eligibility to be uniformly up to the 21st birthday for the new services. Previously, most mental health children’s services were only available to those up to age 18, with a few exceptions (residential treatment).
Another example is the addition of Health Home, an individualized care coordination service, to the state Medicaid benefit package. Medicaid enrolled youth will be eligible to remain with a children’s Health Home care coordinator up until their 21st birthday, whether they are determined eligible because of a chronic condition, their need for treatment to address serious emotional disturbance; or based upon their need for treatment to address complex trauma (a new eligibility category approved in New York’s benefit – “first in the nation” by CMS). There is the ability for some care coordinators to specialize in the care coordination of YIT, as such they may be able to focus on assisting youth in finding adequate housing, identifying educational and vocational opportunities and accessing those opportunities, and promoting active participation in and direction of their treatment.
The highlight of the work by the “Kids MRT” was the addition of six (6) new state plan services to the children’s Medicaid benefit. These services offer options that better address the needs of older adolescents and young adults, including:
Being able to serve young people where they are through Other Licensed Practitioner (OLP) which focuses on serving children and youth in the home or community, rather than being restricted to an office-environment. This service addresses the ability to achieve age-appropriate growth and development, and supports goals identified in the treatment plan to address behavioral health conditions in the home and community.
Through the availability of greater access to Crisis Intervention (CI) services, youth experiencing a seriously acute psychological or emotional event can receive crisis response services, safety plan development, referral and follow-up to assure stabilization.
With the addition of the Community Psychiatric Supports and Treatment (CPST) service, youth can receive a wide array of supports that actively reinforce treatment goals and the skills necessary for age appropriate development such as, –independent living. These may include increased community participation, establishing positive peer support networks, maintaining self-sufficiency, and developing coping strategies in the social environment, work, home, school.
Similarly, Psychosocial Rehabilitation (PSR) provides “hands on” skill restoration and support to facilitate integration as a productive member of the community with minimal ongoing professional interventions. Enabling young people to prepare for the responsibilities and challenges associated with independence.
One of the most exciting new additions to the state plan service array is Youth Peer Support and Training. This service is provided by a young adult, aged 18-30, who has lived experience in the children’s mental health system. They assist the youth in enhancing their ability to manage comprehensive health needs, strengthening resilience & self-advocacy, and developing competency to utilize resources and transition to adulthood.
Finally, the addition of Family Peer Support Services helps to strengthen the family; to build advocacy skills of the family/caregiver; and to enhance family and home functioning. This service can assist youth and their families/caregivers in maintaining positive familial relationships into adulthood.
How the New Services Array Will Aid in Transitioning
Currently, the transition between the child-serving behavioral health system and the adult system is abrupt and often times inappropriate, especially when it comes to housing and employment expectations. The new service array should support treatment that strengthens the ability of youth to build and eventually sustain enduring relationships as they learn develop skills needed to live independently. Relationships, housing and employment are the key developmental milestones for any young adult and maintaining independence depends on skill-building in those domains.
Lastly, some of these services can be provided in community settings. Youth concerned with the stigma of their treatment needs will not have to go to the clinic to receive the new services, as they can all be offered in normative settings. We believe this will improve treatment compliance for young people who definitely have social priorities that compete with their clinical needs.
New Home and Community-Based Services Array
In addition to the new services that will be in the state plan and available to any eligible youth, New York will seek approval to re-align the existing array of services under various 1915-c Waivers into a uniform set of Home and Community Based Services (HCBS) under 1115 Waiver authority. Of specific interest to those hoping to address the needs of the YIT population are these 12 HCBS services, including: Habilitative Skill Building; Prevocational Services; Supported Employment; and Community Self Advocacy Training and Support.
To access HCBS will require both a Level of Care determination and a Level of Need determination as part of the eligibility determination. By aligning waiver services uniformly, the new array will break down silos, enable equal and seamless access for youth with multiple diagnoses, and address older adolescents and young adults more effectively with Pre-vocational and Supported Employment.
Conclusion: The new services array in New York State, and the ability provide services to youth up to their 22nd birthday, offers great promise for YIT. Updated services that can be provided outside the clinic walls and in normative settings, can focus on strengthening and maintaining functioning, to address untreated trauma and to treat each individual’s diagnosis with an update array of clinical services. Most importantly, the new service array can assist youth in building emotionally health relationships with family and peers can offer a new foundation upon which successful transition aged youth services can be built.
Andrea Smyth is Executive Director of the NYS Coalition for Children’s Behavioral Health; David Rossetti is Clinical Director of the Northern Rivers Family of Services; and Leonardo I. Rodriguez is Executive Program Director, Children’s Residential Services at The Jewish Board.