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Intermediary Groups for Two-Generation Approaches
One of the panels consisted of representatives of organizations that work with both children and their parents or caregivers on behavioral health issues. This two-generation approach can improve the lives of children and adolescents directly and through improvements in their parents’ health, the panelists noted. However, they added, a two-generation approach requires even greater coordination of programs and policies that may have been designed to serve different populations.
COMMUNITY INITIATIVES FOR VULNERABLE CHILDREN
The National Institute for Children’s Health Quality1 is a national nonprofit organization located in Boston that is focused on large-scale initiatives to improve the health of socially, emotionally, or medically vulnerable children. It began in 1999 with a mission of improving health care quality and over time has expanded into the realms of public health, community health, and family engagement.
Shika Anand, pediatric director at the Whittier Street Health Center in Roxbury, Massachusetts, described several initiatives as examples of the kind of work the institute supports. The 100 Million Healthier Lives campaign, which is being run out of the Institute for Healthcare Improvement, is a multi-community and whole-of-community approach to promoting health, with health defined very broadly. It is focused on promoting social
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1Additional information on the National Institute for Children’s Health Quality can be found at: http://www.nichq.org (accessed July 30, 2015).
and emotional development, creating access to behavioral health services and community supports, and building the capacity of the health care system to address these issues.
Another initiative is focused on infant mortality in all 50 states and 6 U.S. territories. This effort involves screening for and addressing behavioral health issues and substance use in women of childbearing age as a way to prevent infant mortality and poor outcomes in infants.
Finally, the National Institute for Children’s Health Quality is partnering with the Einhorn Family Charitable Trust and other funders to promote socioemotional development in early childhood. “We need primary care to be connected to all the different agencies in the community,” said Anand. This initiative is focusing not just on the 30 to 40 percent of children who have impairments or who are at risk, but on the others who are “good enough,” as Halfon put it in his keynote address (see Chapter 2). “We don’t really believe that the good enough is good enough,” said Anand. For example, a group of experts were convened to identify nurturing behaviors that can easily be identified within the context of primary care where pediatricians or other providers can give positive reinforcement in the exam rooms of clinics.
The ACA provides many opportunities to better integrate physical and mental health, Anand pointed out, through better access to care coordination and patient navigation, better funding streams for those activities, and a new emphasis on prevention and early childhood development. But Anand also emphasized the need to focus on the people with the greatest needs and not just on those who show up at clinics. “The kids I’m most worried about are the kids who don’t go to school, and don’t go to clinic, and don’t go anywhere else. We still haven’t figured out how to find them.”
INTEGRATED CARE IN EAST TENNESSEE
Cherokee Health Systems is a comprehensive community health care organization based in east Tennessee that provides integrated primary care and behavioral health services. It has more than 20 clinics in 14 counties in which it provides integrated primary care, behavioral health, and substance abuse services to more than 60,000 patients. “We see people cradle to grave, so we don’t just see children and parents; we see cousins and grandparents and great-great-grandparents,” said Parinda Khatri, chief clinical officer for Cherokee Health Systems.
The organization brings in psychologists, social workers, care coordinators, community health workers, integrated psychiatrists, and others. “We’re all on the same team,” said Khatri. “We want to do everything we can at the point of primary care.” Cherokee Health Systems also has school-based health clinics and provides telehealth into about 25 schools
in the mountains of east Tennessee. “Wherever there’s a need, we’re going to go.”
The goal of the team is to “address issues at a subclinical level before they turn into a diagnosis,” she said. For example, developmental psychologists who are trained specifically in autism spectrum disorders can provide more intensive evaluation when a primary care screen is positive.
The organization also targets high-risk populations. For example, it has a partnership with the Department of Children’s Services (DCS) and the foster care system in Tennessee to provide optimal care coordination for children who are in or at risk for DCS custody. In its prenatal clinics, it provides services to vulnerable populations to reduce the risk of neonatal abstinence syndrome, which in east Tennessee “has become a tsunami,” said Khatri. Every woman sees a psychologist, has a case manager, and receives help with housing, transportation, food, and parenting. “Our goal is for them to be able to take their babies home. Most of them typically would not be able to do that.”
Khatri also briefly mentioned the Collaborative Family Healthcare Association (CFHA),2 which brings together stakeholders around integrated behavioral health and primary care, and holds a conference every year on collaborative care. The word family is included in the name specifically because the organization wants to change the health care landscape by focusing on the family. “CFHA is 25 years old, and now everyone is talking about it. Before it was just considered these very small fringe people on one side of the room.”
Finally, the Patient-Centered Primary Care Collaborative (PCPCC)3 is a coalition of individuals and organizations with the goal of not letting primary care get lost in ACOs. “ACOs can be great, but they’re huge entities,” she said. “How do you keep that focus on the medical neighborhood and patient-centered care?”
Khatri briefly discussed the differences in negotiating with payers before and after the ACA. The biggest opportunity as a provider organization, and also for CFHA and PCPCC, is moving beyond fee for service and having flexibility in payment. With this flexibility, providers and other stakeholders have the ability to link payment with outcomes. One challenge is that payers are still focused on their most expensive cases, such as older people with three or more chronic health conditions. Such patients are heavy users of the emergency room and are repeatedly in the hospital, which consumes health care resources. Payers are less interested in covering
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2Additional information on the Collaborative Family Healthcare Association can be found at: http://www.cfha.net (accessed July 30, 2015).
3Additional information on the Patient-Centered Primary Care Collaborative can be found at: https://www.pcpcc.org (accessed July 30, 2015).
psychologists and case managers in schools, for example, because the high users contribute to their medical loss ratio. “If we want to see long-term change, we’re going to have to intervene much earlier, when these kids are on the trajectory.” Khatri recently saw an 8-year-old girl who weighed 240 pounds, but the insurance company would not pay for her to be in an obesity program. “They said, ‘She has to get diabetes first.’ This is not the way we want to do it.”
INTEGRATED CARE IN SCHOOL-BASED HEALTH CENTERS
Both schools and community health organizations could do a better job if they could intersect on behalf of children and adolescents, particularly children and adolescents who have suffered great inequities in the health care systems in communities, said John Schlitt, president of the School-Based Health Alliance. Referring to the 2,400 school-based health centers in the United States, he issued his own audacity challenge: “What if we thought differently about what medicine is and brought a team of providers together, integrated the notion of primary care, public health, oral care, and health education and nutrition, and brought that team together and brought that force into the school to help disadvantaged children?”
Schlitt referred to school-based health centers as “the progenitors of health care transformation.” They have been doing integrated care in schools for decades, he said. In doing so, they help students succeed academically and graduate from school, which Schlitt called “one of the single greatest things that we can do.” They represent partnerships, a manifestation of community health working in and through the schools to deliver high-quality, prevention-oriented care and attending to academic success in the classroom for all children.
A school-based health center is a two-generational model because delivering pediatric care to children in elementary school means communicating with parents or guardians. Some schools work directly with parents, many of whom trust the school because their children are there every day, and feel it is the only societal institution they feel safe going to for services. For adolescents in particular, schools provide a context difficult to achieve in community-based settings where there is some stigma attached to going to community mental health clinics.
Schlitt said that his organization has always emphasized that the need for a safety net will not go away, no matter how much insurance coverage is provided for children and families. “They are still going to need systems of care that will see them.” But efforts to include school-based health centers as essential community providers in the ACA did not succeed, nor have efforts succeeded to get an ongoing authorization for funding for school-based health centers from the federal government. Instead, Congress
earmarked $200 million in mandatory money from the ACA for the capital construction of school-based health centers across the country over a period of about 3 years. Though money for construction was helpful, the federal government provided no money for the programs to operate.
In some cases, school-based health centers are being considered as eligible for funding as patient-centered medical homes, which is a positive development. But setting the bar too high for patient-centered medical homes risks losing many good providers. Schlitt also pointed out that the change horizon remains too short for school-based health centers. For example, the initial CMS Innovation Grant award applications required that grantees demonstrate cost savings to the system within 3 months. “School-based health centers were going to have a hard time making a case for that.”
Miami and Orlando both have innovation awards that are focused on integration of school-based health care in their transformation work, and progress is being made elsewhere involving school-based health centers in the broader system, but it is happening in a minority of communities. “We are not thinking downstream about these upstream providers,” Schlitt said. In general, effective payment mechanisms for upstream providers under a global budget with high-cost needs remain unclear.
An issue that arose in the discussion following Schlitt’s talk involved the use of school information systems, which are relevant to health by including information on behavior, academic achievement, cognitive achievement, absenteeism, and even whether students take algebra, which is an indication of whether they will attend college. Schlitt observed that school-based health centers are today largely disconnected from health systems, without a strong data interface with larger systems of care. Though both health and education privacy laws have hindered the exchange of information, communities are being smarter about that today and are figuring out a way to integrate—such as through the use of consent forms. For example, Miami is aggregating education data and health system data in a way that both systems are able to figure out where they are doing well and where they are not doing well and reallocate resources. “It can be done, and it is being done, again on a small scale.”
POLICIES TO PROMOTE A TWO-GENERATION APPROACH
The National Academy for State Health Policy (NASHP) is an independent academy of state health policy makers, including representatives from Medicaid, children’s health insurance programs, state insurance exchanges, state mental health agencies, and public health agencies. NASHP helps to identify, promote, and provide technical assistance around policy and program levers for change, with a further goal of spreading best practices
across the country and providing technical assistance to its members and others.
Behavioral health is a major priority for state health policy makers, said Karen VanLandeghem, senior program director at NASHP. Nationally and in states, much of the work to transform health care delivery systems, including efforts to improve behavioral health outcomes, access to services, and reduce health care costs, have focused on adults, but reforms also have an effect on children and families, and “We think that will happen even more.”
VanLandeghem focused her comments on four areas. An important opportunity for a two-generation approach to behavioral health is the “triple aim” of health care reform: improving patients’ care experience, improving the health of populations, and reducing the per capita cost of health care. States and the federal government have been pursuing this triple aim through reforms and investments such as patient-centered medical homes, ACOs, and multi-payer payment reforms—all areas that present important opportunities for promoting and improving children’s mental health, noted VanLandeghem.
The Maternal, Infant, and Early Childhood Home Visiting program4 also provides an opportunity for a two-generation approach, but so far it is only reaching a tiny percentage of the women who need home visits. NASHP is monitoring the health homes option as a way to take a two-generation approach, and many states have looked to that provision to focus on behavioral health, including among children.
A third area is the opportunity for states to expand Medicaid for those under 138 percent of the federal poverty level. Not all states are taking up that option, but the effect of adult coverage on children’s coverage is clear. “If adults have coverage, research shows that their children will be more likely to have coverage,” said VanLandeghem.
Finally, the ACA mandated mental health coverage for adults and children, but many important questions concerning this coverage remain unknown. For example, what does mental health coverage look like in insurance exchanges? At the time of the workshop, NASHP was doing some work to look at behavioral health coverage in the small group insurance marketplace, but the results of that work were not yet available.
BUSINESS SUPPORT FOR BEHAVIORAL HEALTH INTERVENTIONS
ReadyNation represents the demand side of the supply–demand equation for healthy development, said Sara Watson, the organization’s director.
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4Additional information about the Maternal, Infant, and Early Childhood Home Visiting program is available at: http://mchb.hrsa.gov/programs/homevisiting (accessed July 30, 2015).
It is a national business membership organization of more than 1,000 executives, from Fortune 500 CEOs to current and former small business owners. It encourages its members to reach out to policy makers and say they care about the workforce of the present and the workforce of the future, and that the best way to promote the workforce of the future is to invest in children and provide them with a good start in life. It is part of an organization that has four other related groups that each mobilizes a different type of high-level unexpected messenger. The first is Fight Crime, Invest in Kids, which consists of 5,000 law enforcement leaders, including police chiefs, sheriffs, district attorneys, and attorneys general, who believe “The best way to reduce crime is not to build more prisons but to invest in kids.”
The second is Mission Readiness, which consists of about 500 retired admirals and generals who believe “To have a safe and secure country, we need to start early to grow kids who can qualify to serve in the military and serve in any other careers.” Currently about 70 percent of young adults between the ages of 17 and 24 cannot qualify to be an army private, often for health-related reasons, said Watson, according to data developed by the Department of Defense and popularized by Mission Readiness.
Shepherding the Next Generation mobilizes conservative evangelical religious leaders to advocate for public funding for investments in children, as do the elite coaches and athletes who are part of Champions for America’s Future.
Watson’s request at the workshop was
We need your data. When a business leader meets with a member of Congress or signs an op-ed, that leader needs to know that the steps he or she is advocating translate into benefits that will result in healthy, productive adults. The more you can relate what you’re treating and seeing in young people to later outcomes, [including] workplace behaviors, the easier it is for me to get the former CEO of Procter & Gamble or the current Chairman of General Motors—two people who belong to our group—to say to their legislators, We should invest in getting children off to a good start.
Watson also emphasized the importance of CHIP, which was being considered in Congress at the time of the workshop. It is one of a number of programs that have a relationship with the workforce, she said, by keeping employers’ costs down, both direct costs and costs related to absenteeism and workplace problems. She emphasized the need for building support among all of these people who have a vested interest in better health outcomes, whether inside or outside the health care system.
An issue addressed by this panel and at other points in the workshop involved the preparation of a workforce that take advantage of the opportunities created by the ACA. In response to a question, Khatri said,
We need all hands on deck. . . . We need to train the existing workforce, we need new people, we need new people going into existing disciplines. . . . Probably we will have all kinds of variations of different workers. We have to go through systems like schools, teachers, and churches. We have to use every resource available to us.
Anand said the strongest programs employ community organizers who are able to change not just the health of children but the health of the community by focusing on food access, home visiting where children are exposed to asthma triggers in the home, organizing with tenants around the quality of housing, and safe routes to school. “You need somebody like that working in partnership across a prevention workforce to achieve all those kinds of goals.”
Another workshop participant pointed out that the distribution of the workforce historically has been at least as big of a problem as the size of the workforce. Mechanisms are still lacking to ensure that people skilled at team care are located in the places where they are needed.
