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Implementing Innovations in Other Settings
Many of the professionals involved in children’s behavioral health work in child welfare, foster care, juvenile justice, early childhood education, schools, and other settings. These settings traditionally have not been closely connected with mental health systems, observed several of the speakers on a panel on implementing innovations in disparate settings, but they offer many opportunities for treatment and prevention of behavioral health issues.
More than 3 million children required services or responses from the child welfare systems in the United States in 2013.1 Most of the children in these systems are under 1 year of age or are preschoolers, with the numbers tapering off as they get older.
These systems are outside of traditional mental health services systems, noted Mark Chaffin, a psychologist and professor of public health at Georgia State University. There is no diagnosis, billing code, or Medicaid reimbursement. Foster care is often a gateway into traditional mental health service systems, but children in foster care represent less than 20 percent of those in child welfare. The other 80 percent are children who are served with their families and for whom child neglect, often recurrent neglect, is their dominant problem.
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1For additional information please see HHS, Child Maltreatment (2013), available at: http://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf (accessed July 30, 2015).
These services are often delivered by paraprofessional home visitors, not by an agency or its employees. Agencies purchase these services from networks of community-based organizations. Using the metaphor Halfon introduced in his keynote talk (see Chapter 2), Chaffin said the child welfare system is absolutely a version 1.0 service. It is episodic, it is reactive, and children have to be reported and get into the system to get services. Once the services are done children are out on their own, and follow-up is minimal.
Yet the face of child welfare is changing, Chaffin said. It is starting to consider the kinds of developmental and chronic problems at the heart of the workshop. States are starting to implement evidence-based models that show substantial savings in child welfare, quality monitoring, and development of the workforce. Yet, for the most part, a mismatch still exists between the nature of the problem and the systems available to solve that problem.
Though the ACA does not offer much for children in child welfare systems, it does offer a great deal for their parents, said Chaffin, which can have a major effect on children. Child maltreatment does not occur in a vacuum. It occurs predominantly in a context of dire poverty. The odds of a family below the poverty line entering child welfare is more than 40 times that of a median income family. In the last trial in which he was involved, the median family income of the families served was $900 per month, Chaffin said. “Stop and think about what your life might be like on $900 a month, and if you had two or three kids.”
Another risk factor is substance abuse. Thus, greater access to substance abuse services could powerfully influence the lives of children, Chaffin observed. In addition, access to services for parental depression is an opportunity under the ACA to improve the long-term development of children.
IMPLEMENTING EVIDENCE-BASED PROGRAMS
Bernadette Melnyk, associate vice president for health promotion, university chief wellness officer, and dean of the College of Nursing at Ohio State University, said that she has spent most of her career developing and testing interventions to improve mental health outcomes in children, teens, and their families and then figuring out how to get evidence-based interventions implemented. For example, multiple randomized controlled trials demonstrated that a program she helped develop for parents of premature babies decreased parental stress and improved child outcomes through 3 years of age. “But no one was implementing it until I showed it reduced length of stay in the NICU [neonatal intensive care unit], and then everybody started calling me and asking me to come and teach them how to implement it because of the cost savings.”
Melnyk also has developed the COPE (Creating Opportunities for Personal Empowerment) Program, a lifestyle intervention to help adolescents engage in healthy behaviors and improve their mental health. A randomized controlled trial, funded by the National Institute of Nursing Research, of 779 teenagers in 11 high schools who were taught by their teachers showed improvements not only in healthy lifestyle behaviors but in depression, alcohol use, body mass index, social skills, and academic performance (Melnyk et al., 2013). Almost 300 health care providers have been trained to deliver the seven cognitive-behavioral therapy based intervention sessions to depressed and anxious teens and children that are part of the 15-session COPE program, and they are being reimbursed for it in primary care, noted Melnyk.
The ACA is now calling for reimbursement to health care providers who follow the evidence-based recommendations for primary care screening and behavioral counseling by the USPSTF, said Melnyk. However, the number of evidence-based recommendations for children is relatively few because of insufficient evidence to guide practice recommendations in many areas of child health, she noted. This lack of evidence should drive federal research investments, Melnyk explained, given the heavy toll of children’s mental health issues.
She also pointed to the need for providers to implement evidence-based interventions and practices that exist, even if they traditionally have done things in different ways.
HEAD START AS A MODEL OF INTEGRATION
Coincidentally, the workshop was held on the same day as celebrations to celebrate the 50th anniversary of the Head Start program. Kris Perry, executive director of the First Five Years Fund said Head Start is one of several programs for children that have been shown by research to produce such outcomes as higher lifetime earnings, better health, and less use of social programs such as special education or juvenile justice. By bringing educational and health services to both the child and the family, Head Start and other early childhood programs provide models for the integration of services. “We know that it prepares kids for school and life,” Perry said, “but we are leaving literally millions of children out of the Head Start program because we’re not funding it adequately.”
Perry urged everyone in the health professions to think of early childhood as a period in which to deliver such services as nutrition, education, and immunization. “The early childhood educator is the perfect person to deliver that information to parents, whether they’re a small family day care provider, a Head Start teacher, or part of the K–12 system.”
Perry also advocated the prescription of reading. “I’m being overly
simplistic because it’s so obvious, but no one is doing this.” As Halfon observed earlier in the workshop, children in poverty are exposed to 30 million fewer words by the time they turn 5, which is “absolutely the biggest contributor to the achievement gap, and one that really can’t be resolved once they hit kindergarten. It needs to be addressed very early on.” Exposure to language not only increases a child’s brain growth but builds the attachment between the caregiver and child. Anyone who interacts with parents of young children could promote reading, and physicians and nurses are particularly influential messengers, according to polls. They are in “a unique and powerful position to influence how parents interact with their children around literacy and learning.”
INTEGRATED PROGRAMS IN SCHOOLS
Olga Acosta Price, associate professor at the George Washington University’s Milken Institute School of Public Health and director of the Center for Health and Health Care in Schools, turned to the subject of school-based health programs. Her center seeks to maximize child development and learning by looking at physical, oral, and behavioral health in its entirety. It is a resource and a policy center that supports the implementation of effective programs, practices, and policies, as well as being a broker and an intermediary for evidence-based practices and programs.
One of its major goals is to decrease the cultural divide between education and health. These systems have different drivers and different funding mechanisms, which can create tensions when the two systems are brought together, Price said. Schools are not just buildings with a captive audience of children. They can be sites for multilevel interventions focused not just on treatment but also on intervention and universal prevention. For example, schools can be partners in the development and use of surveillance and data systems that can track indicators of well-being, not just prevent negative outcomes. Schools also can be major providers of behavioral health and physical health care for adolescents through school-hired providers, school-based health centers, or partnerships with other community organizations.
A robust literature points to a significant link between positive school climates and students’ attendance, engagement in school, and decreases in conduct problems, said Price. Many educators understand that health and educational performance are inextricably linked. They recognize that, for students to meet academic standards, they need healthy school environments that promote students’ competencies and strengths.
Price also noted that schools need to be ready to educate all children, or gaps reappear, even if good early childhood programs succeed in reducing those initial gaps. The majority of programs funded under the Elementary and Secondary Education Act allow federal education dollars to be used for
health prevention–related activities, so long as a case can be made that the use of those funds is connected to the aim of the federal program.
Price pointed to four other opportunities arising from health care reform. The Free Care rule is a regulation saying that Medicaid will not pay for services that are offered to the general public without charge. This created concern among school health providers who were restricted from billing for eligible services offered to eligible children. However, recent guidance from Medicaid clarified that the Free Care rule does not apply to school health services and reimbursement is allowed for covered services under approved state Medicaid plans. This was a “big win” for school-based health services, said Price. However, the issue is not completely resolved because it is not clear how states and school districts will implement the rule or how state Medicaid offices will respond.
A second opportunity is provided by changing regulations around the types of providers that can be reimbursed for preventive services. States now have greater discretion over nontraditional providers who conduct prevention in nonclinical settings, including schools. This opportunity has particular implications for communities of color and immigrant communities. For example, family liaisons or cultural brokers, who function as community health workers, can play a significant role in helping to navigate systems that can address a vulnerable family’s needs.
ACOs are a valuable way of integrating services, Price said, though few such organizations are focused on children. Schools and school health providers can be a part of these developing entities if local communities are committed to supporting child health.
Finally, innovative and growing models of telehealth can bring primary and mental health care to shortage areas, whether rural or urban. However, payment models for such services are still underdeveloped, and much has yet to learned about implementation and best practices, Price noted.
INTEGRATING HEALTH INTO SCHOOLS
A major topic of discussion throughout the workshop was the potential to integrate health and behavioral services into the education system. Sheppard Kellam, professor emeritus at the Johns Hopkins Bloomberg School of Public Health, argued strongly for moving schools and education into health care and forging a unified a life course system based in political support from the community and larger levels. For example, schools are already collecting large amounts of data about their students that relate to such conditions as attention deficit and hyperactivity. However, some teachers see these conditions simply as students who are impossible to teach and disrupt the classroom. Teachers tend to get little or no training for how to deal with such students and often burn out as a result, said Kellam. An
integrated system involving health, education, and other agencies as needed could generate and share information “for purposes of child development and teacher survival.”
Kellam also pointed out that even though the ACA is giving more people entry to primary care, the children who are not being reached by the act are still registered in school. Joining the primary care site with the public health perspective can be done by including schooling in the structure of health care. This would maximize the integration of primary care with the community, including its social, political, and cultural characteristics.
One workshop participant pointed out that schools already make requirements of students related to their health, such as requiring immunizations or requiring hearing and vision screens. Screens for developmental issues or mental health concerns would be an extension of these policies.
Another advantage of the school setting is that many parents are not able to take their children to primary care clinics during the day when they are working, another workshop participant observed, so school-based programs can reach children where and when they are available.
A workshop participant pointed out that schools will be willing to share data only if they trust an outside partner, and so far many schools have refused to share their data. As Kellam observed, “Each district has their own personality, and it has been challenging.”
Another participant made the observation that community data dashboards could include such things as whether schools are ready for children who are not ready for school. This would be a way of integrating multiple programs in schools, because those programs would need to exist within schools for the schools to serve all the needs of their students.
Melnyk, B. M., D. Jacobson, S. Kelly, M. Belyea, G. Shaibi, L. Small, J. O’Haver, and F. F. Marsiglia. 2013. Promoting healthy lifestyles in high school adolescents: A randomized controlled trial. American Journal of Preventive Medicine 45(4):407-415.
