A remarkable development took place on Tuesday at the SAMHSA National Children’s Mental Health Awareness Day kickoff. The Centers for Medicare and Medicaid Services (CMS), along with the Substance Abuse and Mental Health Services Administration (SAMHSA), issued a Medicaid bulletin to states regarding “their options for structuring mental health benefits as part of an agency-wide effort to draw attention to behavioral health services.” The bulletin “encourages states to design benefits that allow many young patients with mental health needs to live at home and get services in the community rather than be institutionalized.”

This is really important Network faithful, and here is why:

• This groundbreaking document identifies the critical importance of incorporating home and community based services into benefit designs specifically to support young people with significant mental health needs and their families. Such services include:
  • Intensive Care Coordination (Wraparound);
  • Family and youth peer support services;
  • Intensive in-home services;
  • Respite care;
  • Mobile crisis response and stabilization; and
  • Flex funds.
• Each of these services is described in the Bulletin, along with financing strategies. The report notes that “States have significant flexibilities in the Medicaid program to cover mental health and substance use services for youth with significant mental health conditions. CMS staff are available to states to further discuss how they can use the authorities below to promote better coverage.” (Our bold emphasis)

Let’s let this sink in for a moment
For those of you reading this who have been involved with the Child Mental Health Initiative you know how important this document is. In the over 25 years I have been involved with this movement there has always been a brutal conundrum facing those trying to implement a system of care approach to improving services and supports for children, youth and families – how the heck do you pay for what has been shown to work once the demonstration grant ends? Sustainability of “proven” effective service delivery approaches unfortunately often falls just outside of what is considered Medicaid billable – hence the conundrum and the often predictable slide towards “usual care,” a term coined by Garland, et al. in a recent journal article titled Improving Community-Based Mental Health Care for Children: Translating Knowledge into Action (see our review here). The journal article lays out some sobering statistics regarding quality in traditional mental health services. They note that 68% of the care in the studies reviewed was clinic based. A sobering reminder of how fragile our current mental health services are is the finding that “a third of the directors with site-specific budget data indicated that their agency ran at a budget deficit.” This is so important for advocates to understand. For us, “what works” goes far beyond usual care. It involves the active participation of community groups and families and the use of services and supports like those mentioned in the joint bulletin released on Tuesday. If we allow policy makers to just fund what we do now, (i.e., usual care) then we are doomed to a mediocre at best mental health service delivery system.  We need a system that evaluates and supports services beyond usual care if we are going to make significant improvements. This bulletin is a huge step in helping to make that happen.

So what should you do? We are so glad you asked!

• Download the Bulletin, print it out and carry it wherever you go. You never know when you are going to be in a meeting where you might here someone say, “Well, I wish we could provide family and youth peer services, but there is no way we could ever get reimbursed for that…” This is when you pull out your now dog-eared copy of this bulletin (cuz you have been showin’ it to everyone you know) and say, “Well now wait a minute, I’ve got a joint bulletin from CMS and SAMHSA that not only says we can, but backs it up with research and state specific examples.”
• Schedule a meeting with your state Medicaid Director for the sole purpose of discussing the recommendations within this bulletin and how your state can move forward with implementing tangible change.
• Send a copy of this bulletin to any and all community and state level collaboratives you may be involved with. Knowledge is power folks, and we need to spread the word about this important document.
• Schedule a meeting with your local health and mental health provider agencies to discuss the bulletin. The Feds have made a big step on their part, now we need street-level advocacy to get these services recognized as mainstream, productive, cost-effective and billable services.
• Push for continued training and evaluation of the effectiveness of the services identified in the bulletin. The Garland article points out a troubling finding that indicates big gaps between identified evidence-based practice and common usual care practice. All 50 states in the U.S. reportedly “promote, require, or support” the use of EB practices in children’s mental health service delivery in some way, but only eight states have explicitly mandated their mental health care systems to “promote, support, or require” specific EB practices (Cooper et al., 2008). The article cites that in one study they “found that approximately half of the patients’ charts did not meet basic treatment quality indicators based primarily on EB “best practices.” If the services and supports mentioned in this bulletin are to become mainstream we must advocate for rigorous and continued evaluation of their effectiveness.

Okay, that’s a start. Let us know what your ideas are for promoting services that work and enable children with complex mental health needs – many of whom have traditionally been served in restrictive settings like residential treatment centers, group homes and psychiatric hospitals – to live in community settings and participate fully in family and community life.

Scott Bryant-Comstock
President & CEO
Children’s Mental Health Network