Helping Children Thrive: Strategies to Support Children’s Mental Health

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Welcome everyone. Thank you so much for joining us this afternoon.

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I'm Sheree Crute, Director of Communications at the National Institute for Health Care Management Foundation, NIHCM.

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Today, we will be exploring the emerging crisis in mental health among children and young people in the United States.

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Nationwide, we have seen a significant, consistent increase in mental health conditions in young people under age 17, with nearly 20% of them having a mental, emotional, developmental, or behavioral disorder.

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Beyond the heartbreaking impact of this on young people, their families, and their loved ones, these conditions also are a primary cause of disability and poor health, And they contribute to an estimated $185 billion in healthcare costs each year.

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The experts we will hear from in just a moment will help us understand this crisis and offer strategies and examples of how we can improve access and care while addressing the cost issues as well.

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I do want to take a moment to thank NIHCM’s President and CEO, Avik Roy, and the NICHM team for all of their help with today's event.

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You can find biographical information on our speakers, today's agenda, and our speaker's slides on our website.

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We also encourage you to join the conversation about the webinar while we're live at #Children's Mental Health.

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After our speakers have completed their presentations, we will all come back online for a brief Q&A where we will take questions from the audience as time permits. And so now I would like to introduce our first panelist.

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Ken Duckworth MD is the Chief Medical Officer for the National Alliance on Mental Illness, NAMI, the nation's largest grassroots mental health organization with more than 600 affiliates dedicated to building better lives for the millions of Americans affected by mental illness.

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He is going to help us understand the post-pandemic mental health landscape and how to better protect young people.

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Dr. Duckworth?

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Thanks, Sheree, and thanks to NIHCM for putting this together.

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Children and youth mental health is an important issue and the National Alliance on Mental Illness can be part of the resources that people benefit from.

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I have some gray hair, so I thought I'd experiment with asking AI to help introduce me.

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In terms of my name, Ken Duckworth, AI went with the duck.

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Chief Medical Officer, I guess it's kind of sexist because it looks like a guy, but the National Alliance on Mental Illness, is clearly a brain-based framework there.

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So I feel like that introduction captures me in some regard.

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I'm very fortunate to be the Chief Medical Officer of NAMI.

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We are the largest volunteer army across the world and you can find help there.

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This picture is the state of what I'd like us to get to, kind of an engaged, positive engagement in the mental health space.

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We're not there yet.

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So I use this slide as a reminder of what I'd like us to be, but we are not.

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Let's go to the next slide, please.

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So it's pretty obvious that the first wave of the pandemic was a biological process that caused a lot of pain.

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The isolation, anxiety, and grief around the pandemic did increase both for children, adolescents, and young adults, anxiety, depression, trauma reports, and addiction vulnerability.

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And so in a way, the pandemic made mental health a we thing, not a you thing, which is one advantage.

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But for the most part, I think a lot of people experienced a developmental vulnerability during this time, and that has resulted in more mental health challenges.

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Next slide, please. Yeah, so I mentioned this slide from, this is a study the CDC did, and 7 in 10 women under age 30 reported a negative impact from the pandemic.

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I mention this because these are some of our moms and our teachers the numbers are pretty high so because of the nature of the study they didn't go below 18 on this but I wanted to highlight this 18 to 29 I know three women who are teachers in that age 30 to 48 and of course, a lot of moms fall into that age as well so it's just a reminder you know the centrality of parents parental figures like teachers and attending to their mental health is part of this entire equation as well. Let's go to the next slide, please.

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Post-pandemic mental health was more like a stretched-out sock than a rubber band.

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We don't really understand why it didn't snap back.

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I happened to attend the University of Michigan. We had a fun day on Saturday.

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If you're from Ohio, we love Ohio.

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It's one of our strongest state organizations and I happened to go to Michigan so when I selected a picture of a sock it seemed only natural.

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Next slide, please.

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So this is something that many of you know but this illustrates how centrality youth is to mental health. Three-quarters by age 25, half by age 14.

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I mean, really, when you look at the causes of disability and vulnerability in young people, it's essentially mental health.

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As they age into their teen years, their mental health and addiction are the primary vulnerabilities because of the centrality of the developmental challenges of growing up, particularly in a more complex society, which I will mention briefly.

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Next slide, please.

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These are just a couple of things.

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I want to emphasize there was already a mental health crisis before COVID.

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So COVID did not cause the entire phenomenon.

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Between 2007 and 2018, suicide rates increased pretty substantially among youth aged 10 to 24.

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And there are increasing rates of high schoolers recording increased, sadness, helplessness, helplessness, and creating a plan for harm.

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So, I want to emphasize COVID accelerated what was already happening in our youth.

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Let's go to the next slide, please.

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It's tough to prove any causation, but there's a lot of interest in how social media is impacting youth mental health.

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And it correlates quite strongly with the 2007 onset of some of these vulnerabilities.

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You may have seen that the country of Australia has banned anyone age 16 from using social media, and they're willing to act on difficult things after a mass shooting in Australia.

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They banned all kinds of weaponry.

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So Australia is willing to wade into territory that we haven't really been willing to do here in the States.

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What I would encourage people to do is to delay the onset of social media whenever humanly possible and to really have a conversation about mental health literacy, because it does in social media because does seem to be a strong correlate of some of the vulnerabilities that we're seeing. Next slide, please.

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So this basically the COVID pandemic exacerbated all of these trends really across the board, particularly for adolescent girls.

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We've seen a rise in suicide attempts for black males who are teens.

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So it has accelerated the prior trends, I guess is one of the meta points, but the trends were already there.

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Next slide, please.

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There are protective factors.

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We'd like to talk about risks in our line of work.

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You, a trusted adult, parents, teachers, counselors, community connection, belonging, a sense of purpose, such as faith, believing in something, participating in a mission.

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We have some teens in our NextGen group at the National Alliance on Mental Illness.

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These people have an incredible sense of purpose and connection.

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One study noticed that a sense of purpose best predicted post-traumatic growth when you look at teens who've been through something.

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Some teens would report that COVID-19 impacted them greatly.

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Some would not.

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A lot depends on your circumstances.

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Next slide, please.

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So, of course, this is a problem that one of the next speakers will be talking to, Courtney and Ellen, about how to expand our professional role.

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We literally don't have enough professionals and we're not making more.

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What we did was see a great drive in demand with no material change in supply.

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So what we're talking about in the next couple of speakers, is how to deploy who we have smarter.

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That's important and I'm no economist but this is one of the reasons it's harder and harder to find somebody.

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Demand increases, supply stays the same, and everybody's chasing after more scarce resources.

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One other solution, next slide to that, will be the National Alliance on Mental Illness.

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I want you to know wherever you are in America there is a NAMI group near you and you've heard the term science to service.

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This is a big deal in the National Institute of who we love and have a long-standing relationship with.

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We do service to science.

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So people create programs and then we study them.

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And this is true of several of the programs I'm going to mention to you.

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And if you have a need to chat with us, or wanna connect locally, nami.org will help you find the closest affiliate near you.

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And happily, we are everywhere.

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And that's why it's such a joy for me to be the doctor for this group.

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Take the next slide, please. NAMI Basics is a free education program.

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This is six weeks. It can all be done at home.

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We surveyed people who've been through the program. 98% of people said they would recommend the program to others.

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It's available both in person through that NAMI affiliate and online.

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A lot of people with young kids don't have time to go to a group and so we put this program together online. Next slide, please. Ending the silence.

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This was invented by one woman, Brenda Hilligos, in Nami DuPage County who saw a need to increase the knowledge of teenagers and middle school kids about mental health.

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People with mental health conditions talk about it in schools and that is something that is available through our affiliates again. Next slide, please.

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NAMI on campus.

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This is a program where people with mental health conditions connect with each other and find community.

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I interviewed a woman who was not treated very well by a major prestigious university, formed a NAMI on campus and it remains the largest group at that prestigious university many years later.

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Hundreds and hundreds of people have joined this group. Next slide, please. So we have a couple of books. You Are Not Alone.

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That's the first book. You Are Not Alone, A Guide for Parents and Caregivers.

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That was written by my associate medical director and friend, Christine Crawford.

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All the royalties from these books are donated to NAMI.

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What Christine and I did was the radical idea that real people might have learned something. This is semi-radical in the psychiatric world.

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Typically, doctors don't celebrate the individual experience.

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And let's go to the next slide, please.

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And so how I thought about the first book, which was a USA Today bestseller, and it's done really well, is evidence-based research.

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So there's communication with a lot of the best researchers in the country and experience-based evidence.

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And those unusual combinations are how you get to NAMI's book.

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In the chat, we're having a buy-one-get-one special.

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This is a shameless promotion here.

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But all the royalties benefit NAMI and about 130 people in the adult book and about 50 people in the parent and caregiver book use their names and share what they have learned both Christine and I interviewed experts in the field to help people navigate this space. Let's go to the last slide, please.

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So, this is how a non-AI person would choose to represent themselves.

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My name is Duckworth.

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I do like ducks.

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Those are my three daughters traveling behind me.

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My email is ken.nami.org.

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HR and I have an agreement at NAMI that no one named Ken can be hired there.

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So, it's like a vanity license plate.

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If any questions, if there's any way I can be of help to you, email me at ken.nami.org.

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And I want to thank you for having me.

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and I look forward to learning from the next couple of speakers. Thank you.

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Thank you so much Dr.Duckworth for giving us the community perspective and also a long-term view of some of the things that led to the situation we're in now.

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Our next speaker is Courtney Benjamin Wolk, PhD.

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She's the Associate Professor of Psychiatry at the University of Pennsylvania School of Medicine, Associate Director of the Penn Center for Mental Health Department of Psychiatry, and Director of Mental Health Implementation Research at the Penn Implementation Science Center.

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She's going to discuss new evidence-based strategies for improving mental health care.

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Dr. Wolk?

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Thank you for the introduction and for having me here today.

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So as Sheree mentioned, I'll be speaking a bit about opportunities for advancing children's mental health services through both integrated care models and specifically in schools and primary care, as well as how we can leverage methods from the field of implementation science.

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Throughout, I'll try to provide some concrete examples from our team's work at Penn, and I'll share QR codes and links to some of our papers if you're interested in learning more.

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Next slide.

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So Ken got us started with a really nice overview of the current state of affairs in children's mental health.

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And given what you've heard, it probably won't surprise you that in 2021, a coalition of the nation's leading experts in pediatric health from the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association jointly declared a national emergency in child and adolescent mental health.

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And importantly, they advocated for a number of priority areas for funding and research.

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There are many, but the three specific ones that my team and I have tried to largely tackle in our work are those related to improving school-based mental health care, improving integrated mental health care services in primary care, as well as specifically focusing on suicide prevention in some of our work.

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Next slide.

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As we've attempted to tackle these priority areas, as I said, we've worked to leverage frameworks and methods from the field of implementation science.

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At its core, implementation science is really a field that's focused on understanding how to change the behavior of people and systems in order to align practices with the evidence base.

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and with the ultimate goal of improving the quality of care and population health.

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Mental health care is not all created equal.

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We have a number of well-established, evidence-based psychotherapies, for example.

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However, they're largely not accessible or offered in community practice.

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So implementation science is really focused on offering tools and methods to address those gaps.

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In our lab at Penn, we specifically focus on efforts to increase the integration and quality of mental health care in non-specialty settings.

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So given the mental health care workforce shortage, we see settings like schools and primary care as really important contexts for increasing access to care.

17:26Howevert these settings do not have mental health care necessarily as part of their primary mission, so there are some unique considerations for expanding mental health care into these contexts. Next slide.

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So why should you care about implementation?

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Well, I'll argue that everyone should care about the implementation of evidence-based practices.

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If you're a patient or family member, you want to use your time and resources wisely to be able to obtain the highest quality care efficiently and ideally close to home.

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Researchers care a lot about implementation.

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We work hard to develop the best treatments that help people, it's really frustrating to know that on average it takes about 17 years for many of our healthcare innovations to become part of routine community-based care.

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Clinicians certainly care about this too.

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Most people go into clinical practice because they want to help people.

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However, we have some real gaps in pre-service training and supervision.

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That means that lots of well-meaning clinicians without necessarily, you know, intending to sometimes provide low-value care.

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So there's a lot we can do to increase the quality of care in the community. And certainly, payers health systems, and regulators care about implementation.

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We want people to get safe and effective care.

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We want it to be cost-effective, and we want it to be accessible. Next slide.

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So just to highlight a few key features from implementation science.

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So first and foremost, as implementation scientists, we tend to come in when there's already an evidence-based thing or practice to be implemented.

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If the evidence base hasn't been established, you really want to focus a little further back in the translational pipeline and work towards establishing a robust evidence base before you start thinking about implementation and scale-up in routine care.

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The work that we do is done in close partnership with communities, organizations, and clinicians.

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And the outcomes that we focus on in our work are different from traditional effectiveness research.

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So we're really interested and focused on how we can increase adoption, increase the feasibility of evidence-based practices in the community, reach more people, and sustain practices that work.

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In our field, we really try to embrace the messiness of the real world.

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So we want to understand and plan for the nuances of the context that we work in.

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We have, as a field, developed specific terms, methods, theories, frameworks, and strategies, some of which build upon or are borrowed from other fields, like organizational psychology and quality improvement science. Next slide.

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So now that I've given you a little bit of background, I want to talk specifically about schools for a minute.

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So through our work partnering with school systems and payers of school-based services, we've identified two key priority areas for advancing school mental health services that we've been attempting to tackle in our research.

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The first is that school mental health services are very much a team sport and we need to do more to gaps between mental health and education in order to maximize our impact.

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The second is that we cannot just pull kids out for mental health services in schools.

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We also need to be more nimble and push in and leverage mental health expertise to support our educators and school climate and culture.

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And I'll illustrate each of those with examples from our research in the next two slides.

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Next slide.

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So I told you that a key priority of ours is reducing siloing between mental health and education.

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We think this is really critical to having effective school mental health services.

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There are lots of practical reasons why siloing occurs.

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Mental health clinicians and educators typically use different record systems.

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They're sometimes limited in what they can close to one another due to things like HIPAA and FERPA regulations.

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But we can work around some of these things by treating teaming and care coordination and collaboration in school mental health, much like we do in other areas of health care.

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So one way that we've attempted to do this through an ARC-funded study was to collaboratively adapt a widely used team training intervention from health care called TeamSTEPPS to specifically improve collaboration and communication between school mental health clinicians and their educational partners, and what we found through this work is that with actually just a few hours of professional development focused on teaming and a little bit of ongoing support, we can see really meaningful and significant improvements in collaboration between the sectors.

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So we think that focusing on teaming and bridging some of those gaps and siloing that occurs between education and mental health is really key. Next slide.

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And then The second priority area for school mental health that we've been focusing on is, as I said, needing to do a better job of pushing in mental health supports as opposed to just pulling kids out for individual or group therapy during the school day, which is sometimes what happens when you implement a school mental health program.

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There are lots of good reasons why we should want to do more of this.

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We know that positive teacher-student relationships are hugely beneficial to kids, and they can reduce later risk for suicide and substance use, among other things.

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We also know a major reason that educators like the workforce have difficulty with classroom behavior management, and that's an area that mental health professionals can help with.

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And of course, we know that kids are in school to learn, and we want them to be in class receiving instruction and being with their peers as much as possible.

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So with all those goals in mind, our team partnered with Philadelphia County's Behavioral Health Medicaid Managed Care Organization to provide training and ongoing consultation to co-located mental health clinicians working across the school district of Philadelphia in a particular evidence-based model for mental health consultation to teachers called BRIDGE.

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So this pair, Community Behavioral Health, has invested in a number of evidence-based practice trainings for their network over the years.

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And it's been really heartening because they tell us over and over that this has been one of their most successful partnerships because it builds a real gap in the pre-service training of mental health clinicians.

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And it also addresses a really practical need from the school's perspective.

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And we can do it in ways that are really feasible for the clinicians of schools we work with.

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So this paper that I have on the screen here outlines how we approach that and some of the ways that we have adapted teacher consultation models to be more feasible in highly stressful systems.

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Next slide.

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I also want to talk a little bit about primary care because we've identified some additional opportunities here as well.

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So first, just want to acknowledge there's always going to be a place for specialty mental health services like outpatient therapy.

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But we also desperately need more innovations to address the fact that high-quality specialty care is very difficult for the average person to access.

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We need more partnered work, again, to bridge silos, not just in practice, but also in evaluation.

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So for example, both insurance claims data and electronic health record data are incomplete on their own, but when we can merge them, we can answer a lot of really important questions.

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And really importantly, we can do it without burdening providers and patients who are already busy and tasked with many, many things.

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So, and then the last piece that I'll touch on before we wrap up today is suicide prevention.

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Next slide.

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So I wanna just briefly share how we've approached reducing some access barriers to primary care at Penn Medicine.

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So, in 2018, our primary care and psychiatry service lines partnered to instantiate a collaborative care program.

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Collaborative care is an evidence-based model for integrating mental health services and primary care.

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We started in eight practices, we're now in about 40, and one thing that we did differently in our version of collaborative care that I want to highlight was to develop a centralized intake and triage center.

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So primary care providers in our program can refer anyone with mental health needs to this intake center.

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We call it our resource center.

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This resource center is staffed by bachelor's level intake coordinators who are trained and supervised to do standardized intake using validated measures, and they're supported by an algorithm to guide triage decisions.

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They can schedule patients, they can support community referrals, and this has really importantly allowed us to task shift that portion of the care to these intake coordinators, which allows our master's level mental health clinicians in primary care offices to really focus on direct intervention and supporting patients in crisis.

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So with a relatively small tweak, we've been able to support everyone in really spending as much time working at the top of their licenses as possible.

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Next slide.

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And then we've also seen through our work the power of establishing data-sharing infrastructures between health systems and payers.

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One concrete example from our work has been in partnership with Independence Blue Cross in Philadelphia to develop an infrastructure for data sharing and a collaborative research agenda.

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So one example, we have lots of really exciting and interesting evaluations in the works, but one concrete example is a completed evaluation that we did to understand the impact of collaborative care services on total medical spending, which included both medical, psychiatric, and also pharmaceutical claims.

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We found that the initial amount of spending on collaborative care services did not increase overall healthcare costs.

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So that's important because there certainly are some upfront costs to establishing a collaborative care program.

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So it's reassuring to see that when we do this in a community health system context we can keep costs under control.

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Next slide.

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And then I would just want to lastly share a little bit about the importance of attending to specific high-risk populations, like individuals at risk for suicide.

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One thing that we've identified in our work and that others are doing as well is really focusing on speeding the pace with which we can develop and test strategies to get people at risk engaged in care.

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So this is an example of an NIMH-funded study that I co-led with Shari Jager-Hyman, PhD, at Penn.

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So, for this particular study, we used various sources of quantitative and qualitative data to understand some barriers to engagement in mental health services, specifically among our primary care patients with suicidal ideation.

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Then we used methods from behavioral economics and implementation science to develop and test strategies for supporting engagement, and we did this through a series of mini-pilots that allowed us to really quickly identify and iterate on promising strategies and to also quickly identify things that were not gonna be feasible or less likely to be effective at engaging patients so that we could kind of move away from those quickly and work as efficiently as possible towards being able to definitively test through research and in practice to scale things up more quickly without spending five years running a study to test a strategy that ultimately was not going to be feasible, for example.

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Next slide.

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And then finally, in addition to the priorities we've already discussed, I just want to highlight a few final additional future directions for work.

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So there is a lot of really great quality improvement work that already happens to solve local problems, but we also need to increase our generalizable knowledge base by developing more cross-setting strategies to support evidence-based practice implementation across a range of contexts in various populations.

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We need more generalizable approaches and practical implementation toolkits that can support evidence-based care, particularly in low-resource settings.

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We also need to do more to incentivize and reduce barriers and upfront costs related to setting up some of these integrated care models.

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Last slide.

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And then just before I wrap up, I also want to share with this group, I'm partnering with John McConnell at Oregon Health and Sciences University in a new study that's focused on understanding how managed care organizations and professional and advocacy groups approach important issues in adolescent mental health.

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It's a primarily quantitative study where we're using national claims data, but we're also conducting some brief one-time qualitative interviews to help us contextualize the data.

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We're just getting started, and I know there are a lot of people on this call who have probably really important and impactful perspectives to share on this topic.

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And because community partnership and engaging end users are so critical to our work, I wanted to share this.

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If you're interested in learning more and potentially partnering with us for a brief interview so we can learn from you as well, please take a moment to scan this QR code or grab this link.

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There's a brief interest form and we can send you more info if you're interested in any more.

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I would love to hear from you and look forward to your questions in a bit. Thank you so much Dr.Wolk for helping us understand not only important new research but how to translate that research into action.

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Our final speaker today is Ellyn Saren, LCSW Vice President of Behavioral Health at Blue Cross Blue Shield of North Carolina. Ms. Saren is going to share the high-impact solutions she and her team have put into place as leaders of Blue Cross Blue Shield of North Carolina's efforts to improve mental health services, access, and resources for youth in their state. Miss Saren?

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Thanks, Sheree. Thanks very much for having me.

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And, you know, I don't think it's by accident that I'm sort of ending our panel today.

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Because I think Ken did a really nice job table setting the crisis.

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And then Courtney really spoke to some of the research and the strategies.

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So in my limited time, I'm gonna share some of the highlights of the programs that we've developed for the state of North Carolina.

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Our company mission is really about making healthcare better for all.

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and I will share a bit about how youth mental health has become very much part of that company's mission.

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I'm gonna talk a little bit about the state of mental health youth in North Carolina, talking about developing a more robust network, that seems to be threaded through the presentations that you've already heard, and also about our developing of our behavioral health continuum.

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Next slide.

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Before I go into some of the details around some of the innovative programs that we've created, Ken did a very nice job table setting this, but clearly, in North Carolina, I think like the rest of the country, youth mental health is really a crisis.

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It's important to know that North Carolina is only second to Texas in the number of rural counties in North Carolina.

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We have a hundred counties and many of them are very, very rural, which makes access both for youth as well as for people in general to mental health services very, very challenging.

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What we know in North Carolina is that 130,000 young people ages 12 to 17 indicate that they have some symptoms of depression.

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Certainly, that is coupled, as I shared before, with the issues around rural mental health and access.

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We know that about half a million adults in North Carolina didn't receive mental health services though they would have needed it.

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But because of access and issues of cost, they were not able to or they did not access mental health.

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Next slide.

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As I mentioned, we really as a company are very invested in learning about the mental health challenges in North Carolina.

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So about a year and a half ago, the senior leadership of our company, including our CEO and President, Dr. Tunde Sotunde, who you see there in the blue, went on an extra-mile tour.

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They visited all 100 counties over a period of about a year and a half to really meet with community leaders, to meet with our members, to meet with youth, and to really understand what healthcare challenges our communities are facing.

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Across the board, they heard firsthand much of what Ken talked about, widespread feelings of lack of purpose, social isolation, and loneliness among the youth in North Carolina, Mental health and the well-being of our young people is a pressing and urgent need, so much so that the company has taken this on as their mission to really improve the state of youth mental health. From the highest level, from Dr.

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Sotunde all the way down to the folks that answer our phones, youth mental health is very much at the core of our mission if you will.

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Next slide, please.

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In August, Blue Cross North Carolina launched its first phase, it's a multi-phased roadmap, if you will, of a statewide transformational commitment to improve youth mental health, well-being, resiliency, and connectivity.

36:06

The initial offering is really around looking to develop support services and access to care across all 100 North Carolina counties.

36:20

And these, this focus or these programs are very much in the area of on-demand mental health, increased network providers, school-based counseling, you've heard that threaded to my co-presenters, and simplifying mental health care through navigation, and also training on youth mental health, mental health first aid training in all 100 counties.

36:55

If you're not familiar with youth mental health first aid training.

37:00

It's the opportunity for lay people to engage with young people and be sensitive to the signs and symptoms potentially of mental health and engage young people around perhaps ongoing care.

37:16

Blue Cross Blue Shield has made a commitment both to train 10% of their workforce plus partnering with youth organizations to train 3700 people in youth mental health first aid training by the end of 2025.

37:40

Next slide. So building a more robust network. This is certainly a focus for all of us.

37:54

As Ken mentioned, folks are just not going into mental health counseling as much as they have in the past.

38:01

So what are some of the prongs, and strategies that we can come up with to build a more robust network?

38:09

First, we're looking at provider access.

38:12

We're looking at those high-quality providers who would be interested in taking on specialty populations like autism, adolescents, and substance abuse, and then paying those providers through some incentive programs, like prompt pay or direct financial payments for needing specific performance benchmarks.

38:42

In addition, Blue Cross Blue Shield has partnerships with Alo, which is a very, very large multi-provider network that has the largest number of psychiatric providers as part of that network.

38:58

In addition to FASPMED, we have a partnership with FASPMED, which is a series of urgent care centers.

39:05

Our goal would be that these could be access points for our members, for our youth.

39:11

Perhaps they go into a FASPMED, an urgent care center for physical health, for a physical health issue, an opportunity to perhaps evaluate them for mental health for depression and connect them accordingly.

39:26

So really looking at not mental health or physical health, but just health.

39:33

The second prong of our building of our network is school-based behavioral health.

39:40

You heard that threaded through both Courtney and Ken's presentations, we know that youth are six percent more likely, six times more likely, to access mental health resources in schools versus in more traditional settings.

39:58

We know that providing counseling services in schools will help eliminate the need for transportation and an extra burden for parents or caregivers.

40:10

So starting in January, Blue Cross Blue Shield of North Carolina will reimburse behavioral health providers for providing counseling psychotherapy in the schools.

40:22

We've been working with schools to create either bricks and mortar, office-based places for services to be offered, or connectivity for virtual telehealth sessions.

40:36

Finally, from a reimbursement perspective, we're looking to align innovative reimbursement strategies for providers to incentivize them to join the network.

40:52

Next slide.

40:56

Access is a challenge.

41:00

You've heard about it in all of our presentations, and all of you who are in mental health know It is probably one of the primary concerns.

41:11

We've developed a program, Care Navigation, the goal of which is to make it easy for members and providers to access care.

41:20

A member anywhere from youth to geriatric can go online to our Blue Connect website or call in telephonically, be connected to a care navigator who will help them find a provider that meets their specialty needs and will also, if need be, schedule the appointment for the member or provide the referral information for the member to schedule it, him or herself.

41:52

It's also an opportunity to increase continuity of care.

41:56

Our care navigators work with our discharge planners in our facilities to ensure that there is continuity of care following hospitalization or higher levels, and episodes of care.

42:13

Next slide.

42:17

So when we developed the programs at Blue Cross, we really looked at a continuum of care with the member being in the center.

42:29

Not only is it a continuum, but each of these programs is sort of knitted together in a way that they provide a true continuum.

42:40

So you have care navigation, which is really the tool to access care.

42:45

Right care, right place, right time.

42:48

Rapid response, which is a program that is in demand.

42:54

In essence, the goal is to keep people from having to go to the emergency room.

43:00

And anybody who's been to the emergency room knows how challenging it can be, particularly if you have a mental health issue.

43:07

This is really the opportunity to deploy a clinician to a member's home, certainly, family issues, kids, acting out kids, and to really do an at-home assessment and create either a same-day appointment, either bricks and mortar or virtually, to be able to divert from an emergency room visit or potentially higher level.

43:37

We have our youth behavioral health area which is or bucket if you will. All of our programs have youth threaded through them.

43:49

Our school-based program and our opportunity to increase our network are all designed to focus on youth.

44:00

We have our traditional case management, really a 360 opportunity to look at our members from both physical and behavioral health perspectives.

44:13

We have our UM, our utilization management area, which is really around an innovative approach that we've taken this year, where we put blue-cost staff, and discharge planners in our high-volume facilities and an opportunity to ensure continuity of care, discharge planning at the bedside, if you will, to really get to that follow-up after the seven-day follow-up after hospitalization.

44:44

And finally, BH Rapid Response, which is, for all purposes, really a BH psychiatric medical home where we're carving out individuals with serious mental illness and wrapping around both mental health and physical health services.

45:17

Excuse me, I'm fighting a bit with the cold.

45:21

So that's really our continuum of care.

45:25

So what does this mean for us at Blue Cross?

45:29

I've shared a bit of a brief presentation in order to let you know we're trying to make a difference in addressing our state's mental health crisis.

45:39

We know we must really look at some of the root causes.

45:45

Through innovative planning, we're really trying to improve youth mental health well-being with a variety of solutions, a more robust network, school-based counseling, and pay-for-performance models.

46:01

Finally, we have a real commitment.

46:03

it's imperative to support our children and have the potential to positive impact not only on them but the future.

46:14

Thanks very much for your time and look forward to having my panelists join me for some questions.

46:23

Thank you so much, Ellen.

46:24

And if all our panelists will come back on, thank you, Ellyn, for that state-level approach and look at model state-level programming.

46:34

We have a little bit of time for a Q&A now, so I'm going to begin with some of the questions that have been sent in for our panelists.

46:43

Ken, you were first, and so now you are first again.

46:49

One of our attendees would like to know, how can access to mental health care be improved in underserved communities, and we've some additions to that, meaning communities of children in foster care, urban communities, et cetera.

47:05

I would invite all panelists after Ken responds if you want to add to the answer, please do chime in.

47:13

NAMI is actually a great education support group, but it's also a great advocacy group.

47:18

So I have worked with people who've created advocacy for underserved areas, whether they're urban or rural with NAMI.

47:27

So, many states control access to a lot of state-funded programs, Medicaid, for example.

47:36

NAMI is working to expand Medicaid in some of the states that don't have a Medicaid expansion.

47:42

Models like collaborative care, because even in many rural and urban underserved areas, there are primary care setups.

47:51

What Courtney was talking about is using mental health practitioners to consult with primary care as opposed to doing one-on-one services which is actually quite limited.

48:04

So there's also a group called Rural Minds which NAMI is you know connected to and that is another group that is working on this problem.

48:14

Few things get done in American mental health without NAMI so I would encourage you to contact your local NAMI group. We're all across America.

48:23

We're responsible for most of the positive developments in our field, honestly, along with our partners, which we're all for.

48:29

But it's really people who have a personal investment in these outcomes because they love someone who lives with a mental health condition or they have one themselves that have been the most successful advocates.

48:45

Thank you, Ken. Dr.

48:48

Wolk, one of the questions that we have directed to you is about strategies to address the workforce issue, which has come up in each presentation, including one question we had about if there was any support for nurses or school nurses who were trying to provide mental health care. Would you be able to address that?

49:09

Sure. It's a great question.

49:11

I've been involved in some work that partnered with school nurses around asthma care, not mental health services.

49:18

But what we have found in that work is that particularly in highly stressed, low-resource school districts, like many of our large urban school districts, there's so much turnover and limited staffing for positions like nurses.

49:33

It's really hard for them to incorporate additional things like mental health into their workflow.

49:40

But I think that it's an important opportunity and would be really great to see increased staffing that would allow them to support that space a little bit more.

49:50

I'd love to see more efforts to partner with training programs and develop pipelines to get people into the workforce, particularly in traditionally underserved communities.

50:01

I think there are lots of opportunities we can borrow from other training areas doing things like having loan repayment opportunities for years of service, things like that.

50:12

I think there are ways that we could increase both the quality of training and the amount of people that we get working in our public mental health system.

50:21

I think those opportunities, in addition to more integrated collaborative models that allow consultation expertise to expand the reach of mental health support to more people than direct intervention can provide is another important area to focus on.

50:39

Thank you, Courtney.

50:42

Ellyn, I wondered if you would be able to help us understand, well, this is obviously your area and you've done a great job in North Carolina, but I guess this is a national question, which is how can we get services, mental health care services to children faster?

51:00

Yeah, it's a really good question.

51:02

I think training like first aid mental health is an opportunity for laypeople to learn and symptoms and signs, which I think means that family members, educators, and community-based organizations can identify a youth with some of those challenges and look to hopefully engage them around some additional care.

51:36

I think school-based care is a great example of providing services to kids and it's a You know, I think really leveraging community-based organizations, whether they are youth-based or not, you know, I talked about phase one in my comments, but phase two of our roadmap in North Carolina is really looking at working with community-based agencies around both workforce development as well as providing assessment evaluation services for young people to really look to get into treatment earlier.

52:39

So I am sharing this question with a group.

52:43

We have an attendee who wants to know if any of you know about effective programs or models for homeless youth for mental health care. Anyone, feel free to answer.

53:00

This is all going to be city by city. There are programs in Los Angeles.

53:04

Boston has a very well-known program called Health Care for the Homeless, which has been up and running for 40 years.

53:11

Jim O 'Connell, there was a book written about homeless outreach programs, not just for youth though. It's called Rough Sleepers.

53:20

And so, but this is very locally dependent, which is what I want to emphasize, which I've been emphasizing advocacy because people created this grant for Health Care for the Homeless in Boston.

53:32

People created the program, you know, in Los Angeles, which is very well known and regarded.

53:37

But these programs are not available in many places.

53:42

So contact your local NAMI, and find out what is available, it would be one place to start.

53:50

The local state mental health authority may know, but it's not an easy quest.

53:57

I think that's important to acknowledge.

54:02

Courtney, I'm not sure if you can address this question, perhaps anyone on the panel can.

54:09

Is it feasible to train teachers to provide mental health support in addition to the referral programs to mental health counselors?

54:18

Is it feasible that there's a role for teachers?

54:20

I'm not sure if there's any research on that.

54:23

There is.

54:24

There's absolutely a role for teachers.

54:26

teachers can play a vital role in supporting mental health by setting up their classrooms for success and having infrastructure that helps kids, especially kids with ADHD or disruptive behavioral challenges, be successful in the classroom context.

54:42

And they can also be a resource for delivering real targeted interventions to support particular students who need more help.

54:50

So in that bridge model that I mentioned that we've been implementing in Philadelphia schools, the mental health clinicians in the school system work directly with the teachers who do all of the implementation in the classroom context.

55:05

So they support teachers in things like introducing self-monitoring strategies, utilizing positive reinforcement systems, engaging families by sharing positive reinforcement and positive feedback, strategies that help improve the classroom climate and all of those things by improving teacher-student relationships, improving classroom context, and supporting kids who might be having challenges engaging during the school day in academic instruction can have really important impacts on children's mental health and not just in sort of directly helping to address mental health challenges that might be ongoing, but also from a prevention standpoint.

55:49

There's some nice research that shows the value of teacher and peer relationships for reducing risk for things like suicide and substance use.

55:59

And so by engaging and partnering with folks like teachers more and supporting them and implementing some of these strategies, we absolutely can see some really important and promising impacts of that work.

56:11

I think that based on everything Courtney said, I think the extension of that is what know for young people if they have a trusted relationship with an adult that goes a long way to making that engagement and getting kids into care or whatever support system and I think teachers have a key role, critical role. And this will be our last question today.

56:42

We've talked a lot about systems responding to crises.

56:46

We have a question Is anyone aware of good work advocating for systemic causes that may be contributing to the mental health crisis such as income inequality, discrimination, and the impact of climate change in some communities on youth?

57:05

Is anybody aware of great work in that direction or what we might need to do?

57:16

The social determinants of mental health are big, right?

57:20

And so it sometimes feels like it's out of the grasp of say an individual researcher, a practitioner,r or a nonprofit.

57:29

But I'll just point out, that I'm gonna get a little political here.

57:32

The world is changing.

57:34

On the United States and how they're gonna fund things is gonna be disruptive.

57:38

We had a bipartisan agreement to fund 988, which NAMI led.

57:42

I had nothing to do with this, but our policy team ran this entire thing.

57:46

Pulled together all these groups to reduce the amount of police involvement with people in crisis.

57:53

And that was a bipartisan agreement.

57:55

And I don't know how many of that kinds of things we'll see, but that's an example of something that's within our scope.

58:02

There is the Climate Action Alliance.

58:05

I think it's at the University of, based in the University of Washington.

58:09

Those are psychiatrists who are very concerned about climate change and its mental health impacts.

58:14

just to give one example, the Climate Action Alliance.

58:21

Well, thank you all very much.

58:23

I'd like to thank our speakers for their new research, their visionary look at helping young people, and their extremely valuable advice on providing better and more affordable care.

58:35

There were several questions about resources and whether our resources would be shared.

58:40

An archive, along with our speakers' resources and slides, will be shared a few days after the actual webinar.

58:48

So yes, you will have access to that information if you join us today.

58:53

Thank you to our audience for joining the discussion and sharing questions.

58:58

We really do value your feedback.

59:00

So please complete the survey that will pop up on your screen after we are done.

59:05

And please join us on Wednesday, December 11 for our next NICM webinar, Reducing the Rx Burden, Pathways to Lowering Drug Prices and Increasing Access, which will include the work of our CEO, Avik Roy.

59:21

Again, thank you all for a great session, and thank you to our audience.

59:26

Have a great afternoon.