The Commission on Children's Mental Health: presented to Governor Nathan Deal

The Commission on Children's Mental Health
Presented to: Governor Nathan Deal
December 11, 2017
Authored by: Commissioner Frank Berry, Stephanie Blank, Director Bobby Cagle, Katie Childers, Commissioner Judy Fitzgerald, Dr. Jordan Greenbaum, Director Teresa MacCartney, Erica Fener
Sitkoff

The Commission on Children's Mental Health
Presented to: Governor Nathan Deal Table of Contents
Executive Summary Commission Members Introduction Commission Recommendations Autism Benefit Update Services for 0-4 Update Acknowledgements
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Executive Summary
On June 7, 2017, as a part of the state's continuing efforts to improve the care of Georgia's most vulnerable populations, Governor Nathan Deal signed an executive order creating the Commission on Children's Mental Health. The commission was tasked with developing recommendations on improving children's behavioral health services in Georgia, in order to address outstanding need, maximize recent improvements to the system, and ensure that Georgia's children grow up as healthy, productive members of society. Over the course of two months, the commission conducted a thorough review of current programs and services, funding, and opportunities for improvement within the children's behavioral health system. Ultimately, the commission settled on eight recommendations to improve the delivery of children's behavioral health programs and services. These recommendations seek to strengthen high functioning pieces of the current system, close critical gaps in care and access, and utilize early intervention and prevention strategies to intervene with two of the state's current youth behavioral health crises.
"This commission is modeled after several successful interagency collaborations, including the First Lady's Children's Cabinet, the Child Welfare Reform Council and the Criminal Justice Reform Council," said Deal. "These councils have provided invaluable guidance in helping shape effective, meaningful policies. In fact, the Child Welfare Reform Council's advocacy on the importance of early examination and treatment resulted in changes to mental health coverage for Medicaid and PeachCare members. This year, my budget included an additional $2.5 million to provide mental
health services to the full population of children from birth to age five." -Governor Nathan Deal
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Commission Members
Co-Chair Judy Fitzgerald- Commissioner, Department of Behavioral Health and Developmental Disabilities Co-Chair Katie Childers- Deputy Chief of Staff for Policy, Office of Governor Nathan Deal Frank Berry- Commissioner, Department of Community Health Stephanie Blank- Board Chair, Georgia Early Education Alliance for Ready Students Bobby Cagle- Former Director, Division of Family and Children Services Dr. Jordan Greenbaum- Medical Director, Stephanie V. Blank Center for Safe and Healthy Children Teresa MacCartney- Director, Governor's Office of Planning and Budget Erica Fener Sitkoff- Executive Director, VOICES for Georgia's Children
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Introduction
Over the last 30 years, Georgia has made substantial investments through federal grants, agency policies, legislation, and other initiatives to develop its children's behavioral health system. Within the past five to six years in particular, Georgia has experienced a flurry of activities, programs, and funding aimed at improving children's behavioral health. In 2011, Georgia launched the Interagency Directors Team (IDT), a children's behavioral health collaborative comprised of representatives from all child-serving state agencies, child and family advocates, and provider organizations. Georgia agencies worked in partnership to receive SAMSHA-funded awards for Project LAUNCH, Project AWARE, and the Cooperative Agreements for Expansion and Sustainability of the Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances Grant (Systems of Care Expansion Grant). Apex, Georgia's school-based mental health program was launched, and various telemedicine initiatives were introduced in order to improve access to services. A series of reforms expanded the coverage of children's mental health services under PeachCare and Medicaid. By the end of 2015, there were four study committees of the Georgia General Assembly committed to children and child services. In addition, in 2017, IDT developed a System of Care (SOC) State Plan for children's behavioral health, which was approved by the state's Behavioral Health Coordinating Council.
Although Georgia has made significant improvements to its children's behavioral health system over the past few years, opportunities remain for state agencies, providers, and communities to further improve the delivery of children's behavioral health programs and services. Children's behavioral health challenges continue to present in home, school, and community settings. Children and families, particularly in rural areas of the state, still face difficulties in accessing basic and specialized children's behavioral health services. The closure of state hospitals coupled with an underdeveloped community-based provider system have led to gaps in the continuum of care, many of which remain unfilled. Rising rates in suicide and opioid abuse among Georgia's youth and emerging adult populations are in need of advanced solutions.
As a part of the state's continuing efforts to improve the care of Georgians, particularly the most vulnerable, Governor Nathan Deal signed an executive order creating the Commission on Children's Mental Health on June 7, 2017. The commission was tasked with "evaluat[ing] Georgia's approach to children's mental health and research[ing] appropriate future actions for the state in addressing children's mental health concerns". The commission members included state leaders, health care experts, and child advocates.
The commission's final recommendations, outlined in this report, were developed after a thorough review of current programs and services, funding, and opportunities for improvement within the state's children's behavioral health system were conducted. The recommended initiatives have risen to the top as high leverage points, expected to directly increase access to high quality care for Georgia's children and families. The following report provides a detailed summary of each of the eight recommended initiatives, including challenges to be addressed, target populations, desired impacts, and estimated time frames required for launch.
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Commission Recommendations
Recommendation A: Increase access to behavioral health services for Georgia's school-aged children by sustaining and expanding the Georgia Apex Program (GAP) for school-based mental health.
Challenge to be addressed:
A need exists for better coordination and collaboration among school systems, mental health providers, and other community stakeholders. School-based mental health programs promote access to mental health services, increase early identification of mental health needs, and provide coordinated interventions for children in need of behavioral health services. As of March 2017, DBHDD's GAP provided technical assistance in the areas of program implementation, evaluation, and program sustainability to 29 grantees working with 214 schools. As Georgia has over 2,200 schools with approximately 1.6 million students, it is not only necessary to maintain GAP, but also to expand it to serve additional schools and children in the state. The state recognizes participating community behavioral health provider organizations need program evaluations and technical assistance (TA) in order to achieve best possible outcomes.
Target population:
Youth enrolled in pre-kindergarten through 12th grade; both students who are at risk of developing serious behavioral health concerns and those whose needs may be addressed through universal supports and services
Desired impact:
Children and youth in schools (and their families) would have increased access to a continuum of behavioral health care. Current GAP community behavioral health provider organizations would maintain and grow partnerships between schools, mental health providers, and community members, allowing more children to access coordinated school-based behavioral health care, minimizing barriers to care and reducing stigma associated with mental health care. Expanding the program would significantly increase access to critical behavioral health services for many children and families. Support for GAP evaluation and technical assistance would allow the state to ensure that program resources and positive outcomes are maximized.
Timeline for implementation:
The four components of Recommendation A require different time frames to launch:
1. Re-contract with current GAP providers: 1-3 months 2. Contract, onboard, and start up additional GAP providers: 3-6 months 3. Evaluation: 3 months 4. TA: 3-4 months
Recommendation B: Fund Supported Employment/Supported Education programs for youth and emerging adults with severe mental illness.
Challenge to be addressed:
Sustained and satisfactory employment is a critical component of recovery for individuals with severe mental illness. Research shows that most individuals with behavioral health needs identify going to work as a main goal of their recovery process; however, assistance with employment is largely overlooked as a component
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of treatment. In recent years, Georgia has expanded access to Supported Employment for adults. The need remains for these youth and emerging adults to have access to specialized approaches to employment and/or education through evidenced-based Supported Employment and Supported Education.
Target population:
Youth and emerging adults aged 16 -26 with severe mental illness
Desired impact:
Youth and emerging adults in Georgia with severe mental illness would be able to access supports that would allow them to improve daily functioning, including achieving recovery goals, and holding a job/completing school. Through Supported Employment and Supported Education, youth and emerging adults with severe mental illness will be able to identify and achieve their goals, whether it be attaining a particular job or entering a school program. They will also be able to receive support in the form of care coordination, personalized benefits and career counseling. Placing youth and emerging adults with severe mental illness into integrated and appropriate work or school settings would result in higher self-esteem, better behavioral functioning, and increased financial stability and independence. These placements may also contribute to higher functioning as this population ages into adulthood which will reduce the need for costly and severe interventions.
Timeline for implementation:
3-6 months to launch
Recommendation C: Provide support for the development and implementation of additional levels of support within the behavioral health continuum of care for youth with the highest levels of need.
Challenge to be addressed:
There is demand for a continuum of care for children with behavioral health needs, but we know there are gaps in this continuum, especially at the highest level of need. Georgia no longer has state hospital beds available for children and youth, and the community-based provider system is not yet fully prepared to address the needs of behavioral challenges that are present in home, school, and community settings. Georgia also recognizes the need for additional levels of care, enhanced workforce training, and awareness of emerging conditions that should be addressed within the public behavioral health system.
Target population:
Youth/young adults aged 4 to 26 who are in need of crisis respite, specialized foster services centered around care coordination, and increased crisis stabilization capacity for individuals dually diagnosed with Serious Emotional Disturbance (SED) and Intellectual and Developmental Disabilities (I/DD), categories of need that require unique and individualized support and services
Desired impact:
Youth at the highest level of need would be able to access more appropriate urgent and responsive care. These services would lead to a reduction in emergency room boarding, respite for families that are struggling to meet their children's behavioral needs, and more adequate transitions between levels of care.
Timeline for implementation:
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The three service lines within Recommendation C require different time frames to launch:
1. Increased crisis stabilization capacity: 6-9 months 2. Crisis respite services: 9-12 months
Recommendation D: Strategically increase telemedicine infrastructure capacity for child-serving, community-based, behavioral health provider organizations in order to improve access to children's behavioral health services.
Challenge to be addressed:
Many of Georgia's children and families, particularly those living in rural areas, face significant difficulties in accessing children's behavioral health services due to a shortage in child and adolescent behavioral health providers. In 2014, there were only 186 active child and adolescent psychiatrists in the state; there is also an inadequate capacity among existing providers to serve individuals with complex needs. Georgia recognizes the need to support innovative ways of reaching children in need of behavioral health services, and has identified telemedicine technology as an opportunity to increase provider capacity and reach, particularly in rural areas. Despite having many of policies in place to support behavioral health services through telemedicine, many providers still lack a flexible telemedicine infrastructure to serve children and families where they spend the most time, home and school. There is also a need to identify any remaining policy barriers and/or provider knowledge gaps of existing policies that may exist.
Target population:
Youth/young adults aged 4 to 26 who are diagnosed with either a behavioral health issue, SED, or who are at risk for developing behavioral health disorders
Desired impact:
Youth/young adults would have increased access to children's behavioral health services, particularly in rural areas. By providing and enhancing existing telemedicine infrastructure to child-serving, communitybased, behavioral health provider organizations, the state would increase access to services, including shortage areas such as child psychiatry. These organizations, along with our public health departments, also provide school-based mental health services through GAP for children in schools and other settings collaborating with provider organizations. Newly available telemedicine services would leverage and add to the developing network of telemedicine-capable clinics and offices.
Timeline for implementation: 3 months
Recommendation E: Invest in coordinated training for priority areas of interest and concern for the child-serving workforce. This may include additional clinical training in evidence-based practices, including trauma-informed care, and may also include administrative practices that support the delivery of high quality behavioral health services across service settings.
Challenge to be addressed:
Georgia's child-serving agencies and providers currently conduct a wide array of training activities throughout the course of a year. These trainings target diverse areas of interest and need which address different youth populations. There may be redundancies or gaps that could be successfully addressed with a broad network view of state priorities so that investments in training are serving the needs of Georgia's
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current workforce and priority populations. Georgia needs a pathway for a statewide, coordinated transparent approach to the training of the behavioral health workforce.
Target population:
Staff members of clinical providers, state agencies and stakeholder group in need of training to support the delivery of evidence-based care and promising practices to Georgia's children, youth and families.
Desired impact:
Advance the planning, coordination and delivery of behavioral health workforce training throughout the state to promote the delivery of high quality, evidence-based services, reduce redundancies and gaps in training opportunities and enhance workforce retention. Require the Interagency Director's Team (IDT) to conduct a statewide inventory of trainings. IDT can then engage a workgroup to review and identify redundancies and gaps and to recommend to Annual Training priorities to the Behavioral Health Coordinating Council. This will raise awareness of current training activities and allow for targeted investments in those areas deemed most critical for the behavioral health workforce.
Timeline for implementation:
Immediate launch of Statewide Training Inventory 6 months for review and prioritization of training investments for presentation to the Behavioral health Coordinating Council
Recommendation F: Fund expanded provider training, fidelity monitoring, TA, and evaluation for evidence-based High Fidelity Wraparound (HFW).
Challenge to be addressed:
HFW is an evidence-based program that uses a team approach to integrated and individualized care in order to keep children and youth with high behavioral health needs in the community and out of intensive out-ofhome settings (e.g. psychiatric residential treatment facilities). Georgia currently has two Care Management Entities (CME) providing HFW services; in 2017, the two CMEs served approximately 4,240 youths, combined. Starting in October 2017, many components of HFW services became billable through Georgia Medicaid under Intensive Customized Care Coordination (IC3); state agencies anticipate this will increase the demand for providers trained in and delivering HFW services. The state recognizes the need for both current and future HFW providers to receive guidance, evaluation, and training on HFW in order to ensure fidelity to the model and positive outcomes for youth served.
Target population:
Youth aged 5 to 21 with a mental health diagnosis, co-occurring substance-related disorder and mental health diagnosis, or co-occurring mental health diagnosis and developmental disability, who are at serious risk of physical harm
Desired impact:
Increased access to HFW would allow more youth with serious behavioral and emotional concerns to remain in the community and avoid placement in intensive out-of-home settings, including psychiatric residential treatment facilities, DFCS placements, and youth detention facilities. Increased fidelity monitoring and
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evaluation would allow the state to ensure that the HFW model is being properly implemented by providers.
Timeline for implementation:
3-4 months to launch
Recommendation G: Support multi-pronged early intervention and prevention approaches to combat the opioid crisis among Georgia's youth and emerging adults.
Challenge to be addressed:
Opioid misuse has become a national public health crisis, prompting President Trump to declare a nationwide State of Emergency. In 2015, two-thirds of all drug overdose deaths were opioid-related. In Georgia, from 2012-2015, opioid overdose deaths among youth and emerging adults aged 20 to 24 increased by 41.9%. According to the CDC's 2011-2013 Youth Risk Behavior Surveillance System, approximately 17.7% of Georgia high school students reported misuse of prescription drugs at some point in their life. In order to combat the opioid misuse crisis among the youth and emerging adult population, Georgia is in need of a multifaceted approach, including an expansion of education, outreach, and prevention programs throughout the state.
Target population:
Youth and emerging adults aged 10 to 25, as this is a critical window of vulnerability in initiating opioid misuse or abuse, especially among youth already at risk for alcohol or drug abuse
Desired impact:
These approaches would decrease opioid misuse, abuse, and overdose deaths among Georgia's youth and emerging adults. It would improve reach of programs designed to prevent opioid misuse among students enrolled in colleges and technical schools in high need counties. This would include the implementation of a statewide opioid and prescription drug misuse curriculum for youth at risk of drug abuse.
Timeline for implementation:
The three initiatives comprising Recommendation G require different time frames to launch:
1. Strategic Prevention Framework at 5 technical schools: 4 months 2. Expansion of GEN Rx to 3 new sites: 3 months 3. Opioid Curriculum implementation: 2 months
Recommendation H: Support a multi-pronged suicide prevention approach, including the expansion of prevention programming and expansion of Georgia Crisis and Access Line (GCAL) hours, to reduce rising suicide rates among Georgia's youth and emerging adults.
Challenge to be addressed:
Suicide is a national public health concern; in 2015, suicide was the third leading cause of death in Georgia for youth and emerging adults ages 10 to 24. From 2011 to 2015, suicide rates among this age group in Georgia increased from 11.6 to 12.5 per 100,000. In 2014, 20 to 24 year olds in Georgia had the highest suicide rates of any age group (12.94 per 100,000). The most common circumstances of death for this age
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group include a current depressed mood, mental health concern, treatment for mental illness, crisis within the preceding two weeks, and an intimate partner concern. Over the past few years, Georgia has taken a number of steps to increase its suicide prevention efforts for youth and emerging adults; however, the need still exists to build upon these efforts with statewide education and outreach, implementation of a Strategic Prevention Framework for suicide, and increased access to GCAL during peak hours.
Target population:
Youth and emerging adults aged 10 to 24, as these youth are at the highest risk for suicide according to historical trends in Georgia
Desired impact:
Expanding the capacity of GCAL to field calls and make local referrals during peak crisis hours (nights and weekends) will help meet the needs of Georgia's youth and families seeking help. Implementation of a suicide prevention pilot using the Strategic Prevention Framework (SPF), which is very effective with youth with substance use disorders, would also help to reduce suicide attempts in the target population.
Timeline for implementation:
The two initiatives comprising Recommendation H require different time frames to launch: 1. Strategic Prevention Framework Suicide Pilot: 4 months 2. Expansion of GCAL hours to 24/7: 2 months
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Autism Services Benefit Update
Over the last several months, an interdepartmental team has come together as a multi-agency state autism collaborative created to build a more comprehensive approach to autism care in Georgia. These agencies include the Department of Community Health, Department of Public Health, Department of Behavioral Health and Developmental Disabilities, and Department of Human Services. Some examples of these agencies' existing autism activities and initiatives include work with the Emory Autism Center, the Marcus Autism Center, GSU Autism Training for Families and Inclusion Specialists, and Rita Young and Associates. These initiatives and agencies work in conjunction with one another to build a strong, multifaceted foundation of care for Georgia families with children who have Autism Spectrum Disorder, or ASD.
ASD affects every 1 in 64 children (ages 0 to 21) in Georgia and it is estimated that of the 1.1 million children in Georgia on Medicaid, 17,000 of these children have autism. Because children with ASD require varying levels of support according to criteria set by the DSM-V, there are many different treatment options available. These levels include Level 1 (requiring support), Level 2 (requiring substantial support), and Level 3 (requiring very substantial support). As determined by a specialist, the treatment options vary from Adaptive Behavioral Services, to Nonbehavioral therapies, and even medical and psychiatric treatment for associated conditions. Non-behavioral therapies include options such as speech-language, occupational, and physical therapy. Adaptive Behavioral Services, or ABS, on the other hand, is a form of behavioral therapy, which is a foundation for ASD treatment and includes social skills development, but it is not currently available through Medicaid in Georgia. ABS providers are comprised of a diverse group of individuals known as Behavioral Analysts.
As defined by the Behavior Analyst Certification Board (BACB), behavior analysis is the scientific study of principles of learning and behavior. Behavioral Analysts are certified nationally by the BACB and are qualified to provide services of behavioral analysis to address organizational functioning, skill deficits (e.g. communication and adaptive behavior), and problem behavior (e.g. aggression and self-injurious behavior). The distinct levels of ABS providers include Board Certified Behavior Analyst Doctoral Level (BCBA-D), Board Certified Behavior Analyst (BCBA), Board Certified Assistant Behavior Analyst (BCaBA), and Registered Behavior Technicians. While there is a range of ABS providers in Georgia, there is also a lack of adequate statewide access due to capacity limitations based on the currently employed workforce. The more rural areas of the state in particular do not have enough providers available to ensure that care is widely accessible, creating a need for capacity building solutions.
Proposed solutions for capacity building involve the utilization of telemedicine, infrastructure investment, and expansions to include crisis services. The utilization of telemedicine requires an accompanying increase in access to equipment and training. Infrastructure investment needs contractual agreements with vendors to provide administrative oversight and implementation of key workforce and infrastructure activities, a co-location hub model for southern/southwestern hub, and education opportunities. The inclusion of crisis services entail crisis respite, mobile crisis services, and an intensive support coordinator. Based on these recommendations by the multi-agency state autism collaborative, the guiding principles of the benefits coverage and design package include leveraging existing infrastructure, opening ABS procedure codes, phasing in multiple access points, investing in early intervention, and expanding a qualified provider network through enrollment of BCBAs.
Furthermore, ABS providers would be reimbursed based on a tiered system where providers command a higher reimbursement rate according to their level. This reimbursement system includes Level 1 (physicians and
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psychiatrists), Level 2 (psychologists and BCBA-Ds), Level 3 (BCBA), Level 4 (BCaBAs or Master's level Behavior Analysts without certification), and Level 5 (Registered Behavioral Technicians [RBT]). Finally, in order to inform the public about amendments to state plans, public notices will be created regarding ABS coverage for children and the enrollment of BCBAs. Within 90 days of submission, CMS will hopefully approve the changes to the system, ensuring further accessibility to Georgians. Communication and engagement with the community about healthcare for children with autism will be conducted by establishing a seat on the DCH Medical Care Advisory Committee for an Autism Services Provider and deploying communication plans such as email blasts, letters, mailed "toolkits", symposiums, conference representation, teleconferences (VICS), and webinars.
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Services for 0-4 Update
Children between the ages of 0 to 4 years are showing early signs and symptoms of behavioral health challenges. The Division of Family and Children Services (DFCS), the Department of Early Care and Learning (DECAL), the Georgia Child Welfare Reform Council and others have varying experiences with these unique challenges. Governor Nathan Deal's response for Georgia was a proposition of a total of $8 million in state and federal funding to help address these issues. The Georgia General Assembly supported and approved Governor Deal's proposal as a part of the FY 2018 budget. The agencies involved in the programmatic approaches are the Department of Community Health (DCH), Department of Behavioral Health and Developmental Disabilities (DBHDD), Department of Public Health (DPH), DFCS, and DECAL. DFCS often encounters children who have experienced early trauma and toxic levels of stress resulting in behaviors indicative of the need for early screening and intervention services. DECAL's organizational approach to these issues provides technical assistance to early care and education providers throughout the state when they encounter significant and persistent behavioral challenges in very young children in order to help them maintain structure and safety in the early childhood classroom. The Georgia Child Welfare Reform Council identified this matter and a lack of services as a source of concern. Behavioral problems in very young children will be dealt with as developmental concerns, with the approach explicitly focused on evidence-based and trauma-informed assessments and services. To create a true comprehensive screening, assessment and linkage system, broad program architecture is proposed to identify and select cutting edge tools most appropriate to Georgia's desired system. Each segment should have an articulated connection to existing services. These services include Early and Periodic Screening Diagnostic and Treatment (EPSDT), Children First, Babies Can't Wait, and Maternal Infant and Early Childhood Home Visiting (MIECHV) programs with possible models including Project LAUNCH and Help Me Grow. Implementation of the system should also include consideration for a designated Medicaid service category and the need for changes to the state Medicaid plan. The initial workgroup members are DCH Deputy Commissioner Lisa Walker, DPH Commissioner Dr. Patrick O'Neal, DBHDD Commissioner Judy Fitzgerald, DECAL Commissioner Amy Jacobs, and DFCS Director Bobby Cagle.
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Acknowledgments
The Commission would like to thank the following people for their hard work and invaluable assistance: Office of Governor Nathan Deal Sarah Berks, Policy Intern Department of Behavioral Health and Developmental Disabilities Monica Parker, Director of the Division of Behavioral Health Department of Community Health Brian Dowd, Medicaid Division Division of Family and Children's Services Virginia Pryor, Interim DFCS Director The Commission would also like to express its appreciation to those who shared their expertise and experience with the Commission, through submitted and spoken public comment. *Presentations from the two public meetings may be found online at https://dbhdd.georgia.gov/commissionchildrens-mental-health
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