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By Margaret M. Conner-Levin, MSW

In 2018, the National Association Of State Mental Health Program Directors outlined a model for creating a comprehensive crisis care continuum for youth up to age 18 years old (see Making the Case For A Comprehensive Children’s Crisis Continuum Of Care). This model, or aspects of it, has been adopted in numerous states—including New Jersey, Massachusetts, Oklahoma, Nevada, and Michigan, with two specific goals. First, readily available treatment for youth in crisis with emphasis on safety and de-escalation of immediate crisis. Second, stabilization within 72 hours.

What does a Comprehensive Children’s Crisis Continuum Of Care look like? A fully-developed system includes a readily accessible network of provider organizations and naturally occurring supports that offer strengths-based services. There are six fundamental best practices in this model:

  1. A single point of access that can be reached from anyone and staffed 24/7 with trained hotline staff who also provide triage services
  2. On-site assessment conducted wherever the youth is located at the time: school, home, another treatment setting, police station, or youth correctional setting, and others, including psychiatric assessment
  3. Immediate access to in-home supports, respite care, and short-term care coordination for up to 8 weeks
  4. Residential crisis stabilization to prevent out of home placement in a hospital, juvenile justice center (JJC), another alternate placement whether through residential, child welfare, or other
  5. Recovery and reintegration through a well-coordinated network of services focused on effective transition out of the crisis back to activities of daily living
  6. Ongoing education and training throughout the community to primary care professionals, child welfare agencies, law enforcement and first responders, schools, hospital emergency departments, JJCs and family courts, and non-clinical child serving community-based groups.

As a former executive of a provider organization that piloted the model in New Jersey, my assessment is simple: it works. I’ve seen how the crisis continuum of care concept can deliver positive clinical outcomes. And the model results in overall system cost reduction with fewer crises and less intense crisis needs, preventing hospitalization, reducing use of emergency department care, and avoiding long term residential placement out of the home. The model’s success is shown in one important measure—94% of all youth served through a crisis continuum have remained in current living situations throughout the crisis episode.

If the model is so good, why is it the exception rather than the rule? The model presents financial challenges for provider organizations. Currently, braided funding strategies are necessary to provide the full continuum of services and supports, including grants, Medicaid or health plan reimbursement, the juvenile justice system, and other state and local funding sources for social supports. Health plans will cover what are considered medically necessary services, such as initial clinical examinations by appropriately credentialed professionals, psychiatric and psychological evaluations, and licensed outpatient treatment. Medicaid may cover other services that function as a component of the continuum, e.g. specialized foster care home placements for short-term respite from the crisis paid by a separate fund of public dollars. The other services that make this model a success (or, as I like to say, “glue the continuum together”) have traditionally been covered through grant funding or coordination with other state and local government entities.

I think the solution to this situation is Medicaid and health plans moving to case rate or bundled payment models—with performance targets—for responding to children in crisis. As a former executive, I can speak to the complicated (and often unpredictable) nature of braiding funding. Additionally, serving youth in crisis with complex care issues means that there is a high clinical risk. These children need hands-on coordinated care management. This requires constant attention from all staff—from executives to direct care professionals—to develop and manage an effective network of services. Case rate types of funding, free from fee-for-service billing and allowing the provision of consumer-specific support services, would allow a provider organization to build a continuum in a community that involves multi-level partnerships with primary care, social support agencies, schools, and the juvenile justice system. These systems could be augmented with telehealth, mobile interventions, and other technology tools to provide rapid service delivery and better care coordination. What payers and health plans would get is what they say they want—care without walls and mobile with rapid response time.

For more on the current state of children’s services, check out these resources:

  1. North Carolina Sets 10 Statewide Goals To Improve Outcomes For Young Children
  2. The Child Mental Health Gap-More Prevalence, Less Treatment, More Opportunity?
  3. Adolescent Psychiatric Visits To U.S. Emergency Departments Increased 54% Between 2011 & 2015
  4. 283,000 U.S. Children Sustain A Traumatic Brain Injury Annually
  5. 16% Of U.S. Youth Have A Mental Health Condition
  6. Nearly One-Third Of Students With ADHD Receive No In-School Interventions
  7. New York City Administration for Children’s Services To Include New Requirements For Preventive Services In Child Welfare RFPs
  8. Virginia To Establish Safety Measures For Public School Use Of Seclusion & Restraint
  9. New York Medicaid To Transition Foster Children To Managed Care In October 2019
  10. Iowa Plans To Launch A New Children’s Behavioral Health System

For more on building innovative models of care, join us in New Orleans at The 2019 Strategy & Innovation Institute on June 5, where Lynda Zeller, Senior Behavioral Health Fellow, Michigan Health Endowment Fund will present Harnessing The Power Of Analytics To Create Innovative Solutions For Complex Consumers.

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