Disclaimer: Moving Health Care Upstream is a collaborative effort originally co-led by Nemours Children’s Health and the Center for Healthier Children, Families & Communities at the University of California- Los Angeles (UCLA). The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of Nemours, UCLA or the Moving Health Care Upstream initiative.
- Kara Odom Walker, MD, MPH, MSHS; Executive Vice President, Chief Population Health Officer; Nemours Children’s Health
- Laura Hogan, MPA, Consultant, Laura Hogan Consulting
- Daniella Gratale, MA; Associate Vice President, Federal Affairs; Nemours Children’s Health
Thank you to Hannah Wagner, MPP, Senior Advisor, Policy Development and Partnership, Nemours Children’s Health, for editing this blog post.
“[The] challenges today’s generation of young people face are unprecedented and uniquely hard to navigate. And the effect these challenges have had on their mental health is devastating […] If we seize this moment, step up for our children and their families in their moment of need, and lead with inclusion, kindness, and respect, we can lay the foundation for a healthier, more resilient, and more fulfilled nation.”
– Vivek Murthy, MD, MBA, US Surgeon General, Protecting Youth Mental Health Advisory: The U.S. Surgeon General’s Advisory, 2021
America’s children and youth report staggering rates of sadness, depression, anxiety, and loneliness. This can result in high risk for suicide, depression, substance use disorder, poor academic performance, and other severe consequences. Nearly 60% of female high school students and about 30% of male students surveyed reported experiencing persistent feelings of sadness or hopelessness for two weeks or more in the past year. Moreover, a 2023 survey showed that 86% of children report that they worry, and 36% report being sad or miserable when they worry. While substance use among young people decreased over recent years, the spread of fentanyl has led to a tragic epidemic of overdose deaths. And, younger children are showing signs of acute distress with suicide now reported as the second most common cause of death for children ages 10 to 14.
Solutions for Youth Mental Health Crisis
Solutions are at hand. Schools are critical. Increasing school-based behavioral health (SBBH) services can be implemented urgently since children and youth spend so much of their time at school. School-based approaches eliminate transportation barriers that create challenges preventing children, youth and families from accessing services and deepening inequities. A 2019 report states, “Effective comprehensive school mental health systems contribute to improved student and school outcomes, including greater academic success, reduced exclusionary discipline practices, improved school climate and safety, and enhanced student social and emotional behavioral functioning.” School-based services also promote equitable access by reducing barriers for underserved populations, including children from low-income households and children of color.
Donna Jean Robertson tells of her frustration trying to find mental health services for her daughter when she struggled in high school. With no school-based services, Donna Jean and her daughter waited two months for an appointment with a therapist 15 miles away. To go to the appointment, Donna Jean missed work, and her daughter missed school. Each session cost $100 in copays. More recently, when her grandson needed help, Donna Jean was fortunate. Thanks to a clinic run by Nemours Children’s Health at his elementary school, he got services within one week, and Donna Jean was referred to a local support group.
Current Policy Response
Policy makers have taken notice: In 2022, the Bipartisan Safer Communities Act became law, with numerous provisions to support school-based behavioral health services. In May 2023, the Centers for Medicare and Medicaid Services (CMS) released guidance to make it easier for schools to receive payment for Medicaid-covered services and launched a technical assistance center (TAC) to assist state and local stakeholders focused on expanding access to Medicaid funded physical and behavioral health services. The question becomes – how do we translate this policy into accessible services for more students across the nation?
Creating more widespread implementation of SBBH models
It’s complicated: Every school should offer a comprehensive SBBH approach – but they don’t. The reality is that SBBH services exist as a patchwork of programs and services, which are too often based on the heroic efforts of individuals working locally. Although 84% of public schools offer some individual counseling, only 66% refer to external behavioral health providers and just 34% offer universal behavioral health screenings to identify student needs.
Providing SBBH services requires alignment and partnership between two mammoth systems (education and health), each one operating with longstanding – and very different – policy and financing frameworks. Educators and behavioral health providers each have a role to play in the schoolwide promotion of prevention and wellbeing. Together they must implement systems that incorporate prevention programs and training for school staff as well as systems to identify and serve children and youth who need clinical behavioral health services. However, the integrated and cohesive alignment between educational and health care systems and personnel can be difficult due to differences in professional cultures, goals, and terminologies, which layer on top of a variety of other barriers and complicating factors.
Consensus is emerging about the barriers and solutions: In May 2023, more than 150 pediatric and behavioral health organizations, state and local education agencies, philanthropic organizations, federal officials, youth, and parents met and surfaced a range of barriers that stand in the way of having comprehensive SBBH services in every school. The most pervasive challenges include:
- Complexity of Medicaid reimbursement in schools.
- Inadequate funding for services, upstream approaches, collaboration, training, and coordination.
- Workforce shortages of diverse behavioral health professionals, counselors, social workers, nurses, community health workers, peers, and others.
- Retention of qualified professionals who leave because of high caseloads, inadequate administrative support, burnout, lack of competitive salaries and career advancement.
- Varying and complex state regulatory standards for licensure.
- Student debt to obtain degrees and certifications resulting in fewer workers able to accept lower-paying positions in schools.
- Lack of reimbursement for expanded workforce models like peer support, community health workers and other non-traditional providers.
Fortunately, many positive examples have emerged to show that effective models of SBBH are in place now and could be spread and scaled if coupled with lessons from the field.
Federal leadership and philanthropic action can meet the moment.
The federal government, states, philanthropy and local leaders all have roles to play in making SBBH models more widely accessible across the nation. These solutions are highlighted in this brief. In particular, the newly launched Technical Assistance Center (TAC) can be part of a comprehensive and systemic solution to advancing equitable wellbeing for all children and youth. The list below spells out priority recommendations for the TAC and philanthropy.
Focus Areas for the Technical Assistance Center
- Support Expanding and Optimizing Medicaid in School-Based Settings: The TAC could support states in enabling the expansion of behavioral health services into schools.
- Serve as a Clearinghouse: The TAC could establish itself as a national clearinghouse for Medicaid waivers and State Plan Amendments, policies, memorandums of understanding, data-sharing templates, and toolkits. It could curate the wide variety of federal grant opportunities available to support school-based health to navigate Medicaid billing more effectively.
- Build and Leverage Learning Networks: The TAC could establish learning collaboratives, bringing together Medicaid, state education entities and local education entities to exchange ideas and innovative practices, including how to address Medicaid billing complexities, overcome data-sharing and privacy challenges, and address workforce shortages. Through online webinars, workshops or conferences, the TAC could also facilitate knowledge sharing, dialogue, and capacity building among stakeholders. Follow-up resources like toolkits and guidance would promote sustained application of the knowledge gained.
- Provide Tiered Support with Technical Assistance Specialists: Different geographies, from urban to rural areas, and different stages of Medicaid billing implementation require different types of technical assistance. To meet this need, the TAC could assign technical assistance specialists to work with a small number of states, focusing on their specific types of school-based Medicaid programs. Technical assistance specialists could also help identify relevant grant opportunities that states might be interested in applying to pursue.
- Promote Interagency Collaboration: In 2022, the U.S. Department of Health and Human Services unveiled the HHS Roadmap for Behavioral Health Integration to prioritize policy actions to improve access to behavioral health care. To continue to advance the goals of the roadmap, federal agencies could collaborate with the TAC to establish a network of federal interagency contacts. This would provide TAC clients with valuable support navigating the federal landscape by offering general guidance, support for blending and braiding of funds, and sharing best practices. Continued collaboration among these agencies would enhance the TAC’s ability to provide comprehensive and tailored assistance.
- Collaborate with the TAC: Philanthropy should collaborate closely with the TAC and state policymakers to raise up the needs and opportunities to improve youth behavioral health. Especially for universal and prevention-based approaches, philanthropy should collaborate with the TAC to identify approaches that could in time be reimbursed by Medicaid or supported through blended or braided funding streams.
- Fund Innovation and Promote Effective Practices: The philanthropic sector has a unique role to play, especially to start up, evaluate, and scale new and innovative SBBH services.
- Youth and Caregiver Voice: Philanthropy is well-suited to engaging youth and caregivers so that program priorities reflect their evolving needs – in particular, ensuring that strategies are effective in closing disparity gaps for places and people who experience inequity.
- Facilitate a Comprehensive Approach: Local, state, and national philanthropy can work in concert to build capacity for a comprehensive array of programs and services tailored for each age and locality. Philanthropy can play a complementary role by addressing the community conditions and experiences that interfere with the healthy development of children and youth.
Culture and context matters. Let the voices of youth and their caregivers guide our efforts.
As a country, the pandemic era found us speaking more openly about behavioral health and our human need for social connection and meaning. Our nation should continue to talk about what should be in place to support behavioral health and encourage everyone who needs help to ask for it and have access to it.
Perhaps the most important recommendation we can offer is to make sure that programs are implemented based on the reality and experience of youth and their caregivers; that policies are developed to support the wellbeing of every child and youth; and, that we hold collective accountability for every youth attending a school with comprehensive programs and services to support social and emotional health.
For more information about school-based behavioral health services, please see Nemours Children’s writing on the issue: