Young people are experiencing elevated rates of anxiety, depression, and suicide, with an accompanying increase in emergency department (ED) visits for those having behavioral health crises. To address this, communities are working creatively to find solutions, including expanding behavioral health mobile crisis teams, to help stabilize youth before they reach crises.
Hospitals have become overwhelmed with youth “boarding” in EDs — that is, young people staying in EDs while waiting for inpatient beds. A recent study found that pediatric mental health ED visits increased by 43 percent from 2015 to 2020, or 8 percent per year — whereas all other pediatric ED visits increased by only 1.5 percent annually. Thirteen percent of pediatric patients had a mental health emergency room revisit within six months.
Before reaching the point where a young person needs to go to an emergency room, families deal with incredibly difficult situations at home, including managing young people who become emotionally dysregulated and express themselves with physical and verbal aggression. For these families, the toll isn’t just mental anguish but also the financial stress of holes in walls and broken furniture and very few options for support. No parent wants to end up in the ED. For many, particularly for parents with children with autism spectrum disorders, emergency rooms can be overstimulating and do more harm than good.
States are addressing the growing need for robust youth mental health services in various ways:
- California is investing more than $4 billion to revamp its approach to youth mental health, ensuring that services are community-based, equitable, and inclusive of many different types of providers (e.g., schools, juvenile justice, and foster care).
- Ohio has implemented a new Medicaid waiver that coordinates and integrates intensive home- and community-based services (HCBS) for youth with complex behavioral health needs; OhioRise offers a range of services through Medicaid managed care, including respite (i.e., short-term, temporary relief during the day or overnight for caregivers and/or behavioral health support in the community for a young person), mobile response and stabilization, and intensive care coordination. Services are designed to work across youth service systems (e.g., child welfare, juvenile justice, and public schools) to help stabilize youth and support families.
- Oklahoma has a statewide system of care for young people that engages an array of stakeholders, including families, schools, child welfare, and behavioral health staff. Oklahoma has developed a data platform that can flag trends, allowing staff to respond in real time with support for local communities when there is an uptick in youth behavioral health crises. For instance, using its crisis data dashboard, Oklahoma was able to see an uptick in suicide attempts in a particular community and respond in real time with supports to a local school district.
These states are all incorporating a youth “system of care” philosophy — that is, one that is community-based, family- and youth-driven, includes nontraditional partners (e.g., faith-based programs and housing providers) and that uses wraparound planning processes. High-fidelity wraparound is an evidence-based model of care coordination that puts a family and young person at the center of a highly structured, team-based planning process. Services should reflect the cultural and linguistic needs of young people and their families, with staff who look and speak like the people they serve. Community-based youth mental health services should, whenever possible, be utilized to help avoid 24-hour care and be designed to meet the specific needs of youth and families. So much of the behavioral health system has been built with a focus on adults, not young people and their families. Youth services should include:
- family and youth peer support
- intensive family therapy
- intensive care coordination
- mobile response stabilization services.
States also should rethink the range of services they offer families and consider new ways to fund them. States typically shy away from investing in youth services because the return on investment is not immediate. To improve the well-being of youth, states will have to consider investing in preventive, upstream services. Medicaid offers opportunities through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) entitlements and waiver options to expand services before a young person reaches an ED. While there are minimum standards states must meet in delivering their Medicaid programs, such as covering certain benefits, states have flexibility in eligibility, optional benefits, and strategies involving payment and provider networks. State Medicaid authorities have leverage through state plans, plan amendments, and waivers to deliver their programs flexibly, in ways that meet the behavioral health needs of youth.
States also have leverage to require that commercial insurance health plans operating within the state ensure behavioral health parity and access to services. In Massachusetts, the Division of Insurance and Department of Mental Health issued guidance requiring all regulated state commercial health plans to cover certain community-based and outpatient mental health services for young people, including intensive family therapy, the use of family partners (i.e., peers who have raised a young person with behavioral health needs), and mobile crisis response.
Comprehensive programs that incorporate youth “system of care” principles and link young people and families with HCBS, counseling, and a range of wraparound services have been found to keep youth in their homes and improve outcomes. States can maximize Medicaid funding to pay for many of these services to improve the health and well-being of youth and families.