Reimagining Connecticut's behavioral health system for children

The pandemic has revealed to the public that our children’s behavioral health system is in desperate need of investment and expansion.

The fear, stress, social isolation, grievance, and trauma associated with COVID-19 led to a higher prevalence and acuity of many behavioral health conditions. Youth, families, community providers, schools, pediatricians, and hospital emergency departments are overwhelmed.

Jeffrey Vanderploeg

The crisis has hit under-resourced communities and families the hardest and exacerbated racial and ethnic health disparities.

In October 2021, the American Academic of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association took the unprecedented step of jointly declaring a national emergency in children’s behavioral health. Even though Connecticut has among the most robust array of services in the country, we have not been spared from the current emergency.

As we prepare to enter into the legislative session, behavioral health appears to be at or near the top of the agenda for both major parties. Over the last several months, I have had the privilege to convene multiple workgroups involving providers, state agency officials, legislators, and families focused on generating concrete recommendations for investment and expansion. These solutions can be grouped together in the areas of workforce development, expansion of key services, and investments in quality.

Ssupport the behavioral health workforce.

Behavioral health clinicians are compensated at low levels relative to their training, expertise, and importance to the health and well-being of our most vulnerable youth and families. Connecticut provides most of its children’s behavioral health services through a network of private, non-profit organizations, many of whom barely get by financially but have worked heroically throughout the pandemic to continue to meet families’ needs.

It is time to show them how much we appreciate and value the services they provide. Providers pay their clinicians and cover their expenses primarily through Medicaid and commercial fee-for-service rates and grant funds, many of which have not kept pace with rising costs. In fact, many psychiatrists and other behavioral health professionals no longer accept Medicaid or private insurance due to these low rates, making their services unaffordable for many families and widening inequities.

Connecticut needs a comprehensive review of Medicaid and commercial rates and enforcement of mental health parity legislation. By examining the actual cost of delivering care, Connecticut can bring rates and grant funds in line with those costs.

Connecticut also needs investment at the level of the individual clinician in order to attract and retain a sufficient number of qualified clinicians in an increasingly competitive market. Recently, Oregon invested $80 million in increasing and diversifying its behavioral health workforce. Connecticut must take comparable action.

To compete for talented clinicians, the state should consider tuition and loan forgiveness programs, sign-on and retention bonuses, paid internships, and regular COLA increases. Expediting the licensing and accreditation process and reducing the administrative burden on providers would allow clinicians to spend more time delivering care.

We can do all this with a goal of attracting a more racially, culturally, and linguistically diverse workforce.

Expand key services.

It would be difficult to identify a behavioral health service that does not need enhancement and expansion; however, certain services are crucial to a better-functioning system.

First, increase funding to expand the state’s outpatient clinics and mobile crisis services, the backbone of the children’s behavioral health system.

Second, invest in behavioral health assessment centers and short-term crisis stabilization units. These are community-based settings for meeting the needs of youth in crisis and reducing the burden currently placed on hospital emergency departments because youth have nowhere else to go. Many states are generating new revenue to fund crisis behavioral health services through small surcharges on wireless plans.

Third, expand intermediate levels of care, including extended day treatment, intensive outpatient, partial hospitalization, and intensive in-home services. These services often have wait lists because they are frequently the most clinically appropriate setting for youth being discharged from emergency departments and inpatient psychiatric hospitalization and youth who need more than a once-a-week outpatient therapy appointment in a school or community setting.

Finally, expand the integration of behavioral health services within primary care and schools. Bringing services into these settings will increase access and coordination of care.

Invest in quality.

Access to services is critical, but it is imperative to ensure that the services offered are of the highest quality. We expect this in physical health care, and we should expect no less in behavioral health care. Connecticut’s network of providers require ongoing training and professional development to deliver evidence-based interventions, which research shows are more efficient and effective than “treatment as usual.” Effective services rely on robust data collection and reporting, outcomes measurement, and quality improvement activities. Access to real-time data across payers and systems illuminates emerging needs and allows us to act quickly to address gaps in our service delivery system. Understanding which services are most effective, for whom, and under what conditions enables policymakers and legislators to invest only in the most effective services, and quickly identify and address disparities.