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DATE: |
September 24th, 2024 |
12 |
SUBJECT
Title
CREATING A CHILDREN, YOUTH, AND TRANSITION AGE YOUTH BEHAVIORAL HEALTH CONTINUUM FRAMEWORK FOR SAN DIEGO COUNTY (DISTRICTS: ALL)
Body
OVERVIEW
The youth behavioral health crisis is now well-documented, and evidenced through innumerable health advisories, surveys, and research from leading institutions including the U.S. Surgeon General, the Centers for Disease Control (CDC), the American Academy of Pediatrics, the American Psychological Association, and the U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) among many others.
Since 2010, nearly every indicator of mental well-being among children and youth has deteriorated. Ensuring access to prevention and intervention services and to primary care clinicians and behavioral and mental health specialists are critical components of any plan to address the youth behavioral health crisis and to support children and youth as they navigate these challenges. Additionally, the long-lasting benefits of early detection and intervention extend beyond the individual themselves with estimates that for every dollar invested in early childhood prevention and intervention returns $2 to $13 in long-term public savings.
Yet, the broader public and private behavioral health system of care has struggled to meet the needs of our children and youth. The Children’s Report Card 2024, which grades California’s ability to support better outcomes for kids from prenatal to age 26 has consistently awarded the state a D grade for mental health supports. Additionally, California ranked 51 (out of 50 states and D.C.) in 2024 for parents reporting it was not possible to obtain mental healthcare for their child, citing denials by health plans as a major barrier. Locally, the UCSD Health Partnership Community Engagement Annual Report (FY 2023 -24) found that mental health and substance use across the county were of major concern with youth-specific challenges cited as vaping, anxiety, depression, bullying, suicide risk, and social media influence and/or peer pressure.
The County plays a critical role in caring for the well-being of children, youth, and transition age youth (TAY) and focuses on serving, primarily through partnerships with community-based organizations (CBOs), children, youth, and TAY from 0 up to age 25 who are Medi-Cal members or who have no insurance. While the County has a robust system of care in place, the growing needs among youth and families for behavioral health services and the mounting pressure on schools and CBOs to provide these services, are proving untenable. These needs are exacerbated by a wider behavioral health workforce shortage. Furthermore, these challenges are playing out in the context of state-level policy and programmatic shifts in behavioral health and other youth-focused programs, including shifts in First 5 programs, recent changes to the Mental Health Services Act (MHSA) via the passage of Proposition 1, and Medi-Cal Transformation efforts.
The convergence of these factors, plus demographic trends, and historic public spending focused on expanding behavioral health services all raise major concern our region is not prepared to meet the specialized behavioral health needs of our children, youth, and TAY. This presents a major opportunity to develop a Children, Youth, and Transition Age Youth Behavioral Health Continuum Framework for our region.
Today’s actions request that the Chief Administrative Officer work with the Health and Human Services Agency (HHSA) to create a Children, Youth, and TAY Behavioral Health Continuum Framework across the 0 to 25 age continuum that considers current changes within the broader behavioral healthcare system and that is based on data analytics, consistent with the previous work performed on the Optimal Care Pathways Model (OCP) developed by Behavioral Health Services (BHS), that will quantify optimal service levels to inform a comprehensive long-term plan to address identified gaps in services. Additionally, today’s action requests the engagement of stakeholders during the development process.
The County has already taken bold action to move our behavioral health continuum from a model of care driven by crises to one centered on continuous care and prevention. We have focused on adding capacity and recalibrating the Continuum of Care to more appropriately service the behavioral health needs of adults, particularly those experiencing homelessness and/or experiencing concurrent diagnoses of serious mental illness and substance use disorders.
With this progress well underway, the County is now poised to turn its attention to the child and youth behavioral health crisis and to build upon the work done for adults. Specifically, BHS’ development of the OCP model, which uses data-informed algorithms to quantify optimal utilization across the behavioral health system.
If approved, today’s actions will enable the transformative vision required during a time of crisis and ensure the equitable investment of resources placing the County on an accelerated path to operating a Continuum of Care that supports San Diegans’ behavioral health across the entire lifespan.
RECOMMENDATION(S)
VICE-CHAIR TERRA LAWSON-REMER
1.) Direct the Chief Administrative Officer to work with the Health and Human Services Agency (HHSA) to create a Children, Youth, and Transition Age Youth Behavioral Health Continuum Framework across the 0 to 25 age continuum. This effort will consider current changes within the broader behavioral healthcare system and identify strategies to maintain and/or enhance services, including but not limited to leveraging Payment Reform through Medi-Cal Transformation and workforce development investments. The Framework will be based on data analytics and evidence-based research, consistent with the previous work performed on the Optimal Care Pathways (OCP) Model conducted by the Behavioral Health Services Department, and will quantify optimal service levels to inform a comprehensive long-term plan to address identified gaps in services. This effort will also be in collaboration with other respective HHSA departments, with each deliverable reflecting a planful approach to community input and feedback with a report back to the Board in six months (1.1) and return to the Board in 18 months (1.2):
1. Six (6) months with an outline of any interim strategies to maintain and/or enhance services and an outline of a long-term plan approach for creating a comprehensive framework, timeline for deliverables, report drafting, methods for community engagement, and any estimated costs, identified funding, and resourcing necessary for the creation and/or implementation of the plan, and
2. Eighteen (18) months with a final report to include prioritized recommendations for action and investment, contingent upon the approval of resourcing and funding identified at the report back under Recommendation 1.1.
2.) Direct the Chief Administrative Officer to seek out methods to optimize payments for all payers that hold Medi-Cal products to support the implementation of prioritized actions identified in Recommendation 1.
EQUITY IMPACT STATEMENT
If approved, today’s actions will support County efforts to enhance behavioral health services for children, youth, and TAY throughout San Diego County. The stark economic, gender, racial, and ethnic disparities shaping American childhoods today are disproportionately resulting in and contributing to troubling behavioral health issues among many subsets of children and youth. Included here are the effects of the COVID-19 pandemic which brought children trauma and tremendous loss with research showing the pandemic amplifying disparities with certain minority groups.
Comparing pre-pandemic to the first year of the COVID-19 crisis, the share of children struggling to make it through the day due to anxiety and depression rose nearly 26% - from 9.4% (5.8 million kids) in 2016 to 11.8% (7.3 million kids) in 2020. In 2021, 9% of all high school students had attempted suicide. This rate rose to 12% for Black students, 13% for students of two or more races, and 26% for American Indian or Alaska Native high schoolers. Among LGBTQ+ youth, the statistics were similarly skewed, with 23% of gay, lesbian or bisexual students reportingly having attempted suicide compared to just 6% of their heterosexual peers.
Furthermore, recent data suggests that 44% of youth are struggling with their mental health versus an estimated 39% of adults. Prioritizing every child’s ability to access the mental health care they need - when and where they need it - and bolstering a health continuum framework that considers young people’s experiences and identities is imperative to ensuring equity and well-being throughout the lifespan in the County.
BHS already has plans to weave in efforts currently underway through the Community Experience Partnership (CEP). The CEP is a collaboration between BHS and the University of California San Diego to integrate data and community engagement to advance behavioral health equity. Behavioral Health Equity Index allows the public to view behavioral health equity data through dashboards that include data from surveys, vital records, hospitalization, and emergency departments, along with service and outcome data for individuals receiving services through BHS. It also includes indicators of equity over time and across neighborhoods by race/ethnicity, gender, sexual orientation, age, justice involvement and more.
BHS will pursue efforts to connect the Behavioral Health Equity Index work to the OCP model and now the Child and Youth Behavioral Health Continuum Framework integrating three immensely impactful bodies of work to inform where the highest priority area of future investment to address current inequities exists. This will support regional distribution of services across the communities most in need to ensure they have access to behavioral health care in close proximity to where they live.
SUSTAINABILITY IMPACT STATEMENT
Transforming the children, youth, and TAY behavioral health continuum of care in San Diego County will result in sustainability enhancements in terms of health, wellbeing, and equity as we advance access and the regional distribution of services that will allow children, youth, and TAY to receive care that is in close proximity to their support systems and provides a wider availability and range of connections to care.
Today’s actions will evaluate and allow for a strategic approach to supporting children, youth, and TAY with behavioral health needs in order to prevent individuals from not receiving the right care at the right time in the right place. Additionally, the County of San Diego Health and Human Services Agency, Behavioral Health Services will continue to explore thoughtful and sustainable designs for infrastructure, programs, and service delivery that are in alignment with the County’s Sustainability Goals.
FISCAL IMPACT
Recommendation #1
For Recommendation 1.1, it is anticipated that the Health and Human Services Agency can absorb the impact to staffing and consultant needs in the Fiscal Year 2024-25 Operational Plan to address the six month return back. For Recommendation 1.2, it is anticipated that the final report will require a significant investment in staffing costs and consultant needs to report back with prioritized recommendations for action and investment. The resource needs to address Recommendation 1.2 is contingent upon the approval of resourcing and funding identified at the report back under Recommendation 1.1. At this time, there will be no change in net General Fund cost and no additional staff years associated with today’s actions.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
N/A
BACKGROUND
The challenges today’s young people face are unprecedented and uniquely hard to navigate. And these challenges are having a devastating effect on their behavioral health with direct impacts to their mental and emotional well-being. The youth mental health crisis is now well-documented, and evidenced through innumerable health advisories, surveys, and research from leading institutions including the U.S. Surgeon General, the Centers for Disease Control (CDC), the American Academy of Pediatrics, the American Psychological Association, and the U.S. Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) among many others.
Since 2010, nearly every indicator of mental health and psychological well-being among youth has deteriorated. In 2019, one in three high school students reported persistent feelings of sadness or hopelessness, an overall increase of 40% from 2009. And a 2023 CDC report found that three in five (57%) female students reported persistent feelings of sadness or hopelessness, representing a nearly 60% increase since 2011 and the highest level reported over the past decade. In California, from 2016 to 2020, the percentage of children ages 2 to 17 who had anxiety or depression increased by 70%. Trend data related to eating disorders, substance use, cyberbullying, social media usage, and emergency room visits for anxiety and depression among youth are all heading in the wrong direction. The most alarming of these trends being a 62% increase in the suicide rate among youth ages 10 to 24 since 2007. Additionally, more than 1 in 10 (12%) LGBTQ+ youth reported attempting suicide in the past year and 39% reported they seriously considered attempting suicide - including 46% of transgender and nonbinary young people. The same report found 50% of LGBTQ+ young people who wanted mental health care in the past year were not able to get it. Access to evidence-based prevention and intervention strategies and to clinicians, specialists, and other support services are critical components of any plan to support youth as they experience these challenges, especially more vulnerable youth who have more urgent and/or complex needs.
Additionally, people are experiencing behavioral health symptoms at younger ages. One study demonstrated that 50% of people with a behavioral health disorder developed symptoms before adulthood, with the average age of onset around age 14 and the specific age of onset depended on the type of disorder. For example, anxiety and phobia disorders initiate on average around 5 years of age, stress disorders around 15 years of age, addiction around 19 years of age, and depression and other mood disorders around 20 years of age. According to the U.S. Department of Health and Human Services, one in five children 17 years old and under are currently receiving a diagnosis for some type of mental, emotional, behavioral or developmental disorder. Research also shows that the long-lasting benefits of early detection and intervention extend beyond the individual themselves with some estimates calculating that for every dollar invested in early childhood diagnosis, prevention and intervention, society saves $2 to $13 in healthcare costs, emergency services, long-term care, criminal justice expenses, and the avoidance of lost productivity.
Yet, the current behavioral health system of care is struggling to meet the needs of our children and youth. The Children’s Report Card 2024, which grades California’s ability to support better outcomes for kids from prenatal to age 26 gave the state a D, D+, and D- for the following three issue areas, respectively-preventative screenings, supporting mental health, and preventing substance abuse. For supporting mental health specifically, California has consistently received a D grade since 2018. Additionally, California ranked 51 (out of 50 states and D.C.) in 2024 for parents reporting it was not possible to obtain mental healthcare for their child, citing denials by health plans as a major barrier.
Locally, the UCSD Health Partnership Community Engagement Annual Report (FY 2023 -24), commissioned by San Diego County’s Behavioral Health Services,<https://bhabrehab.com/wp-content/uploads/2024/05/FY2024-25-CE-Report-UCSD-Health.pdf>found that mental health and substance use across San Diego County (County) were of major concern to community members and lack of healthcare access, support systems, and behavioral health workforce were stated as priority areas of need. Youth-specific challenges that were voiced across the County included vaping, anxiety, depression, bullying, and social media influence and/or peer pressure. Also noted was the rise of suicide among LGBTQ+ youth. And regional differences ranged from an emphasis in the East region on lack of access to services to rising concerns over anxiety, depression, and substance use in the North region.
As a County, we play a critical role in caring for the well-being of children, youth, and transition age youth (TAY) and are responsible for the operation of an accessible, equitable, and responsive behavioral health system. BHS offers a variety of programs to support children, youth, and families, along with TAY who may benefit from mental health services and/or substance use treatment. County-funded behavioral health services are primarily provided by community-based organizations (CBOs) and focus on serving children, youth, and TAY from 0 up to age 25 who are Medi-Cal members or who have no insurance. BHS, in partnership with community-based providers and schools, provided treatment and support through over 120 programs specializing in serving children, youth, TAY, and their families, with additional TAY receiving care across other adult programs as well. In Fiscal Year 2022-23, across the behavioral health continuum care, nearly 20,000 children and adolescents received mental health services, over 3,500 received substance use care, and 12,500 were served through prevention and early intervention.
While the County has a robust system of care in place for San Diego’s children, youth, and TAY, the growing and intense need among children, youth, TAY, and families for behavioral health services and the mounting pressure this demand is placing on schools and CBOs to provide these services, in the midst of a profound behavioral health workforce shortage, is proving untenable.
These challenges are playing out in the context of state-level policy and programmatic changes in behavioral health and other youth-focused programs. Among them are changes in the First 5 programs. First 5 San Diego, managed by the County’s Child and Family Well-being Department, supports the health and well-being of young children ages 0 to 5 during their most critical years of development by providing parents and caregivers with a variety of programs to promote children’s optimal development and school readiness. First 5 funding has funded more than $11 million in pediatric mental health services over the last 25 years for all San Diegans 0 to 5 years old. However, due to the success of smoking cessation programs, First 5 funding has been steadily declining with an anticipated reduction of $16 million in the next fiscal year. Exploring the local impact of shifts within the First 5 program is important to understanding service capacity for young children ages 0 to 5 under the County’s care.
Recent changes to the Mental Health Services Act (MHSA) via the passage of Proposition 1 are also anticipated to impact funding categories for prevention and early intervention services and programs for children with serious mental illness or serious mental illness and a co-occurring substance use disorder(s). Historically, MHSA funds have funded counties to provide prevention and early intervention services directly, however, with the passage of Proposition 1 prevention services will now be provided by the state. Understanding how this transition will impact the provision of local prevention services for children and youth will be important in the months and years ahead.
Medi-Cal Transformation is yet another transition impacting the County’s child and youth behavioral health services system of care. This multi-year initiative by California’s Department of Health Care Services (DHCS) was implemented to improve the quality of life and health outcomes of Medi-Cal beneficiaries by implementing a more comprehensive delivery system with program and payment reform across the Medi-Cal program. While this work began in February 2021 and the County is in the final stages of implementing its phased approach to transition providers and managed care plans from a cost reimbursement system to a fee-for-service system, uncertainty still remains about how to realize and maximize the opportunities envisioned by this initiative. Additionally, the County’s Medicaid Ad Hoc Committee continues to explore additional opportunities to secure adequate reimbursement rates with the goal of improving access to care for Medi-Cal eligible clients. Incorporating child and youth behavioral health services into this body of work will be instrumental to addressing the growing need for these services within our communities.
Furthermore, San Diego County is facing a significant behavioral health workforce shortage. The 2022 report Addressing San Diego’s Behavioral Health Worker Shortage estimated 17,000 behavioral health professionals were employed in 11 key occupations in 2022, including areas specific to child and youth behavioral health services. However, this is 8,000 workers short of the 25,000 needed to fulfill anticipated demand. The convergence of demographic trends, growing mental health and substance use crises, and historic public spending focused on expanding behavioral health services raises major concern our region is not prepared to meet the specialized behavioral health needs of our children, youth, and TAY.
Under the leadership of the San Diego County Board of Supervisors (Board), behavioral health care in San Diego has been undergoing a profound transformation. Since September 2022, the County has been taking bold action and making strategic investments to move the local behavioral health care delivery system from a model of care driven by crises to one centered on continuous care and prevention. These efforts, broadly referred to as the Behavioral Health Continuum of Care (Continuum of Care), have been guided by data, focused on equity, and designed to engineer collaborative work across silos, within and outside of government.
The work performed thus far has been intensely focused on adding additional capacity and recalibrating the Continuum of Care to more appropriately service the behavioral health needs of adults, particularly those experiencing homelessness and/or experiencing concurrent diagnoses of serious mental illness and substance use disorders.
With this progress well underway, the County is now poised to turn its attention to the children and youth behavioral health crisis and to learn from and leverage the work done for adults. Specifically, BHS’ development and utilization of the Optimal Care Pathways (OCP) model, a data-informed algorithm that quantifies optimal utilization across service areas within the behavioral health system. The OCP model recommends recalibration and expansion of existing services for adults, and suggests some additional types of services to remove barriers to care, reduce per capita cost, and most importantly, connect individuals to the care they need, when they need it to ensure wellness over the long-term.
To address gaps and barriers, the OCP model quantifies the optimal utilization needed across various service categories and specifically demonstrates the urgent need to develop and expand care and services, inclusive of infrastructure, specifically for Medi-Cal eligible adults who have behavioral health needs to facilitate connection to services and eliminate waitlists. It also outlines client care pathways to map where adults with behavioral health conditions are entering from, which levels of care they are going to, what barriers are in their way, and what is preventing them from receiving optimal care. It also identifies common characteristics and specialty needs among clients and any missed opportunities for optimization to inform the development of ways to anticipate need and necessary adjustments going forward.
The ultimate goal of the OCP model is to shore up a responsive and sustainable system of care that connects individuals with the right care and alleviates existing bottlenecks. The goal is set to be achieved through incentivizing payment models and data-driven adjustments to infrastructure and services to best align with client needs with an intentional effort towards prevention and health maintenance. An ideal way to ensure that there is a continuous and coordinated Continuum of Care that includes our children, youth, and TAY is to develop a Children, Youth and Transition Age Youth Behavioral Health Continuum Framework leveraging the OCP model.
Critical to developing a representative and comprehensive framework will be the inclusion of the voices and direct experiences of youth, parents/guardians, and service providers. To achieve this, BHS will continue to collaborate with existing departments, councils, and community members to advise and make recommendations on advancing equity for unserved and underserved children and youth with behavioral health needs across the region.
Today’s actions are proposed to directly address the child and youth behavioral health crisis locally and the County’s immediate need for a comprehensive, data-driven approach to set a defined trajectory for the portion of San Diego’s Continuum of Care that services the behavioral health needs of children, youth, and TAY. By leveraging the OCP model, the County can assess and quantify the behavioral health needs of youth ages 0 to 25 and identify the gaps and barriers across the system of care, focusing specifically on Medi-Cal eligible individuals, as well as examining services within the broader context of current shifts in policies, programs, and larger system challenges. This will enable the transformative vision required during a time of crisis and ensure the equitable investment of resources.
Today’s actions request that the Chief Administrative Officer work with the Health and Human Services Agency (HHSA) to create a Children, Youth, and TAY Behavioral Health Continuum Framework across the 0 to 25 age continuum that considers current changes within the broader behavioral healthcare system and identifies strategies to maintain and/or enhance services, including but not limited to leveraging Payment Reform through Medi-Cal Transformation and workforce development investments, and is based on data analytics, consistent with the previous work performed on the OCP Model developed by BHS, that will quantify optimal service levels to inform a comprehensive long-term plan to address identified gaps in services. Additionally, today’s action requests the engagement of stakeholders during the development process.
If approved, today’s actions will set the County on an accelerated path to operating a Continuum of Care that supports San Diegans behavioral health across the entire lifespan. Research consistently demonstrates that many factors influencing behavioral health can be modified during early childhood and adolescence, often preventing mental health and other challenges from emerging at all. Research also establishes that early intervention and support lessen suffering, reduces suicide, and improves quality of life well into the future. While the County continues to work diligently to maintain its current services and programs supporting children, youth and TAY, these additional steps requested today will further sustain and enhance the services, programs, infrastructure, and workforce needs of the County’s Behavioral Health Continuum of Care for the betterment of today’s children and youth who are tomorrow’s adults.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s proposed actions support the County of San Diego’s 2024-2029 Strategic Plan initiatives of Sustainability (Resiliency), Equity (Health) and Community (Quality of Life and Partnership) by ensuring the capability to respond to the immediate behavioral health needs of children, youth, and transition age youth, by reducing disparities and disproportionality of individuals with mental illness and substance use disorders, and ensuring access to a comprehensive continuum of behavioral health services administered through accessible behavioral health programs.
Respectfully submitted,
TERRA LAWSON-REMER
Supervisor, Third District
ATTACHMENT(S)
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