Hope for an improved child behavioral health system

At 13, Anna Mandh is already familiar with several mental health hospitals in Vermont, New Hampshire and Massachusetts.

She can name them with ease: the Yellow Pod at Concord Hospital and Hampstead Hospital, the Brattleboro Retreat over the border in Vermont, and the McLean-Franciscan Children inpatient program just outside of Boston.

Anna, a Hopkinton resident, has been hospitalized six times out of state in the last two years, each time after experiencing a mental health crisis. Most of those occurred while she was in school, and the school often called a police car to transport her to the hospital, a situation she said left her uncomfortable and embarrassed.

Having to travel a long distance to get treatment didn’t help, either. “You don’t want to be in a car, you don’t want to be anywhere that’s going to feel like danger to you,” she said. “It just makes you more stressed out.”

She and her mother hope the state’s system for treating youth can be improved and they are hoping a new bill that passed the Senate on Thursday will become law.

Anna’s trips out of state cost money for the family – one stay cost $20,000, her mother Darlene Gildersleeve said. Eventually, she had to take a leave of absence from her job to care for Anna and her younger sister, Abigail. Anna has missed over 60 days of school over two years due to her hospitalizations, her mother estimates.

If she were an adult, Anna wouldn’t necessarily have to leave her home every time she has a crisis; her 19-year-old brother, who also struggles with his mental health, has been treated by Riverbend Community Mental Health’s mobile health crisis team.

The team is able to meet patients where they are and provide an on-site evaluation, with the goal of deescalating in patients to avoid hospitalization. Gildersleeve said the team’s services have prevented her son from having to be hospitalized at least twice.

Anna’s case is not unusual. The Substance Abuse and Mental Health Services Administration recently found that about 10,000 New Hampshire’s children were served in the state’s public mental health system from 2014 to 2015.

When those children experience a crisis that requires hospitalization, they have few options: New Hampshire Hospital only has 24 beds, and those are usually filled, according to a Department of Health and Humans Service’s July report. Other, private institutions often have long waiting lists and high costs of care.

Children like Anna may soon have other options.

Senate Bill 14, which cleared the Senate in a 24-0 vote Thursday, would put $9.1 million per year towards implementing a comprehensive system of care for children’s behavioral health.

It would do so through several components, including the creation of nine mobile crisis units dedicated to children throughout the state and respond to calls for help within an hour.

Other measures include establishing a family support clearinghouse and system of care advisory committee, which would improve communication between care providers; defining and requiring providers to follow evidence-based practices; creating a resource center for children’s behavioral health; and revamping how children are evaluated for court-ordered placements.

Supporters say the methods will support families by providing community-based services and coordinating care across multiple systems, including health care, child protection and juvenile justice.

“In many cases, a family’s only options during a behavioral health crisis are to turn to law enforcement or an emergency department,” said Rebecca Whitley, policy director for New Future’s New Hampshire Behavioral Health Collaborative, speaking last week before the Senate’s Health and Human Services Committee.

“Emergency rooms and police departments often lack the specialized expertise and training to effectively respond to a child’s psychiatric needs,” she continued.

Anna, who testified in support of the bill with her mother, said she’s experienced first-hand the states’ struggle with juvenile mental health. When Anna talks about her time at Concord’s Yellow Pod, one of the starkest memories she has is people banging on the walls, which made it difficult for her to sleep.

Gildersleeve recalled having to take shifts with Anna’s father during a particularly busy evening. Patients of all different ages and genders were lined up on gurneys in a hallway, she said.

Local, federalrequirements

The state was charged with expanding its behavioral health system of care in 2016, when RSA 135-F went into effect.

But the passage of the Family First Prevention Services Act last year adds another layer of urgency. The bill aims to prevent children from entering foster care by allowing federal reimbursement for mental health services, substance use treatment, and in-home parenting skill training.

It also looks to incentivize states to reduce placing children in care settings outside of their homes, according to a bill summary sheet from First Focus.

To receive federal funding under the law, states have to provide evidence-based, trauma-informed services, like mobile crisis units, and expand home and community-based behavioral health services for children.

Implications forjuvenile justice

The proposed model has elements of New Jersey’s wraparound approach, which services about 12,000 youth through a contracted systems administrator.

Through its program, New Jersey has reduced the utilization of residential treatment/group home beds from 2,000 to 1,000, DHHS found.

The state retains the responsibility of developing the provider network, contracting, rate setting, and payment. It’s funded through a combination of Medicaid and state dollars.

Families access services through a contracted systems administrator, who assesses the needs and eligibility for services, authorizes services, and provides care coordination. Complex cases are referred to care management organizations, who provide care management to youth with both moderate and high needs through a comprehensive Medicaid waiver.

Sen. Dan Feltes, speaking Thursday, said New Jersey’s method has also resulted in no children placed in institutional settings, few if any out of home placements, and no out of state placements.

The picture in New Hampshire is quite different: about 28 children were held at the Sununu Youth Services Center in September. About two-thirds of those children have behavioral health disorders, according to the DHHS report on the adequacy of New Hampshire’s child welfare system released last summer. Many ended up at the center after several failed placements at residential treatment centers.

About 51 children were in out of state placements in September, according to DHHS data. Half of them were placed due to neglect cases; 28 were placed elsewhere due to delinquency issues, like being frequent truants from school or runaways, or because they qualified for the Child in Need of Services (CHINS) program.

Changes in state law have helped to reduce the population at the Sununu Center. Joseph Ribsam, director of the Division for Youth and Family Services, said last week before the Senate’s Health and Human Services Committee that a more robust child’s behavioral health service model could reduce it further by giving children earlier access to care.

“We lack the ability in child protection and juvenile justice to adequately serve kids with behavioral health needs,” he said then. “Ultimately these young folks are best served well before they come before DCYF and CHINS. DCYF is designed to address child abuse and neglect; it’s to address delinquency concerns. It’s not really designed to address behavioral health.

“Those needs come up sooner, and those needs can be addressed better by clinicians and by folks who understand behavioral health needs a family-driven way,” he continued.

The bill heads next to the House’s finance committee.

Click here to read the article in the Concord Monitor.