Land Acknowledgement

Our chapter territory spans from the northern border of California to the southern border of Monterey, Kings, Tulare and Inyo counties. This land was once the home for Native Americans from over 40 different tribes. Native Americans from these territories still live in California and have strong, vibrant communities and cultures. We’d like to acknowledge those tribes and respect the history of the land that we now inhabit.

https://native-land.ca/

Meet Our Speakers!

Diane Dooley MD, FAAP

Dr. Dooley is a general pediatrician and associate clinical professor at UCSF who served low-income children and families in Contra Costa Health Services until her retirement in 2019. She continues to support our Chapter as Chair of the Mental Health Committee and active advocate for improved children’s mental health in California. She is presently a member of the California Children and Youth Behavioral Health Initiative’s virtual platform Think Tank.

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Marielle Ramsay, LCSW

Marielle is a Spanish & English-speaking licensed clinical social worker who has extensive experience in providing therapy and other services for both Medi-Cal and commercially insured families with youth ages 0-18. She is an early-childhood mental health specialist who works with the UCSF Benioff Children’s Hospital Child & Adolescent Psychiatry Program to provide Bridge Care Coordination for families needing extra assistance in navigating recommended resources & referrals.

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Caren Schmidt, PsyD (she/her/hers)

Dr. Schmidt is a Clinical Child Psychologist and the Associate Director of Behavioral Health at Marin Community Clinics. Her work involves overseeing Marin Community Clinics’ Integrated Behavioral Health program which provides primary care providers and patients integrated support by offering a variety of therapeutic interventions, including group and individual therapy. Marin Community Clinics has provided compassionate and affordable health care to uninsured and low-income residents of Marin County since 1972

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New Medi-Cal Resources:�Adolescent Mental Health Concerns ��AAP California Chapter 1 Chat��October 19, 2022

Diane Dooley MD, FAAP

Chair, AAP Chapter 1 Mental Health Committee

Associate Clinical Professor

UCSF School of Medicine

• In October 2021, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association declared a national emergency in child and adolescent mental health.

National State of Emergency in Children’s Mental Health

National State of Emergency in Children’s Mental Health

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• Even before the COVID-19 pandemic, rates of mental health symptoms for children and adolescents were noted to be increasing
• Suicides rates increased significantly for 10–24-year-olds in California before and during the COVID pandemic^1,2
• Suicide is now the second leading cause of death among US adolescents 12-18 years old

Why are we concerned?

Rising rates of mental health disorders

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• Only 18 % of Medi-Cal teens had screening for depression and a follow-up plan in 2020.
• Half of United States children with a treatable mental health disorder do not receive treatment from a mental health professional.¹
• Only 4% of California youth received specialty mental health services in 2020².

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Why are we concerned?

Lack of Preventive, Support and Treatment Services

data.HRSA.gov.July 22

California Mental Health Shortage 2022

Cal-AIM

Federal Medicaid waiver impacting behavioral health for children and youth:

• Behavioral system redesign
• Revised eligibility standards for youth and child specialty mental health
• Standardized screening tools
• “No Wrong Door” entry policies
• EPSDT eligibility criteria
• Integration of Behavioral Health and Substance Use Disorder services
• Enhanced Care Management
• Increased accountability and rewards for access, quality

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Addressing the Crisis

Eligibility for Specialty Mental Health Services

• Children and youth under age 21 qualify for specialty mental health services through county mental health if either:

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• Medi-Cal Health plans provide care coordination for mental health access and services that don’t qualify for SMHS

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Addressing the Crisis

• They have a condition placing them at high risk for a mental health disorder, for example scoring in the high-risk range using the PEARLs screen, involvement in the foster care or juvenile justice system or experiencing homelessness

Or

• Have a significant impairment due to a diagnosed or suspected mental health disorder, and/or significant trauma

• Dyadic care
• To begin January 2023
• Family-centered model of care intended to address developmental and behavioral conditions and support developmentally appropriate parenting and maternal mental health
• Mental health provider sees parents/caregivers in partnership with PCP well child visit. Provides support, education, care coordination and referrals to SDOH and mental health/parenting resources
• Expanded coverage
• Eligibility for children expanded to cover all children if the family’s household income is less than 266% of poverty
• Undocumented, low-income children get full coverage without impacting parental immigration status

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Addressing the Crisis

Expanded Medi-Cal benefits and coverage

• Community Health Workers/Promotores
• Benefit funded 7/22
• “Skilled and trained health educators who work directly with individuals who may have difficulty understanding and/or interacting with providers due to cultural and/or language barriers
• “Provide key linkages with health care services and related community-based resources”
• Enrolled Medi-Cal provider develops plan of care and submits claim for CHW services

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• School and Community Health Coaches
• Wellness promotion and education
• Behavioral health screening
• Care coordination

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Addressing the Crisis

New Resources

School Behavioral Health Incentive Program

• California Department of Health and Human Services contracts with Medi-Cal Managed Care Plans to deliver services to the local Medi-Cal – enrolled population.
• There are multiple plan models. Many of the pre-existing plans were recently reorganized to assure accountability.
• They have many requirements for access and quality. They operate under a distributed risk mode, whereby financial incentives that drive their decisions may be at odds with the needed care for children and youth.

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5.6 million California children and youth aged 0-20 years are enrolled in Medi-Cal.

Overview of the Children and Youth Behavioral Health Initiative

The goal of the Children and Youth Behavioral Health Initiative is to reimagine the way behavioral health support is provided to all children and youth in California, by aligning the systems that support behavioral health for children and youth to create an ecosystem that fosters social and emotional well-being and addresses the behavioral health challenges facing children and youth

The initiative takes a whole system approach by creating cross-system partnerships to ensure that the reimagined ecosystem is child and youth-centered and equity-focused

• Source: California Health and Human Services Agency

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Addressing the Crisis

Virtual Platform

Grant Funding – Evidence-based Practices

• Provide BH support, resources, and coaching and access for:
• Prevention and Promotion
• Community and Peer (by peers, advisors in non-clinical community settings)
• School based (resources and supports by teachers and school staff)
• Integrated care settings (screenings and resources eg primary care, foster care
• Early Intervention
• Early intervention BH services
• Address early-stage psychosis
• Family and Community Engagement
• Family centered, social connectedness, and early childhood support

How Do We Access These Resources?

• Consider participating in a practice improvement grant
• Inform and advocate for expanded workforce in your workplace supporting Integrated Behavioral Health
• Consider recruiting and hiring additional team members to your practice
• Mental health therapists for Integrated Behavioral Health and/or Dyadic Care
• CHWs for follow up and support
• Possible creation of a resource hub in your area
• Family Resource Center or non-profit hires and trains CHWs and Mental Health Therapists
• Contracted with your practice to provide needed services

• Schedule follow-up visits/calls to assess the child/teen’s status and support them in pursuing interim measures
• Foy, Jane Meschan, ed. Managing Mental Health Concerns in Pediatrics.
• Send BH referrals to the responsible Medi-Cal Plan, SMH plan or health insurer stating concerns and qualification for Specialty Mental Health services or MCP services
• Suggestion: Adapt Beacon referral form
• File a complaint with the Department of Managed Health Care (public insurers) or the California Department of Insurance if the family does not get needed services in a timely manner
• 1-877-525-1295
• https://cdiapps.insurance.ca.gov/HPP/login/

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What You Can Do Now

15-year-old girl with increasing depression

Where do I refer her to therapy?

1^st Step in Referral Process

1. Obtain consent from family & youth before making mental health referral

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• Encourage family involvement

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Mental Health Referral Process

Behavioral health services by Insurance

Commercial Insurance

Public Insurance

No Insurance

Call Insurance for Mental Health Referrals

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Psychology Today

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Telehealth Companies (examples: Life Stance, Mindful Health Solutions, Mind Path, Advanced Psychiatry, TeleMed2U)

State/County provide Mental Health Services

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FQHCs

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Victims of crime

County and contracted CBOs provide Specialty Mental Health Services via County ACCESS

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Managed Care Plan provide referrals to services

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Telehealth Companies (examples:TeleMed2U, 3Prong, Mind Path)

Schools

and

Mental Health�

May require a 504 or IEP

15-year-old girl with increasing depression

Where do I refer her to therapy?

Based on Insurance (Commercial or Public) 

Or

Seek out school-based therapy if available

15-year-old girl with increasing depression & increasing severity

Where do I refer now?

Typical Continuum of Care for Behavioral Health

Specialty Care

• Early Childhood Mental Health
• Eating Disorders
• Substance Abuse
• Early Psychosis
• Transitional Age Youth
• Gender Diverse
• Exploited Youth

https://www.aacap-pac.com/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/The-Continuum-Of-Care-For-Children-And-Adolescents-042.aspx

Continuum of Care by Insurance

Mild

Severe

Intensive Outpatient (IOPs) / Partial Hospitalizations Programs (PHPs)

Commercial Insurance

Severe

More

Severe

Therapeutic Behavioral Services (TBS)

• TBS are supplemental specialty mental health services covered under the EPSDT benefit. 
• TBS is an intensive, individualized, in-home, short-term  behavior-focused service available to children and youth under the age of 21 with serious emotional challenges and their families and have full scope Medi-Cal.  
• TBS is never a primary therapeutic intervention and is always used in conjunction with a  specialty mental health service. 
• TBS is designed to support clients to be successful in their current environment or to transition to a lower level of care.

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• Referral made by specialty mental Health Provider
• Referral requirements depend on county but usually are that child is at risk for out of home placement or hospitalization

Public Insurance

Intensive Care Coordination (ICC) - ”Wrap Services”

• ICC is a service that is responsible for facilitating monthly meetings of care team, care planning and coordination of services, including urgent services.  
• ICC requires a designated mental health coordinator whose role is to work within the Child & Family Team (CFT) to ensure that plans from the system partners are integrated to comprehensively address goals and objectives.
•  ICC ensures participation by the child and family 

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Referral requirements depends on county.  ICC programs are run by County Behavioral Health and contracted CBOs

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Public Insurance

15-year-old girl with increasing depression

• Now with active suicidal thoughts and plan

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Accessing Mental Health Crisis Services 

• Parental Crisis Lines
• Contact County Mobile Crisis Team
• Contact Regional Center Mobile Crisis
• Go to ER or Crisis Stabilization Unit
• Call 9-8-8

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Emergency-Behavioral-Health-Resources-by-CA-Counties-2021.pdf

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https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf

Crisis Stabilization Unit vs Emergency Room

Crisis Stabilization Unit (CSU)

• Short-term psychiatric emergency assessment and stabilization instead of going to emergency room hospital or direct to psychiatric hospital
• Services include crisis assessment, safety planning, referral and aftercare planning for youth
• Length of service is up to 23 hours and 59 minutes
• Primary care providers, caregivers and youth can refer direct to a CSU for psychiatric crisis assessment/safety planning
• Some may or may not be able to assess if other medical conditions
• Telecare Willow Rock psychiatric hospital requires medical hospital evaluation for certain medical conditions

Bay Area Examples

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• Stars Willow Rock CSU Alameda (12 -17-year-olds)
• Edgewood CSU in San Francisco (6–17-year-olds)
• Crestwood in Fairfield

15-year-old girl with increasing depression

• Increasing high risk behavior, unable to stay safe at home & school, several psychiatric hospitalizations
• Needs higher level of care 24 hours/7 days a week

Commercial Residential Programs�(most treat mental health & substance use)

Some Bay Area examples

• Discovery Mood & Anxiety Program 11–17-year-old
• Evolve 12–17-year-olds
• Newport Academy (also treats eating disorders)
• Muir Wood Adolescent & Family Service
• Embark Behavioral Health 12-17
• Edgewood 12–17-year-old (also medi-cal)
• Pacific Teen Treatment 13–17-year-olds

Commercial Insurance

Residential Treatment

Some Northern California Examples:

• Victor Treatment – Santa Rosa
• Mountain Valley –Sacramento
• TLC - Sebastopol
• Summitview - Placerville
• Edgewood – San Francisco

Public Insurance

Regional Center �Crisis Stay & Residential Care

Some Examples

• Fred Finch
• Oakland: New Yosemite, 8-18 years old in crisis
• Short term residential, 24 hour support up to 90 days
• Avalon: Oakland, Dual Diagnosis (dev & DSM 5), 12-17.5 years old
• Residential & school setting
• Typical stay 1-2 years
• San Diego: Dual Diagnosis (Dev & DSM 5) , 12-22 years old
• Residential and school setting

Public Insurance

Regional center by County�

• Counseling, Genetic counseling
• Case management, family support, advocacy support
• Early intervention services
• Respite Care
• Crisis Support
• ABA providers (County specific, based on insurance)
• ABA Assessments (county specific)
• Emergency living placement – not available
• Short-term placement – may be available
• Long-term placement-may be available, difficult for <18-year-olds

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Disability < 18 years old

-intellectual disability

-cerebral palsy

-epilepsy

-autism

-other disabling conditions

15-year-old girl with increasing depression

Now having psychotic symptoms

Why refer: Pre-Psychosis Symptoms

• Depressed mood
• Sleep disturbance
• Inattentive to personal hygiene
• Social withdrawal, isolating behaviors
• Decline in functioning at work, at school, or in self care
• Anxiety
• Difficulty concentrating
• Mood swings
• Feeling uneasy around others
• Difficulty communicating thoughts
• Sensitivity to light or other sensory cues
• Having strong inappropriate emotions or no emotions at all
• Fatigue, decreased motivation
• Difficulty managing daily stress

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Early Psychosis Programs

• Commercial Insurance
• BACA, PATH at UCSF, Inspire at Stanford Medicine
• Public Insurance (Medi-Cal)
• Depends on county; contact ACCESS line
• Felton (Alameda, Marin, SF, San Mateo, Monterey Co)
• First Hope (Contra Costa Co)
• UC Davis
• SOAR (Napa, Solano, Sonoma Co)
• REACH (Santa Clara Co)
• PREP and Telecare (San Joaquin Co)

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Diagnoses/Age

• Typically provides services​
• Diagnostic​
• CBT – psychosis​
• Family support​
• Case management​
• Psychiatric medications​
• Educational/Job support​
• Peer support

• Often strict criteria, for example
• Age 15-24 years old
• 1–3-year program duration
• Psychosis w/in last 2 years

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15-year-old girl with increasing depression

Now having substance use and eating disorder concerns

Substance use disorder

• Family involvement in treatment improves outcomes
• Substance use in adolescence can be addressed by mental health services 
• County programs may provide services regardless of insurance type but are usually targeted to Medi-Cal and uninsured youth (examples: Alameda Co Project Eden and SF County Horizons)
• Medi-Cal insured contacted ACCESS line
• Commercial insured can be referred to Youth Outpatient Substance Use Program (YOSUP) at UCSF. Aprox 1-2 month wait for intake.

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Eating disorder Treatment

• Research shows that family therapy supports outcomes for recovery
• Medi-Cal: Call ACCESS line or managed care plan and identify specific need regarding eating disorder symptoms
• Commercial: Call insurance. Can request case management support in order to help find provider.

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Transitional Age Youth (TAY)

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• Clients in Specialty Mental Health programs can often continue with same services when they return 18 
• Counties have specific mental health programs (moderate-severe), shelters, and crisis residential placement for TAY with Medi-Cal
• Include family and natural supports in referral process and treatment for best outcomes

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Younger than 5?

Where do they go?

Early Childhood Mental Health

• Early Intervention reduces likelihood of entering system or needing later intervention
• 80% of Brain Development before Age 3: Critical period
• Support families in accessing mental health services that specialize in early childhood 
• Focus on parent attunement to child's emotional and developmental needs 
• Example: Child Parent Psychotherapy, Early Intervention Services
• Starting Place: Under 3 Developmental Evaluation via Regional Center or Help Me Grow 

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Primary Care

Eating Disorder

Substance Use Disorder

Early Prep/

Psychosis

Regional Center

Individual Therapy

Family Therapy

School Therapy

Psychiatry

Occupational Therapy

Speech Therapy

Psychiatric

Hospital

Mobile Crisis

Crisis Stabilization Units

CPS/

Foster Care

Juvenile Justice

Hospital Specialty (Endocrine, Neurology, etc)

ABA Provider

TBS/ICC

IOP/PHP

Residential Care

Group Homes

Wilderness Programs

Early Childhood

Interpreter Services

Primary Care

Eating Disorder

Substance Use Disorder

Early Prep/

Psychosis

Regional Center

Individual Therapy

Family Therapy

School Therapy

Psychiatry

Occupational Therapy

Speech Therapy

Psychiatric

Hospital

Mobile Crisis

Crisis Stabilization Units

CPS/

Foster Care

Juvenile Justice

Hospital Specialty (Endocrine, Neurology, etc)

ABA Provider

TBS/ICC

IOP/PHP

Residential Care

Group Homes

Wilderness Programs

Early Childhood

Primary Care

Eating Disorder

Substance Use Disorder

Early Prep/

Psychosis

Regional Center

Individual Therapy

Family Therapy

School Therapy

Psychiatry

Occupational Therapy

Speech Therapy

Psychiatric

Hospital

Mobile Crisis

Crisis Stabilization Units

CPS/

Foster Care

Juvenile Justice

Hospital Specialty (Endocrine, Neurology, etc)

ABA Provider

TBS/ICC

IOP/PHP

Residential Care

Group Homes

Wilderness Programs

Early Childhood

Primary Care

Eating Disorder

Substance Use Disorder

Early Prep/

Psychosis

Regional Center

Individual Therapy

Family Therapy

School Therapy

Psychiatry

Occupational Therapy

Speech Therapy

Psychiatric

Hospital

Mobile Crisis

Crisis Stabilization Units

CPS/

Foster Care

Juvenile Justice

Hospital Specialty (Endocrine, Neurology, etc)

ABA Provider

TBS/ICC

IOP/PHP

Residential Care

Group Homes

Wilderness Programs

Early Childhood

Primary Care

Eating Disorder

Substance Use Disorder

Early Prep/

Psychosis

Regional Center

Individual Therapy

Family Therapy

School Therapy

Psychiatry

Occupational Therapy

Speech Therapy

Psychiatric

Hospital

Mobile Crisis

Crisis Stabilization Units

CPS/

Foster Care

Juvenile Justice

Hospital Specialty (Endocrine, Neurology, etc)

ABA Provider

TBS/ICC

IOP/PHP

Residential Care

Group Homes

Wilderness Programs

Early Childhood

Interpreter Services

Interpreter Services

Interpreter Services

Interpreter Services

Family focused referrals

• Our system is individual focused and fragmented
• Many individual behavioral problems are family system problems
• Research shows that family involvement in treatment increases success

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Resource Navigation & Supports

Navigation

• County Access Phone #
• MCP Phone #
• Commercial Insurance Phone #
• Family/Neighborhood Resources Centers (FRCs)
• First Five: Help Me Grow
• Family Resource Navigators/Networks (Parents of children with disabilities)
• Kinship Programs
• Parent Stress Lines
• 211; County Resource Directory

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Supports

• DREDF (school advocacy)
• Advocacy Organizations
• Galt
• StandOut Advocates
• Legal Aid law agencies locally
• Peer Networks
• National Alliance of Mental Illness (NAMI) local offices
• Online support groups

https://oplm.com/support-groups/

Pearls of Wisdom

1. Research shows that family involvement in treatment increases success.
2. Empathize with feelings of caregiver 
3. Make clear goals with caregiver & youth
4. Assess caregiver needs and supports (Maslow's Hierarchy)
5. Educate families on how the system works
6. Follow up: Check in afterwards, office staff call them (standard is 3x)
7. Familiarize yourself with local resources
8. Refer to advocacy organizations
9. Make Early Intervention Referrals 
10.  Refer to Navigators 

Partner and empower the caregivers

Integrated Behavioral Health Services

Responding to behavioral health needs internally

What is IBH?

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Care resulting from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population.

Why IBH?

Benefits of IBH

• Reduce the barriers to accessing care
• Meets patients where they already are
• Reduces stigma
• Ability to offer a same day “warm handoff”
• Population health model reaches patients who would otherwise never seek treatment
• Seamless referral system
• Team-based approach involves PCPs in the care

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Services Offered at MCC

“Recovery” Coaching & MAT

• Assessment, brief intervention & referral to treatment for SUD and addictive disorders
• Medication Assisted Treatment for Opiate Use Disorder

Case Management

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- Care Navigators

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• CALAIM

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• Ryan White Case Management

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• CCS

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• *Healthy Steps

Psychotherapy

• Individual and group psychotherapy
• In-person or telehealth options
• Spanish speaking clinicians and access to translation line
• 12 BH Providers

Psychiatry

• Individual psychotropic medication evaluation and management
• Consultation to PCPs
• 3 BH Prescribers

Our Model

• Mild-Moderate Scope
• 30-45 min sessions, 8-12 sessions
• All patients regularly screened for BH, any provider or patient can refer
• PCP is at center of care team- goal is always to return to PCP
• WHO and same week slots available
• Current wait for non-urgent intakes: 2 weeks
• 3,500 patients seen last year, 700 under 18

• Unable to see severe BH concerns
• Difficulty connecting patients to higher level of care
• Difficulty balancing need for access with need to bridge tx for higher need patients
• Workforce shortage
• High No Show Rate
• Difficulty filling AM slots due to school

Pain Points for our Model

Reflections from our Pediatricians

Having integrated behavioral health services is central to providing whole family care and being able to ensure the health and wellness of our families.  I tell my new mothers at the newborn visit, you can’t have a healthy baby without healthy parents and I really think being able to support a family through whatever challenges they may be facing, whether medical, social or behavioral, is critical to fulfilling that goal.  It feels great to be able to ask about how they are doing with xyz, have them share and be vulnerable with and then say, “I have someone I’d like to introduce you to that might be able to help with that, would you like to meet them?” Instead of having to refer out or handing them a list of “resources” that may not have the capacity to see them for months.

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- Heyman Oo, MD

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Having in house BH helps me to not burn out.  I feel supported and less alone in caring for my patients.  I am much more confident that our patients will not slip through the cracks.  I have a much easier time communicating with our MCC BH providers so that we are all working together.  

- Lisa Leavitt, MD

Thank you!

Caren Schmidt, PsyD

Associate Director of Behavioral Health

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Special Acknowledgement to Elizabeth Horevitz, PhD for the development of our program and the data on this presentation

Resources

• Systems of Care Resource List for California - PDF �
• Emergency Behavioral Health & Crisis Services in California Listed by County - PDF

Upcoming Events & Social Media

https://aapca1.org/events/

: @AAPCA1

: California Chapter 1, American Academy of Pediatrics

: @AAPCA1

: American Academy of Pediatrics, California Chapter 1

NOVEMBER 9 - Mental Health Chapter Chat: Suicide Prevention (virtual) - Save the Date!�

DECEMBER 10 - 7th Annual Puzzles CME Conference (in-person in San Francisco) - View Here