As COVID-19 vaccination rates improve and new infections wane, it is important to remember that the social, emotional, and economic impacts on children and families will not suddenly vanish. Many households are behind on rent payments, even with new legislation through the American Rescue Plan; unemployment remains high; and improved coronavirus statistics do not instantly make families comfortable sending infants to childcare or returning to pre-pandemic practices. After over a year of unprecedented stress, parental resilience continues to be tested. This state of strain may interfere with responsive and nurturing caregiving, which can affect infant and young children’s mental health during a time of critical development.
Medicaid, which is often the first social sector to connect with at-risk infants and young children in low-income families, can play a role in addressing the mental health of parents, caregivers, children, and infants who are experiencing stressful situations, including this prolonged pandemic environment. Aligning Early Childhood and Medicaid (AECM), a national initiative led by the Center for Health Care Strategies in partnership with ZERO TO THREE, the National Association of Medicaid Directors, Social Determinants of Health Consulting, and the Public Leadership Group with support from the Robert Wood Johnson Foundation, is working with select states to enhance alignment across Medicaid and state agencies responsible for early childhood programs. This blog post draws from examples of participating AECM states and additional states to explore strategies for leveraging cross-agency collaborations and strengthening Medicaid to support early childhood and parental mental health during this pandemic crisis and beyond.
Expanding Access to Medicaid Services to Improve Parental Mental Health
Sometimes the best way to support an infant or young child is by addressing the parent’s mental health needs —particularly in the current environment when needs are heightened. Activities to address parental needs may include mental health screenings during well-child visits, 24/7 parent support warm-lines, home visiting (including virtual), Medicaid-funded parent support groups, parents’ own treatment providers, and parent education. The examples below describe state actions to enhance parental mental health, including improving screenings for maternal depression, expanding Medicaid coverage for postpartum women, and changing billing structures to accommodate family interventions. While some of these examples were initiated pre-COVID, they offer valuable strategies for other states looking to address the amplified need that has arisen during the pandemic.
Screen for Maternal Depression
In 2016, the Centers for Medicare & Medicaid Services (CMS) provided guidance to allow states to screen for maternal depression during a well-child visit or as part of a home visitation program, for example, as Virginia has done through their Maternal, Infant, and Early Childhood Home Visiting Program. Rhode Island identified improving mental health, including maternal depression, through the Maternal Child Health Title V block grant program. The Rhode Island Maternal Psychiatry Resource Network Program (RI MomsPRN) was established through a partnership among Rhode Island Department of Health, Center for Women’s Behavioral Health (CWBH) at Women and Infants Hospital and the Care Transformation Collaborative of RI. Due to the success of the RI MomsPRN, a free psychiatry teleconsultation line has been set up by CWBH where providers treating consumers with perinatal issues can receive: (1) clinical consultation services for diagnosis, treatment planning, and medication safety from a perinatal psychiatrist; and (2) resource and referral support to community-based treatment services from a clinical social worker. In addition, the Rhode Island Department of Health helps select health care practices establish universal screening, treatment, and referral protocols for perinatal depression, anxiety, and substance use through quality improvement coaching and joint collaborative learning that is coordinated by the Care Transformation Collaborative of Rhode Island. The department also offers select home visiting agencies an intensive maternal depression training that is coordinated with the Home Visiting Collaborative Improvement & Innovation Network. The Rhode Island MomsPRN teleconsultation line also offers resource and referral support to family visiting staff engaging perinatal clients.
Extend Medicaid Coverage to Women Beyond 60 Days Postpartum
Extending the duration of Medicaid coverage for postpartum women is one way to address maternal mental health and mortality. The American Rescue Plan provides states the option to provide 12 months of postpartum coverage for women on Medicaid and CHIP with the provisions sunsetting in five years. Pre-pandemic, states have had varying degrees of success in expanding postpartum care through Medicaid. California and Virginia successfully passed legislation while New Jersey is one of several states that has submitted a 1115 waiver for a demonstration to CMS. The Equitable Maternal Health Coalition issued a toolkit making a case for extending postpartum care coverage in both Medicaid expansion states and non-expansion states. This type of expanded coverage would be beneficial to keep beyond the five-year sunset clause and make it permanent.
Billing for Family Interventions
Interventions with young children need the active participation of parents, as their social-emotional development and achievement of developmental milestones occur within the context of the parent-child relationship. Access to effective dyadic treatment, when the child and parent are treated at the same time, requires a billing structure that accommodates family interventions — often including sessions with a caregiver alone and with the caregiver and child together. States have treatment policy guidelines that allow for the caregiver to receive treatment without the child if the treatment plan and service delivered is in direct relation to the child’s identified needs.
Leveraging Performance Metrics and Referral Systems to Improve Early Childhood Mental Health
While some aspects of infant and child mental health can be addressed through the adoption of new pediatric practices or parental support described above, the addition of new incentive metrics and referral systems can also improve access to child mental health. States can implement actions, such as the examples listed below, to incentivize partnerships with Medicaid health plans, providers, and community-based organizations.
Incentivize Metrics in Payer Contracts
Performance metrics tied to incentives can be used to improve infant and young children’s social emotional health. In 2012, Oregon launched a new health care delivery model through regional coordinated care organizations (CCOs) that incentivizes health measures for kindergarten readiness. One important element of CCOs is their accountability for performance and outcomes. CCOs receive annual financial rewards when they achieve specified performance metrics. The program has been a great success – since the implementation of these incentives, the developmental screening rate for children three and under has improved from 21 percent in 2012 to 69 percent in 2017. Oregon has launched a Health Aspects of Kindergarten Readiness Technical Workgroup to develop physical, oral, developmental, and social-emotional measures. This social-emotional measure has the potential to result in improved early childhood mental health practices and outcomes.
Educate Practitioners on Local and State Early Childhood Community Service Systems
Provider understanding of early childhood services can increase efficiency of referrals and create partnerships for supporting the holistic development of the child. These services include evidence-based home visiting programs, Part C early intervention services, parent support groups, state infant mental health associations, and information/referral lines, such as Help Me Grow that is implemented by 38 states. Other state strategies to improve family access to services and strengthen the early childhood system include Family Resource Centers, as established by Colorado or the Rhode Island’s KIDSNET, a universal database that begins capturing data at birth and links to the child’s development in the school system.
Cross-walk Services with Billable Medicaid Codes
Colorado is creating a manual that aligns specific early childhood services with allowable Medicaid billable codes. The manual will include learning modules to make the Medicaid billing process easier and more efficient for providers. Services included in the guidance manual include Nurse Family Partnership, Healthy Steps, Early Intervention, child abuse and neglect, and early childhood mental health consultation.
The mental health needs of infants, young children, and their families should continue to be a priority for states in efforts to address the impact of the pandemic and beyond. States have a variety of opportunities to be innovative in their delivery of services and responsive to identified needs more quickly. Many states are finding ways to improve the infant and early childhood mental health system to assure the best foundation for a child’s growth and development.