Where do you obtain treatment for a mental health or substance use disorder? It’s not an easy question. In my former job as a social worker, it was not uncommon to find myself in a frustrating tangle of phone calls trying to locate behavioral health services for my clients. Is the provider taking new patients? Accepting Medicaid? Located near public transportation? Keeping a waitlist? Spanish-speaking? Able to support those with co-occurring disorders? What about childcare? If someone is brave enough to seek treatment for these too-often highly stigmatized conditions, it should be easier to receive it.
Tens of millions of people in the United States have a mental health or substance use disorder, including many who have both. Yet, rates of treatment engagement are dismal — as reinforced daily in news headlines describing unrelenting overdose deaths, rising youth suicide rates, and disturbing disparities in behavioral health access and outcomes for racial, ethnic, and other historically marginalized groups.
In the midst of this, both public and private entities that are least equipped to manage the crises that inevitably arise from unaddressed behavioral health needs are expected to swoop in with answers. Law enforcement agencies across the nation handle a substantial volume of calls related to behavioral health (which has led to deadly consequences) and emergency departments are overwhelmed with mental health and substance use-related visits.
Lee Robinson, MD, Medical Director for Behavioral Health and Senior Director of Behavioral Health Policy for MassHealth Office of Behavioral Health, and other Massachusetts government officials heard this on their listening tours to inform the state’s plans for behavioral health reform. “Everyone kept on saying the emergency room was the only reliable front door for behavioral health care in our state,” he said.
State government officials like Dr. Robinson are increasingly prioritizing the need to respond to the behavioral health crisis in transformative ways. In recent interviews that we conducted with state leaders, the Center for Health Care Strategies (CHCS) heard loud and clear that states were looking for answers to address key behavioral health access challenges. Delivering behavioral health care that is person-centered and equitable will look different in every state depending on each state’s unique landscape. But we also heard common themes across our interviews of strategies to effectively support behavioral health transformation:
Involve all Players in the Behavioral Health Ecosystem
There is a web of systems serving people with behavioral health needs…and states can convene these agencies to tackle the issues collaboratively.
Behavioral health is not just one system that needs fixing. In our interviews, we consistently heard from leaders who conveyed an “all hands on deck” approach to tackling the complexity of the behavioral health crisis. There is a web of systems serving people with behavioral health needs — health care, corrections, child welfare, education, and homelessness services, among others — and states can convene these agencies to tackle the issues collaboratively. And since Medicaid is the biggest payer for behavioral health services, Medicaid should be involved in any transformative effort in order to maximize available funding and help carry out innovations. States also allocate other major sources for behavioral health funding, including federal mental health and substance use block grants and the recent opioid settlement funding.
Engage and Listen to Those Directly Affected by the Challenges
Before designing Massachusetts’ Roadmap for Behavioral Health Reform, Massachusetts policymakers held statewide listening sessions to learn from people with lived experience and their family members, providers, and other behavioral health stakeholders (e.g., emergency medical services personnel, hospital groups, other state agencies). They heard about the difficulties of health insurance hurdles, navigating provider networks, and the lack of appropriate crisis services.
These considerations were incorporated into Massachusetts’ Roadmap, including the establishment of 26 community behavioral health centers that offer 24/7 behavioral health crisis intervention (including mobile crisis teams) — regardless of insurance status — and routine outpatient care. One of the greatest facilitators for establishing these centers, according to Dr. Robinson, was the momentum that came from knowing this service was done with the community, including providers who were “hungry” for a payment model that would enable them to offer team-based care and recovery supports.
Massachusetts commitment to listening to feedback continued to pay off after the rollout of the centers, as the introduction of these new centers required a major culture shift regarding how to respond to mental health crises.
The state’s commitment to listening to feedback continued to pay off after the rollout of the centers, as the introduction of these new centers required a major culture shift regarding how to respond to mental health crises. Despite enthusiasm from the provider community, the Roadmap designers heard that the addition of these new 24/7 community behavioral health centers also challenged providers who — similar to law enforcement, schools, and other stakeholder groups — experienced “medical-legal fear” of not sending patients to the emergency department for medical clearance, like they had always done. Additionally, emergency departments were concerned about discharging people with unmanaged behavioral health needs to less intensive community supports.
The state stepped in to help facilitate relationships between the new centers and other stakeholders, including the emergency departments, police, and schools, to openly talk about concerns, build trust, and change the culture. Before the Roadmap, Massachusetts faced an overloaded waitlist for inpatient behavioral health beds. Today, the wait time for those beds is significantly shorter. Emergency department boarding has decreased by over 30 percent from 2022 (almost 60 percent for MassHealth members) — early indicators of major success for this effort.
Address Legal and Regulatory Barriers to Advance Integrated Care Models
State oversight for behavioral health services is often fragmented. Many states scatter the administration of behavioral health programs across multiple agencies with different rules and regulations.
State oversight for behavioral health services is often fragmented. Many states scatter the administration of behavioral health programs across multiple agencies (e.g., mental health, substance use, Medicaid, public health) with different rules and regulations. This structure creates challenges for developing a continuum of care that actually meets the needs of people in their states: from delivering integrated mental health and substance use services, which is critical for effectively serving people with co-occurring disorders; or integrating behavioral health with physical health care services, which is vital for increasing access to behavioral health care and can address access inequities.
Colorado was one of these states with a siloed regulatory framework. Cristen Bates, Deputy Medicaid Director, Colorado Department of Health Care Policy and Financing, served on the task force that pushed for a more centralized approach to licensing behavioral health facilities in the state. She described some of the inconsistencies that arose in the old system, where conflicting licensing requirements limited how and if providers could serve people with complex needs. For example, providers of detoxification services had a license that required keeping a “locked-door facility.” Yet providers serving people who may become actively dangerous to themselves involved a different license that requires providers keep a “delayed-release door.” Additionally, a provider of mental health services could not co-locate substance use disorder services unless the provider installed a construction barrier between the different services.
Last year, Colorado took the bold approach of establishing a new state agency, the Behavioral Health Administration, that will centralize behavioral health programs under one agency and offer a single behavioral health entity license. This license will replace the multiple mental health and substance use facility licenses from the past. The new agency and licensure framework is designed to ease the barriers previously experienced by both providers and the clients they serve and, in doing so, provide greater opportunities for integrated mental health and substance use disorder care.
Looking Forward
Over the next year, CHCS is looking forward to sharing more lessons from states that are transforming their behavioral health systems. Specifically, we will release “guiding principles” to inform and accelerate person-centered, equity-focused, behavioral health delivery system enhancements across states, especially for people served by Medicaid. Additionally, we will share a series of tools on how states can better engage people with lived experience of behavioral health needs into policy development. These tools will be produced in partnership with people with relevant lived experience. Look for more in the future.
