4 targets of opportunity for addressing the behavioral health crisis

Introduction

Research and practice over the past several decades have provided evidence about the effectiveness of some interventions that treat mental illnesses and substance use disorders (SUDs). That research has identified elements of treatment, including psychotherapies like cognitive behavioral therapy (CBT) and various pharmacotherapies; interventions that combine treatment elements, like relapse prevention for major depression; team-based programs that offer a suite of interventions, such as assertive community treatment (ACT) for severe and persistent mental illnesses; and models that focus on the integration of treatment for depression and anxiety disorders into primary care practices, like the Collaborative Care Model.

Nevertheless, the take up of evidence-based practices has been weak and has stalled in recent years, despite national recognition of the need to address high rates of mental health and substance use disorders. There is a mismatch between the strategies that research suggests are likely to benefit people and the availability of those strategies to people who may benefit from them. The roots of this mismatch may lie in challenges in understanding how to spread effective programs in complex organizational and funding environments, and how to scale the programs, organizational arrangements, and interventions that work. Moreover, though the “technology” for improving mental health and SUD care is understood, there are economic, organizational, and cultural forces that create enormous frictions for efforts aimed at putting knowledge about mental illnesses and SUDs and their treatments to work.  A shaky foundation of behavioral health service access, in which many communities in the U.S. find themselves lacking sufficient behavioral health services, underpins these larger forces.  This is particularly problematic for low-income communities and rural communities, where access issues are large.  And the research itself frequently does not address the impact of the interventions on important populations, including and especially people of color.

In this paper, we focus on four behavioral health policy issue areas that are marked by evidence-based understanding about what works, a need to rely on integration and coordination of effort across multiple sectors of public services, illnesses and circumstances that are highly stigmatized, and a history of institutional designs that create barriers to sustainable programs. These policy issue areas are:

• Deploying interventions early in the course of severe conditions, such as psychosis, expected to be persistent and disabling without intervention;
• Advancing healthy brain development and behavior in early childhood;
• Providing effective and timely response to behavioral health crises; and
• Supporting the reentry into communities of formerly incarcerated people with mental health and substance use conditions.

For each of these issue areas, we conducted an environmental scan of the evidence of the issue area’s impact and conducted facilitated interactions with practitioners, experts, and stakeholders.  Across these diverse areas, common challenges and clear strategies to spread and scale evidence-based behavioral health interventions emerged. Tackling these challenges and advancing these strategies create opportunities for philanthropy, governments at all levels, and communities to engage and advance efforts to strengthen evidence-based behavioral health service provision in the U.S. in these four areas.

What challenges do these behavioral health policy issue areas have in common?

At first blush, these policy issue areas seem disparate, and in many important ways, they are. One may reasonably question whether there are any common themes that link these populations and treatment delivery dynamics. However, upon careful inspection, all four issues share crucial commonalities:

• Each issue area involves marginalized populations. We define “marginalized communities” as those excluded from dominant social, economic, educational, and/or cultural life.”¹ However, it should be noted that each area has different connections between poverty, race, ethnicity, and illness.
• Each issue area involves interventions, treatments, and supports where timing of delivery is critical. Well-timed intervention and care delivery has the potential to significantly alter the trajectory of the affected individual’s life.
• Each issue area contends with multi-sector fragmentation. Because the treatments, supports, and expertise needed to address each issue area crosses multiple silos of the health, human services, and public safety sectors, they all share a need to rely on data systems to track the population in need for the purposes of coordination and effective service delivery. Many of the key activities of these programs must take place outside of traditional health and human services settings. Spreading and scaling will require overcoming silos in which some programs and financing that target a common problem are designed and administered independently from one another. These silos can lead to fragmentation, increased risk and uncertainty of financing, mismatches between infrastructure needs, and unsustainable support of recurrent expenditures and financing program designs.
• Each issue area contends with the “wrong pockets” problem. Within this multi-sector landscape, each issue area can be subject to incentives for public agencies to underinvest in treatment elements when an entity’s costs are disproportionate to the benefits they receive. This is sometimes described as the “wrong pockets” problem and it impedes coordination across sectors and across levels of government. Spreading or scaling successfully will involve organizing a combination of financial support from state, local, and federal sources.

Strategies that can address common implementation problems in the four areas of focus, making them targets of opportunity

In what follows, we consider a set of strategies that can address the common challenges we have identified across the four issues. We focus on actions by philanthropies that can be taken to encourage and advance the ability of communities and government to adopt these strategies. Together, these strategies form a roadmap toward realizing the potential contributions that can be made by harnessing what we know about the evidence in each of these issue areas.

Supporting time-sensitive interventions and care coordination

Each of the four areas of focus involve interventions and supports being put into place at very specific times. Some of the timing involves key events that can be anticipated in advance, such as release from prison or the birth of a child. Others are more unpredictable, like a crisis episode or a first episode of psychosis. All require having available capacity to respond to the events, and they commonly require that treatment and support be provided outside of traditional clinical settings and the establishment of mechanisms for connecting patients to follow-on services.

To support these time-sensitive interventions, several practices are useful. For example, investments in technology that enable provision of a continuum of care can be especially important for these time-sensitive interventions. Information technology can facilitate planning, responding, and tracking service provision. Additionally, investments in staffing and human capital can also aid in providing time-sensitive care. Staff positions that ensure that people are connected to the array of services that will meet their needs as they travel across organizational and sectoral boundaries can be a significant asset. The creation of services such as case management that straddles corrections, Medicaid,  health, mental health, and SUD services and longstanding evidence-based practices such as assertive community treatment has been associated with improved outcomes. Likewise, targeted case management where specialists and care coordinators ensure that families with young children are connected to the array of services that promote healthy child development have been shown to be key to successful interventions that link pediatric practices to other health and human services.  Finally, crisis programs rely on follow-on mental health, health, and SUD services for long-run benefits to be realized. Rarely do existing payment systems and grants fully support the services and supports that ensure the proper responses at the proper time with necessary follow-on support. Philanthropic support and the work of community-based organizations can be essential to ensuring that the programs realize their potential.

Contending with complex needs served by multiple sectors

The “wrong pockets” problem

As noted earlier, each of the four issue areas must arrange for treatments, supports, and funding from multiple sectors and agencies. These organizational structures, though they are needed for effective program administration, can challenge service coordination. The reasons for this involve both technical and incentive issues. The technical issues include the availability of data to track and manage the care of program participants across the various bureaucracies and agencies that provide treatment and supports. These separate and frequently complex organizational and governance structures can at times create incentives for each sector to underinvest and undersupply services and coordination efforts. This stems from the “wrong pockets” problem, which refers to a phenomenon in which costs are incurred by one segment of the health and human services system and the savings or benefits are realized by an unrelated agency. For example, if a mental health agency like a community behavioral health center invests limited budget resources in a crisis response system but most of the savings are realized by the local police department, hospital emergency departments, and fire departments, that reduces the incentive to invest and limits the funds that could potentially be available to bring the program to the most effective scale.

Each of the four issue areas is affected by this phenomenon in different ways. The “wrong pockets” problem affects the incentives facing early intervention programs for severe mental disorders, particularly psychosis, expected to be persistent and disabling without treatment, known as Coordinated Specialty Care (CSC). CSC programs combine evidence-based clinical care, engagement of individuals in activities like schooling and work, and education of family in management of supports. CSC has been shown to increase engagement in schooling and work, delay the need for enrollment in disability programs, and reduce hospitalizations. Thus, much of the costs and coordination efforts commonly rest with behavioral health programs, but the benefits of the investments and coordination fall mostly on income support programs, hospital systems, and health insurers. Likewise, reentry programs involve establishing services before and after an individual’s release from prison or jail. This requires investments by the correctional system, health care providers and payers, and human service agencies. Yet any benefits or savings will likely come in the form of reduced re-arrest and re-incarceration, reduced emergency department visits, and reduced mortality. Because these benefits are spread across the various actors that must pay for and provide services, the cost to any one of them is not outweighed by the benefit to them.  As a result, opportunities to experience significant, collective benefits are lost. Crisis programs are focused on expanding efforts of the health, mental health, and SUD systems’ roles in deescalating behavioral health crises and directing affected individuals into treatment. Ideally, a well-functioning crisis continuum involves coordination across sectors, new costs being incurred by behavioral health programs, and reduced demand on the public safety sector.

Finally, infant and early childhood mental health (IECMH) promotion involves a continuum of services that support young families and caregivers, including promoting caregiver skills. This promotes a child’s healthy brain development and the wellbeing of the entire family.  Some IECMH interventions are aimed specifically at reducing the potential for toxic stress, mental health conditions, and substance use, although even interventions that do not target those conditions may benefit families that experience them. These interventions require efforts that cut across programs related to health care, education, and human services with costs being incurred by each. The benefits of IECMH interventions are diverse, and include improved child and caregiver mental health, an increased likelihood of school readiness, and a reduced probability of justice involvement, with specific outcomes varying with type of intervention.  These diffuse but tangible benefits exceed the investments needed by each of the varying entities and programs that provide IECMH services.

Coordinating funding sources

It is inevitable that policies that emanate from multiple federal agencies with differing legislative authorities, which also involve state and local governments and a mix of organizations that deliver services and supports, will create “wrong pockets” problems. The solution that is frequently proposed is for local government to engage in coordinating diverse funding streams. Promoting local government and provider agencies’ ability to braid funding streams can be advanced by pursuit of the following:

• Providing technical assistance to provider agencies and local governments on how to navigate the complex technical and regulatory requirements associated with braiding of funds that must adhere to the rules associated with each funding stream. Coordinating funding simplifies this by eliminating each stream’s identity and requires redesign of bureaucracies that may involve statutory actions, such as the creation of local management boards in Maryland, which are county-level bodies that act as financial intermediaries in funding coordination, or the fifty Alcohol, Drug Addition, and Mental Health Boards (ADAMH) in Ohio that are statutorily empowered to fund and manage community-based mental health and addiction services.
• Investing in data systems and data use agreements that permit integration of data across programs, populations, and organizations.
• Adjusting federal programs to create sufficient flexibilities to facilitate the ability of local governments to braid funds. To date, many of the most successful attempts to coordinate and braid using integrated data systems have occurred in large, relatively wealthy counties and by state governments (e.g., in Allegheny County, PA and the state of Indiana). Doing so more broadly across the nation can usefully engage philanthropy to aid in establishing technical assistance efforts and developing the design of the relevant data systems.

Scaling programs

The development of well-functioning CSC programs, crisis continuums, reentry supports, and early childhood mental health service networks all serve target populations with time specific needs and require various forms of infrastructure to be effective. In addition, each requires sustainable funding sources that frequently involve services that do not fit comfortably in health insurance arrangements.   In each area, there are important short-term opportunities that can help build toward larger scaling over time.

Scaling early intervention for serious mental illness, particularly psychosis

In the case of CSC programs, multi-disciplinary teams that are trained in the organization and the delivery of the components of CSC is key. Central to the effectiveness of CSC is having effective services applied to people that are in the earliest stages of psychosis. This requires identification and engagement with people experiencing the first stages of serious mental illnesses, sometimes before they are ready to acknowledge their condition.

Currently, CSC services are funded by a mix of federal grant funds designated to CSC and Medicaid payments. The level of funding is insufficient to pay for services at a scale that could address even a significant plurality of the population that could benefit from CSC. Medicaid can and does pay for specific treatment components like pharmacotherapies for people that are eligible. Yet early engagement means finding people before they are disabled by an illness, a timeframe where Medicaid is often not the relevant payer and where private insurance covers only a limited subset of the relevant treatment elements.² The results to date suggest that only slightly more than 2% of those likely to benefit from CSC are served by such programs. Moreover, initial evidence suggested that a population based of 500,000 to 550,000 is needed to sustain a CSC program. Recent evidence  suggests that technology such as telehealth can be used to allow for the creation of CSC teams in lower population density areas. Implementation of 988 is a short-term opportunity to build the capacity for call centers to identify people who may benefit from CSC services and connect them to such services.

Scaling crisis programs

Behavioral health crisis programs prioritize three key elements: An emergency hotline (like the new 988 system), mobile crisis response teams to intervene at the moment of crisis, and so-called receiving units where patients can be stabilized. All three elements typically require new infrastructure. The 988 system is currently reliant on a mix of ad hoc federal grant funding and state financing. Mobile crisis teams require vehicles, communication technology, and trained staff to populate the teams. Operating expenses can be supported by Medicaid funds for eligible people. Few insurers pay for those services even though people with private insurance are served by these teams. Receiving units, which are beneficial in some circumstances, typically offer initial stabilization care and beds that provide a safe and controlled environment. Some states and communities have made targeted investments in receiving facilities often through special bond issues, private contributions at the local level, and special budget allocation at the state level. The current level of attention to crisis services, as well as federal grant funding and policy that is being developed at the federal level to create a crisis service continuum, can be building blocks toward addressing these larger issues of scale.

Scaling reentry services from the criminal justice system

Connecting people with mental health and SUDs to effective services at reentry from incarceration can improve health and behavioral health outcomes and support a successful return to their families and communities. Certain mental health and SUD service models are longstanding but have not yet scaled while other models are emerging and promising.

Barriers to the scaling of effective mental health services at reentry are three-fold.  As noted, coordination and seamless service provision across the criminal justice, health, behavioral health, and social service systems is rare, though essential to effective service provision. While some jurisdictions have made progress in advancing data and systems coordination across the health and criminal justice sectors, the systems remain highly siloed, and more investment is needed. Second, the correctional and criminal justice system is federated and localized. The federal government can offer grants and agenda-setting to support reentry services but has little authority over state and local criminal justice entities. In addition, funding levels for services provided for people when and after they are incarcerated are highly variable across states and localities. The dual stigma of having been incarcerated and having a mental health or substance use condition can reduce access to treatment and engagement with services, as well as disincentivize public investment in making successful reentry a policy priority. New federal and state policies that require or encourage states to use Medicaid to connect people to services at reentry offer an important leverage point to begin scaling reentry services.

Scaling infant and early childhood mental health services

Finally, early childhood services, other than direct medical care of the children, are grant funded through programs like the Nurse-Family Partnership and Early Head Start. Medical services for children in low-income families are covered by Medicaid, but services for parents and caregivers experiencing depression are not necessarily supported. So, the funding challenge is the degree to which scalable-sustainable funding for the continuum of services can be put into place. As noted earlier, the “wrong pockets” problem contributes to this. Additionally, in some cases, programs incompletely support the full continuum of services that produce the positive outcomes, such as the treatment of maternal depression.

Managing funding streams

As a complement to the braiding of funds, state agencies and local governments might deploy funds and organize payment systems so that they make the best use of dollars. For example, governments may choose to use grant funds, which are more likely to be short-lived, to pay for investments in infrastructure and choose Medicaid and private insurance funds to pay for the recurrent costs of delivering eligible services. This will, in some cases, require regulatory changes or reinterpretation of existing regulations that govern the responsibilities of private health insurers (e.g., the Mental Health Parity and Addiction Equity Act). For example, a state agency or local government may choose to use local government funds and philanthropic dollars to establish receiving units in the crisis continuum and then choose to use insurance, Medicaid, and Medicare payments to fund the recurrent costs of serving people in the unit.

In smaller communities and in medically underserved areas, philanthropy can help support technology and staff training that would allow CSC to gain a foothold in such communities. Likewise, philanthropy, local and state funding, and grant funding can also fund the infrastructure investments needed to mount mobile crisis teams, or some of the investments in data-sharing and service and workforce development that will be needed to strengthen mental health and addiction services at reentry.  Community wide efforts, such as issuance of bonds, can be used to establish receiving facilities along the lines of what was accomplished in Pima County, Arizona. This would involve marshalling a wide range of community stakeholders. Grant funds and philanthropy could expand the capabilities of nurse-home visiting programs while including those services as a Medicaid benefit could pay for ongoing costs.

To summarize, each of the four issue areas involve and contend with common challenges, including structural biases against marginalized populations; time-critical intervention and care delivery; multi-sector fragmentation across siloed agencies and levels of government; and the “wrong pockets problem.”

Through our review of the literature, conversations with practitioners and stakeholders, and applied expertise, we have identified a set of strategies that can be promoted to spread and scale evidence-based policies and practices. These include strategies that support time-sensitive intervention and care coordination, contend with complex needs served by multiple sectors, and manage diverse funding streams.

Limitations in evidence and prioritizing equity in efforts to spread and scale

Based on our research reviews, the evidence for action in the four issue areas we explored is strong.   However, there are also critical gaps in that evidence. Most importantly, the evidence we reviewed rarely studied or identified the impact of specific programs or interventions on people of color, people in indigenous groups, people with language access challenges, LGBTQ people, and other important and frequently marginalized groups.³ This is an important limitation and caution in efforts to spread and scale the strategies discussed here, especially given that higher rates of some mental health and SUDs that have been attributed to these groups. Yet consistently, the experts, practitioners, and stakeholders we engaged advocated for prioritizing the needs of these groups in efforts to expand access, who noted that absent such prioritization any expansion in service provision would likely favor other groups of people. Squaring the importance of prioritizing marginalized groups with the lower level of evidence of effectiveness of impact on these groups will require additional exploration and attention, in which philanthropy could play an important role.

Conclusion

Though behavioral health challenges in the U.S. stubbornly persist, targets of opportunity exist to make progress in effectively meeting the needs of people with mental illness and SUDs by engaging in actions that promote the spreading and scaling of evidence-based programs and practices. The strategies identified in this paper highlight various ways for the philanthropic and public sectors to make an impact for people with serious mental illnesses, people reentering society after incarceration, people in mental health crisis, and families with very young children where there is high exposure to toxic stress. Efforts that ensure that these populations receive time-sensitive care, treatment, and supports are a worthy investment. Moreover, the philanthropic sector can promote resource coordination and cooperation between siloed agencies, sectors, and financing mechanisms through investments in technology, data infrastructure, and human capital.