University of Bath Institute for Policy Research International Partners Symposium:

1. Behavioral Health Disparities among Diverse U.S. Youth: Can Integrated Health Services Reduce Risk and Improve Life Chances?Tamara S. Davis, Ph.D., MSSWThe Ohio State University, College of Social Workdavis.2304@osu.edu University of Bath Institute for Policy Research International Partners Symposium: Lost youth in the 21st Century 17-18 September 2014

2. National U.S. Overview • 50% of Americans (including youth) experience a diagnosable mental health disorder over lifetime • Initial onset in childhood or adolescence • 1 in 4-5 children experiences serious behavioral health disorder • Suicideis 3rd leading cause of death in youth ages 10-14; 2nd leading cause of death in youth 15-24 • Only 1/3 receive specialized mental health services (Sources: AACAP, 2009; CDC, 2011; Kessler et al., 2005; Merikangas et al., 2010, 2011)

3. National U.S. Overview (cont’d) Greater disparities in care for people of color • Less access to care and fewer services available • Less likely to receive needed mental health services • More likely to receive poorer quality of care • More often misdiagnosed • Underrepresented in mental health research (e.g., intervention studies) • Less likely to have health insurance (Sources: Fox et al., 2007; Merikangas et al., 2011; President’s New Freedom Commission Report, 2003; USDHHS, 1999)

4. National U.S. Overview (cont’d) Among adolescents, greatest disparities for youth of color and youth living in poverty • Over 42 million adolescents (ages 10-19) in the U.S. (14% of American population) • 9.8% lack health insurance • Racial & ethnic minorities = 39% of U.S. adolescent population • Hispanic and Black children and youth have least access to and use of mental health care • Health outcomes disparities for racially and ethnically diverse youth and youth living in poverty (obesity, teen pregnancy, tooth decay, educational achievement) (Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000)

5. National U.S. Overview (cont’d) • In 2011, suicide attempts for Hispanic girls, grades 9-12, were 70% higher than for White girls (http://minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=9&ID=6477) • In 2012, Major Depressive Episode rate was highest among Latino youth, who were also less likely to received treatment than White youth (http://www.samhsa.gov/data/StatesInBrief/2K14/National_BHBarometer.pdf) • Children & youth in poverty have highest rates of unmet need and highest prevalence rates (Sources: Behrens et al., 2013; Fox et al., 2007; U.S. Public Health Service, 2000)

6. Disparities in the use of mental health services, including outpatient care and psychotropic drug prescriptions, persist for black and Latino children, reports a new study in Health Services Research. “Children’s mental illness is very predictive of poor outcomes later in life—socially, educationally, income-wise and employment-wise.” said lead author Benjamin Lê Cook, Ph.D., senior scientist at the Center for Multicultural mental Health Research at the Cambridge Health Alliance and assistant professor at Harvard Medical School…” (Source: http://www.cfah.org/hbns/2012/mental-health-care-disparities-persist-for-black-and-latino-children)

7. Barriers to Care • Stigma • Negative cultural views on mental illness • Self-care decision-making (medications, managing symptoms, appointment follow through) • Insurance coverage • Workforce shortage • Lack of culturally relevant care • Inaccuracies in identifying and diagnosing mental health disorders • Issues with provider-patient communication • Culturally inappropriate patient care plans • Ill-prepared clinicians (Sources: President’s New Freedom Commission Report, 2003; Conner et al., 2010; Vega et al., 2009)

8. Child and Adolescent Mental Health Policy Challenges and Supports • Challenges • Inadequate funding • Sustained focus on services for children and youth with serious emotional disturbance • Complexity of child mental health service delivery systems and funding • Locally-controlled school policies and priorities complicate state-funded school-based efforts • Insufficient availability of mental health services, esp. for low-income children and youth • Supports • Expanding insurance coverage increases access to services • Increasing advocacy across multiple levels effects policy change • Promising practices to improve access: Telemedicine/Tele-psychiatry, Teacher accreditation and mental health training, Classroom-based social-emotional learning and positive behavioral instructional supports • Support and Challenge • Varying impact of court actions on access to services • Comprehensive school-based care approach increases access to prevention, early intervention and treatment services

9. Access and Service Challenges “When it comes to providing preventive care, early intervention, or multidisciplinary approaches, there are few structural incentives, and many disincentives, to addressing mental wellness.” (Murphey et al., 2014, p. 8.) • Multiple child serving systems • Fragmented public service systems • Silo financing structures, service regulations, electronic records systems • Inadequate funding of mental health services • Funding and services depend on state of residence and sources of funding available to child and family • Funding targets high need children with payment tied to specific diagnoses • Insurance funding lags in covering evidence-based practices (Sources: Garland, et al., 2001; Stagman& Cooper, 2010; Stagman& Cooper, 2010; Cooper, 2008)

10. Consequences of Unmet Need (Sources: AACAP, 2009; Bullock, 2005; Kapphahn et al., 2006; Stagman& Cooper, 2010; United States General Accounting Office, 2003; Colton & Manderscheid, 2006)

11. Federal Response Mental Health Parity and Addiction Equity Act of 2008 and the Children’s Health Insurance Program Reauthorization Act of 2009 Systems of Care for Children’s Mental Health • Increased levels of mental health care covered • Removed limitations and restrictions on mental health coverage • Concern: Managed mental healthcare limitations for chronic illness • Finances collaboration among agencies, families and youth to provide culturally relevant, youth guided and family-driven services using a wraparound service delivery approach • Several years of funding to create integrated system structures across child serving systems • Overall positive outcomes • Concern: Sustainability (Sources: Bailey & Davis, 2012; Murphey et al., 2014)

12. Federal Response (cont’d)11 Patient Protection and Affordable Care Act (ACA) of 2010 • Anticipated health care for over 90% of Americans • Embeds provisions of Parity Law • Emphasizes prevention (with no patient cost sharing), quality of care, efficiencies in healthcare delivery esp. for high-cost chronic diseases (including mental illness) • Guaranteed renewal of insurance policy • Non-discriminatory premiums (poor health ≠ higher premiums) • Supports new healthcare service delivery approaches to increase access and care coordination (esp. integrated health and behavioral healthcare) • Recognizes importance of social determinants of health • Significant role of primary care providers • Emerging evidence base is favorable for patient and fiscal outcomes • Concerns: Focus on adult healthcare models and ability to meet demand for providers (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013)

13. Affordable Care Act and Children and Adolescents (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013)

14. Affordable Care Act and Children and Adolescents (cont’d) (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013)

15. Affordable Care Act and Children and Adolescents (cont’d) (Sources: Bazelon Center for Mental Health Law, 2010; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE), 2013)

16. Child and Adolescent Health – Common Conditions (Sources: Bloom, et al., 2011; CDC, http://www.cdc.gov/chronicdisease/overview/; Kolko & Perrin, 2014; U.S. Department of Health & Human Services, 2011)

17. Accessing Behavioral Health • Families generally seek help most often from family doctor • In rural communities, families seek help from: • Physician (62.5%), teachers (55.1%), family/friends (54.7%), counselor/therapist (24.7%), pastor (10.7%), other (2.8%) Only 21% were in clinically significant range • Over 90% of children in U.S. visit a primary care provider annually • Behavior problems are among top pediatric primary care physician concerns • Primary care clinicians (PCC) prescribe most psychotropic medications in the U.S. • Low rates of problem identification remain among PCCs • PCCs receive little training in recognizing and treating mental health issues • PCCs report payment barriers and problems accessing mental health specialists (Sources: Arndofer et al., 1999; Polaha et al., 2010, Campo et al., 2005)

18. (Source: Behrens et al., 2013)

19. The Evidence for Integrated Care (Sources: Collins et al., 2010; Milliman, Inc. et al., 2014)

20. Opportunities for Study • Little evidence exists to support integrated care efforts for adolescents in the U.S. • Consensus recommendations to improve adolescent healthcare: • Increase adolescent and parent engagement and self-care management • Improve clinical preventive services to reduce risk • Integrate physical, behavioral and reproductive health services • Use combination of Four Quadrant Clinical Integration Model along with Chronic Care and Systems of Care Models to design integrated care practice • Focus on multiple levels of study: (1) child/youth; (2) caregiver/family; (3) organizational relationships, (4) cost-effectiveness • Programs of practice: Bright Futures; school-based integrated care (Sources: SAMHSA-HRSA Center for Integrated Health Solutions, 2013; Campo, 2005; Foy et al., 2010)

21. Opportunities for Study • Access to care with shifts created by the ACA • Use of digital technology for psychosocial screening and assessment • Decision support technologies for team planning and management • Access to medication protocols for primary care providers • Health systems transformation • Process evaluation of provider practices relevant to integrated care • Comparative effectiveness research (Source: Kolko et al., 2012)