Issue Brief 81: Innovative Service Delivery in Response to COVID-19: Strategies to Meet the Needs of Children and Families During the Pandemic and Beyond

September 1, 2021

 Innovative Service Delivery During COVID-19

 Strategies to Meet the Needs of Children and Families During the Pandemic and Beyond

The outbreak of the novel coronavirus (COVID-19) forced an immediate shift across child-serving sectors to meet the needs of children and families. The full extent of the pandemic’s impact on children and families, especially those who are marginalized, has yet to be realized. However, as a result of rapid adaptations at the state and provider levels, professionals across child-serving sectors were able to minimize the disruption of services and do their best to meet existing and new health and behavioral health concerns. This Issue Brief summarizes strategies used to address the needs of children and families during the pandemic in pediatric primary care, children’s behavioral health, school-based health centers and school settings. It also identifies opportunities to permanently sustain adaptations that reduce barriers to care and improve outcomes for children and their families.

Identifying Innovative Practices During the Pandemic

CHDI, through funding from the Children’s Fund of Connecticut, awarded four research grants to identify successful system innovations and promising practices implemented during the pandemic. Each grantee developed and administered a survey and conducted interviews and/or focus groups with their respective stakeholder groups: pediatric primary care, children’s behavioral health services, school-based health centers, and schools. The grantees also explored the impact of those innovations on their capacity to support children’s health and well-being, the innovations recommended for being sustained, and the resources needed to sustain the most valuable innovations. The following is a list of grantees and a brief description of their focus.

• Childhood Prosperity Lab at Connecticut Children’s Office for Community Child Health explored innovations adopted in community-based, pediatric primary care sites.
• Connecticut Community Nonprofit Alliance, Inc. (the Alliance) investigated innovations adopted by children’s behavioral health providers, as well as how state agencies supported these innovations. 
• The Connecticut Association of School Based Health Centers surveyed its membership of school-based health centers exploring how they carried out their work at a time when many schools were offering only remote learning. 
• The Collaboratory on School and Child Health (CSCH) at the University of Connecticut examined innovations in K –12 schools, with particular interest in how school-based mental health services were continued during the pandemic.

Despite relatively small and homogeneous samples across the four funded projects (i.e., the majority of respondents to surveys and focus groups were White and held Executive or Senior Leadership positions), important themes and strategies emerged at the system, practice, and policy levels.

Grantee Findings: Successful Strategies to Meet the Needs of Children During the Pandemic

Professionals across all child-serving systems adapted in the face of the global pandemic to develop and implement promising strategies that support children’s physical, social, emotional, and behavioral health. These strategies enabled child-serving systems and providers to reach families and provide needed care in a way that advances optimal and equitable health and well-being. Research from the grantees pointed to the following four major themes and strategies they used to improve care:   

• Cross-system partnerships enhance connections to community-based services and support a more holistic view of health
• Telehealth promotes more equitable and accessible care
• Increases in children’s behavioral health needs require additional capacity building and resources
• Systems and practitioners must work together to address basic needs and social determinants of health

Cross-system partnerships enhance connections to community-based services and support a more holistic view of health

The COVID-19 pandemic impacted physical, behavioral, and emotional health and development in significant and complex ways, reinforcing the notion that no single sector alone can provide all needed supports to families.[1] Across all of the grantees, stakeholders reported forming new partnerships or reinvigorating existing partnerships to coordinate effective responses to the pandemic.

Grantee findings:

• Both the Alliance and the UConn Collaboratory on School and Child Health reported that schools worked more closely with local behavioral health providers by collaborating to identify and support student behavioral health needs. One innovative strategy was that behavioral health providers conducted outreach to families in order to help children connect virtually to school. Providers engaged in this activity in order to make connections, support education, and create an opportunity to identify any other challenges youth and families were facing.
• The pandemic highlighted the unique role that school-based health centers play in meeting the integrated physical and behavioral health needs of students, especially students from low-income households.[2] For example, school-based health centers worked more closely with host schools as well as with local health districts and sponsoring hospitals to provide a variety of services including assisting with contact tracing and COVID-19 testing as well as supporting drive-through immunizations for scheduled vaccines and flu clinics.
• Pediatric primary care providers reported improved collaboration with hospitals, payers, and specialists to coordinate efforts, improve communication, clarify areas of responsibility, and offer flexibility in when and how services were provided. This was particularly evident in the rapid implementation of telehealth.

Telehealth promotes more equitable and accessible care

Upon the rapid approval of reimbursement for telehealth among public and commercial payers, all of the sectors reviewed by grantees shifted to offer health and behavioral health services using telehealth. School-based health centers, pediatric primary care providers, and behavioral health providers all noted the benefits of telehealth and the importance of sustaining it long-term.

Grantee findings:

• Many providers had to absorb the significant cost of purchasing equipment and other technical supports to provide telehealth
• School-based health centers and primary care providers most commonly used telehealth to provide sick visits, medication management, and follow-ups.
• Pediatric primary care providers also used telehealth for Emergency Department visit follow-ups (including behavioral health-related visits), as well as asthma care, and nutrition counseling.
• As a result of the pandemic, one pediatric practice piloted electronic screening prior to a visit, which had been a previously unused feature of their Electronic Health Record (EHR) system. The practice plans to sustain this strategy long-term.
• Behavioral health providers shifted toward offering some in-person and some virtual telehealth (including both video and audio-only) services to offer flexibility to clinicians and families. Behavioral health providers noted that offering families in-person or telehealth services increased access for families who may face barriers such as transportation, child care, or time. But a more unexpected observation among behavioral health providers was that offering both options increased families’ sense of choice and empowerment in how and where they sought care, perhaps especially among families of color.

As one behavioral health provider noted:

“The advent of telehealth (virtual as well as telephonic) provides clients with choices that we believe directly address racial health care outcome disparities.”

Increases in children’s behavioral health needs require additional capacity building and resources

Providers across sectors recognized the need to increase their capacity, as well as the capacity of all child-serving professionals, to support children’s social, emotional, and behavioral health during a time of increased stress and in anticipation of increased behavioral health concerns among children and youth. To do this sustainably, additional funding to expand the children’s behavioral health system is needed.

Grantee findings:

• UConn Collaboratory on School and Child Health reported that the majority of school respondents identified a need for increased training and professional development for school staff to support student behavioral health.
• In pediatric primary care, over half of survey respondents reported participating in virtual training to build capacity related to behavioral health issues, including interpersonal violence, parental stress and anxiety, and supporting children and adolescents with behavioral health challenges.
• Although schools are well positioned to play an important role in addressing student mental health needs, barriers to increasing capacity in schools included lack of time, volume of work, lack of staff-buy in, variability in teacher skill, lack of student/family engagement among remote learners, uncertainty, and a pressure to focus on performance metrics. School respondents also indicated a desire to support social-emotional learning, but lack of knowledge about how to carry out the approach.
• Primary care practices also play a critical role in identifying and referring youth with behavioral health conditions. However, the Childhood Prosperity Lab’s investigation into primary care practices highlighted a concern about lack of parity in reimbursement for behavioral health visits and follow-up appointments.

Systems and practitioners must work together to address basic needs and social determinants of health

The pandemic has resulted in increases in unemployment, basic needs (e.g., food, housing) and other social determinants of health (e.g., economic stability, physical environment, and access to health care). An increased emphasis on addressing these social determinants of health has become especially important for meeting the needs of children and families. Grantees and the stakeholders they represent recognized that systems and practices must be designed to address basic needs, social determinants of health, and clinical interventions more holistically.

Grantee findings:

• Pediatric primary care respondents answered a series of questions about their patients’ social determinants of health prior to and as a result of the COVID-19 pandemic. The most notable change across respondents was that their patients no longer had consistent and regular access to needed health care services, including behavioral health services. They also reported reduced access to healthy food, quality early care and education, quality recreational activities, and healthy, safe, and affordable housing.
• Behavioral health service providers described the pandemic’s impact on basic needs and social determinants of health. However, partly due to a greater flexibility in funding during the pandemic and support from private foundations, many behavioral health providers were able to establish basic needs programs.Nearly half of behavioral health respondents established new programs or services to provide basic needs or emergency assistance.
• Despite shifting to remote learning, schools became a primary source for food distribution, especially for students who would otherwise receive free or reduced-price lunch during school. Among the many challenges that schools were facing, some respondents noted that basic needs, such as food insecurity, were the most pressing priority even above social, emotional, and behavioral health concerns.

Recommendations

The findings and themes across the four research grants underscore significant practice, system, and policy actions that are needed to sustain the innovations deployed during the COVID-19 pandemic and support children’s health and well-being in a more coordinated and efficient manner. Implementing each of the following recommendations will require significant collaboration among funders, state agencies, providers, families, and advocates.

1. Continue to develop an integrated infrastructure for children’s behavioral health. There are numerous state agencies and local providers involved in funding and providing such services, and many state workgroups committed to various aspects of children’s behavioral health. An integrated system design would include a coordinated high-level governance and decision-making structure, including blended and braided funding. The system should incentivize integrated care and cross-sector collaboration, address social determinants of health, and include family input throughout the system. Such an approach would support the local collaboration and communication across sectors identified as an important ongoing need for addressing children’s behavioral health and well-being.
2. Advance integrated practice settings including SBHCs, FQHCs, behavioral health providers within primary and specialty care settings, and primary care within behavioral health settings. Blended and braided funding streams and reimbursement mechanisms would allow these integrated care settings to address clinical needs along with social determinants of health. 
3. Improve access to high-fidelity Wraparound care coordination that is not sector-specific. Seeking Medicaid reimbursement for care coordination or community health workers through a State Plan Amendment would go a long way toward ensuring better access to this service across sectors. In addition, giving care coordinators or community health workers access to flexible funding will allow them to address basic needs and other social determinants of health. Additional recommendations can be found in CHDI’s IMPACT Improving Care for Children and Families with Complex Needs: Enhancing Care Coordination in Connecticut.
4. Provide workforce development opportunities to increase early identification and improve access to behavioral health services to meet the growing need and demand. A range of child-serving professionals (e.g. primary care, schools, early childhood) should possess basic competencies in behavioral health, including screening and linking families to ongoing assessment and care. Increasing the pipeline of well-trained behavioral health clinicians and providing sufficient reimbursement to attract and retain them will be important to meet the growing demand for services.
5. Enhance family voice and choice at all levels of the service system. This should include family representation on governance bodies and in local service delivery, including high-fidelity Wraparound care coordination (which is very family-driven), and improving options for family choice regarding where and how services are delivered (e.g., telehealth vs. in-person). 
6. Permanently expand Medicaid and commercial reimbursement for telehealth, including options for audio-only services, as a critical strategy for addressing barriers to and disparities in access. Additional recommendations can be found in CHDI’s policy brief Advancing Equity in Behavioral Health Through Telemedicine. 
7. Continue to develop and support an integrated approach to data collection and quality improvement for children’s health and behavioral health services. This should include the analysis and public reporting of data about service utilization, capacity, availability, duration, and outcomes at all levels of care, including within and across child-serving sectors. Reports should also examine the extent to which disparities in service access or outcomes exist by age, race/ethnicity, gender, language, and other characteristics. The availability of such reports will allow identification of service gaps, needs, outcomes, disparities, and trends that can be used for ongoing system improvements and efficiencies to promote equitable care.

References

This Issue Brief was prepared by Stephanie Luczak, LMSW and Jeffery Vanderploeg, PhD. For more information visit www.chdi.org or contact Jeffrey Vanderploeg at jvanderploeg@uchc.edu.

Download printable version (pdf).