With the pandemic taking a massive toll on children’s mental health, Connecticut lawmakers are already beginning to plan what reforms may best target what experts have called a crisis.
Over the last several weeks, legislators have hosted forums with behavioral health professionals, state agencies and child experts to discuss what is happening and where improvements need to be made in the state.
Connecticut emergency departments saw an overwhelming number of children seek psychiatric care as the toll of the pandemic fell on the state’s youngest residents last year and as students headed back to in-person classes this school year.
Legislative leaders say mental health services will be one of the substantive issues during the 2022 session, which begins in February. Next year’s session is only three months, however, and lawmakers will have to move quickly to get important bills through the General Assembly.
“I think you’re going to see it be a major focus,” said House Speaker Matthew Ritter, D-Hartford, who recently convened a forum on the issue. “It’s a problem. It was a problem before COVID, and obviously, things got exacerbated since then.”
Scaling up workforce development
Some of the legislative efforts this session may focus on funding – directing more money toward staffing and incentives to work in the mental health industry.
“There are a real lack of people in that space. So that’s something we have to think about – how do you incentivize people to move to Connecticut and practice in that space?” said Ritter. “That’s probably a combination of loans or one-time payments. It’s like recruiting; you have to recruit people to come to Connecticut to do this.”
Lawmakers are also exploring whether to use out-of-state providers. Some providers in the mental health field must be licensed in Connecticut to practice here. Legislators are considering waiving certain licensure requirements to enable providers from Massachusetts, New York or other states to conduct telemedicine appointments with Connecticut residents.
The co-chairs of the Children’s Committee, Rep. Liz Linehan, D-Cheshire, and Sen. Saud Anwar, D-South Windsor, said workforce development is also one of the top priorities heading into the 2022 session.
They are considering legislation that would increase the number of training programs for social workers and psychiatrists, looking at intermediate and long-term plans to ensure psychiatrists are paid fairly and considering how to improve reimbursement rates.
Linehan wants to build on a bill introduced in 2021 that would provide tax incentives to psychiatrists to buy a house in Connecticut by including doctors and nurse practitioners who “have prescribing abilities in the mental health field all around the country.”
The program’s incentives would include a rebate on the income taxes they pay while working in Connecticut and a grant from the state for a down payment to buy a home if they stay in the state for 10 years after graduating medical school.
Linehan and Anwar have also had conversations about other legislation that could enhance mental health care coordination at pediatrician offices.
“So another thing that I really think is going to be hugely important and that we can scale up very quickly … is to beef up our access mental health program,” she added.
Access Mental Health is a referral program pediatricians can use if they are presented with a child showing mental health symptoms that they do not feel they have the specialty to handle. The pediatrician can then call Access Mental Health to speak to a psychiatrist and get a referral for that child.
Linehan’s top priority is to strengthen Access Mental Health by budgeting for an “immediate infusion of funds” to help double the number of psychiatrists on call for the program.
“The family can receive three telehealth visits with that psychiatrist if they desire and be covered by insurance and, if not, at least for the time being until we’re out of this pandemic, hopefully the state can cover those three telehealth visits for each family,” Linehan said.
Another substantial problem is that many pediatrician offices are not looped into a child’s mental health care coordination strategy, which is why some children who leave the emergency department or an outpatient facility do not get the proper follow-up care they need, Anwar said.
“What’s happening right now is that people have a way of just getting into the system, for management, through the crisis interventions that are there, if they know about it, and the pediatricians may not be in that loop,” he said. “I want to make sure that the rest of that coordination can happen from their office so that these patients are not lost to follow up at the various levels.”
The Connecticut Hospital Association has been in ongoing conversations with legislators about immediate and long-term measures to address the children’s mental health crisis in the state.
Carl Schiessl, director of regulatory advocacy at the CHA, said one way the state could immediately address the issue is by assessing how quickly facilities can expand capacity by adding more inpatient beds and staff to “increase both inpatient and intermediate levels of care, even if it’s just for the short term.”
“That would be a great potential immediate or short term measure that the state itself could take to expand capacity to provide the needed care as an option to having patients sitting in an emergency department waiting for an inpatient admission to one of these intermediate levels of care,” he said. “That’s one way the state can use its revenue, whether it’s their own or derived from federal sources, and we know there’s a lot of federal money coming in.”
But addressing children’s mental health care needs does not stop at emergency care. CHA and legislators are looking at measures that would expand outpatient services in communities and resources in schools to help prevent the need for a visit to the emergency department or so that they can continue receiving the proper level of care once they are discharged.
“When the emergency is over, where do you go? You hear the phrase ‘stuck kids in emergency departments,’ and what that means is the hospital addressed the emergent medical condition. That’s not hospital level, but it’s still care,” Schiessl said, adding that one of the things the state needs to do “on the back end” is to create incentives to expand access to intensive outpatient programs, partial hospitalization and other types of outpatient behavioral health services like group therapy, individual therapy and home care.
“Because if we have a safe place to discharge a child, and get them the right care in the right place at the right time, that again will relieve the crisis of too many children in our emergency departments,” he said.
For the 2022 session, legislators are also exploring funneling more resources to schools.
“It’s not just [health care] facilities. Everyone thinks we just need to add beds. But as you peel back the layers, it’s much more complicated than that,” Ritter said. “It’s the workforce, and it’s also trying to keep people from those beds. It’s so much more expensive. And so that might be hiring people and subsidizing school districts to have more counselors and providers on hand, so situations don’t escalate.”
Resources for children in schools and the community is a key area of focus. While some children will need institutionalized care, others are trying to access resources at home without success.
“There are going to be kids who need beds and who need [institutional] treatment. But a lot of these cases can be handled without that step,” Ritter said. “Take a family where both parents have the resources – they can watch the kid around the clock. Sometimes they’re being told it’s going to be weeks until they can see a counselor. And that’s when it escalates into the emergency room.
“Our emergency room has become the de facto, in some cases, mental health counseling for people. And we need to find a way to say to that parent, ‘We’re not going to have a two-week waiting list [for a counselor].’ But that’s not going to be easy to fix.”
With Connecticut having funding linked to the schools based on trauma, the state can strengthen its ability to manage some of these challenges, Anwar said, but that coordination between the schools and mobile crisis is going to be critical in making that happen.
He said there is an urgent need for a $4.5 million boost to mobile crisis. Currently, phone services run 24 hours a day, seven days a week, but there is no crisis intervention mobile service available on weekends or at night.
“So we need to actually have that available, because if we don’t have that, those same children will go to the emergency room, whereas they’re not going to necessarily get the help in a timely fashion that they’re hoping to,” Anwar said. “So if we do it … with a mobile crisis intervention that we are looking at, that will help us out.”
One of the challenges with getting children to intensive outpatient programs is transportation. Anwar wants to see the state use federal American Rescue Plan Act funding to address that need.
“If you look at the challenges and the proportionality of access, some of these children and their families would need transportation support to be able to get there,” Anwar said, adding that if that is not possible, then they can have further interventions at the hospital level. But the goal, he said, is to prevent people from needing to go to emergency departments or make their discharge process easier by providing resources that make outpatient programs more accessible.
“That’s where we need an intervention for the ARPA funds for the transportation and increase the [outpatient] program capacity and have that done,” he said.
Linehan plans to craft legislation focused on the children who may have missed their opportunity for entry-level behavioral health care or “those mid-level kids who are maybe in need of medication, who may be in need of an intensive outpatient program or a partial hospitalization program,” she said.
She also wants to change the way Connecticut schools handle truancy.
In 2017, the state removed truancy and defiance of school rules as a reason for referring children to juvenile court. Linehan wants to build on this by requiring the state’s mobile crisis services to assess a child before any truancy documents are issued to a review board because “that can help get that individual into care if they need it.”
“The problem is that’s assuming that a child isn’t going to school because they don’t want to, because they’d rather be hanging out with their friends or partying in the woods. That’s not what school refusal is,” she said. “School refusal is when a child has a mental health issue, or their depression and anxiety literally keeps them from going to school, that they are terrified to walk out the door and into their school, or that their depression is so deep that it’s just so difficult to get out of bed.”
Linehan said many licensed clinical social workers in the school systems are telling her that they’re seeing school refusal from students “at an all-time high” and that students refusing to go to school is often a symptom or a warning sign of depression and anxiety.
“I can’t say that every single time a kid refuses to go to school, it’s a mental health crisis … but at this point, there’s nothing that we’re doing on a statewide policy level that is parceling out the kids with the mental health crisis,” she said. “The kids with a behavior issue, sometimes they overlap, sometimes they don’t. So we owe it to the kids to provide a service to figure out what’s going on and how best to help them.”
Legislators are considering putting together a working group to tackle the children’s mental health crisis that is similar to one organized last year that explored the wide-ranging problems in Connecticut’s nursing homes and that made recommendations for reform. The group was announced in late October 2020 and issued suggestions for legislation in January.
Some of its recommended reforms, such as the authorization of cameras in nursing home rooms, were included in bills that passed earlier this year.
A slew of legislative panels, including the Public Health, Human Services, Education, Appropriations and Children’s committees, are expected to be involved in drafting and voting on legislation, and the co-chairs of those committees have begun to talk about how they might coordinate efforts.
“We’ve heard a lot about the emergency mobile system needing to be expanded. We’ve talked about everything from in-hospital to at-home to semi-partial hospitalization to outpatient [services]. And some of these things cost a fair bit of money … This is a significant undertaking,” said state Rep. Jonathan Steinberg, a co-chair of the Public Health Committee. “It’s certainly a worthy one, given the problems the state has with mental health care access in general and in children’s care very much in particular.”
Lawmakers are looking at what initiatives they may be able to tap federal funds to cover, versus “those things that we can build into the state budget,” he said.
Linehan and Anwar said many of their colleagues are on board and want solutions that are swift but will address the problems long-term.
“If we do not have a comprehensive strategy, we will be back here having the same conversation again. So I think no more Band-Aids,” Anwar said. “Let’s fix this and take care of this. Because investment efforts, coordination, is going to save lives, and they’re going to save the lives of our children, and the lives of our children are worth it for us to put all hands in and do it together in a manner that the experts have asked us to do, in a manner that really shows that it works.”