Amidst changes in the COVID-19 landscape, including navigating surges due to new variants, states are working with local partners to prepare for and implement back-to-school plans, while also anticipating the need to adapt as the school year progresses.
These factors along with an evolving set of vaccine mandates and mandate bans complicates public health mitigation plans, not only for vaccinating but for the full complement of tools that reduce spread, including health education, masking requirements, testing, and contact tracing. Additionally, intention to vaccinate and access to vaccines vary widely across the unvaccinated, with vaccination status of eligible children closely mirroring that of their parents.
Health and education officials simultaneously are planning for flu vaccinations and prioritizing catch up for routine childhood immunizations, required in many states for school, which lagged significantly during the pandemic as families followed social isolation and socially distanced recommendations.
NASHP convened a group of state officials from across the country to exchange strategies and creative approaches to navigating this environment in various demographic, political and policy environments. This brief summarizes key themes around accelerating routine vaccination rates and increasing access to the COVID-19 vaccine among eligible youth, including making vaccines convenient, using data to target resources and effectively engage partners, partnering to increase access and address intent, and prioritizing equity.
Making Vaccines Convenient for Families
Making vaccines available at locations that align with individuals’ daily routines enables those who may have limited time or resources due to childcare responsibilities, transportation, and other barriers to become vaccinated against COVID-19. Such convenience is critical to promoting widespread access generally and is an important tool in advancing equitable access for school-age children who rely on caregivers.
Convenience can be achieved by making vaccines available in community settings. To target adolescents and their families, some states are offering vaccine clinics at schools, ensuring that families can have ready access in a community hub and trusted location. Several states are pursuing strategies to ensure people “stumble into” opportunities to vaccinate, through pop up clinics in highly populated places (such as transit centers), on school grounds, or other at popular community events to allow for families to get vaccinated together, like at state fairs (such as Wyoming’s Frontier Days), or sporting events. This type of broad access in community enjoys the benefit of enhanced vaccine confidence when delivered in collaboration with trusted sources.
Another key method for reaching unvaccinated populations is to engage community providers and ensure they are willing and able to administer COVID-19 vaccines, which is particularly important for those living in underserved or rural areas. Most Americans trust doctors, nurses, and pharmacists, especially their own, and states are leveraging this trust and engaging these providers in both COVID-19 and routine vaccination efforts. Early in the pandemic, Kentucky state officials partnered with the Kentucky Board of Pharmacy to encourage pharmacist participation in delivering COVID-19 and routine vaccines. The Department of Public Health, the Kentucky Immunization Registry Coordinator, and the Emergency Preparedness Pharmacist from the Kentucky Pharmacists Association enrolled community and independent pharmacies to participate in the state’s vaccination program to reach underserved populations. Pharmacies are now one third of enrolled COVID-19 vaccine providers in the state, with 482 participating locations.
Prior to the delta surge, states had closed most mass vaccine sites in favor of local clinics, individual demand for vaccines had plateaued, and officials began managing excess doses about to expire. However, many community providers remained reluctant to provide COVID-19 vaccines for several reasons, including being unable to use large quantities of vaccines. To address these challenges, a number of state health officials established distribution programs – breaking down large palettes of vaccine sent by the federal government into small quantities to be distributed to providers. This approach is key to reaching underserved populations through trusted health care providers. For example, the Virginia Department of Health (VDH) federally funded Small Shipment Redistribution Program allows medical providers to order doses using VDH’s vaccine management platform, and a network of distribution centers across the state are used to store and distribute doses to clinics. Mississippi set up a Pfizer vaccine distribution site at County Health Departments using CDC supplemental funds and deployed pharmacists to distribute smaller doses (minimum of 6) to local providers, clinics, pharmacies, and homeless shelters, allowing for broader access to individuals. Kentucky doubled the size of their COVID-19 Vaccine and VFC (Vaccines For Children) program field representative workforce to redistribute doses around the state directly to providers.
Partnerships to Increase Access and Address Intent
Engaging trusted community leaders as messengers is essential to increasing vaccine intent. States are enlisting various community partners to help them engage more individuals in vaccination efforts. Vaccine intent varies across different demographic groups, and states can partner with school staff, healthcare professionals, and community and faith leaders to tailor vaccination engagement approaches.
Schools are important partners when it comes to hosting vaccine clinics and educating families about the importance of getting vaccinated. Mississippi and Kentucky designed school-based programs that bring vaccines to students who are eligible for the COVID-19 vaccine. Mississippi’s Adopt-a-School model incentivizes medical providers to coordinate on-site vaccination clinics at schools by paying participating providers $75 per shot. The Adopt-a-School program is part of Mississippi’s Covid-19 Community Vaccination Program, which is funded through a Center for Disease Control and Prevention (CDC) immunizations grant. The Kentucky Department for Public Health is contracting with a private vendor to host mobile vaccine clinics at schools. The state reimburses this vendor $80 per shot using FEMA (Federal Emergency Management Agency) funding. Other states are exploring partnerships between FQHCs and schools as well as public health and school nurses to organize school-based vaccine clinics.
Several other states are partnering with schools to circulate vaccine messaging and encourage students to get vaccinated. One state is collaborating with the American Academy of Pediatrics (AAP) chapters, school nurse organizations, and health and education departments to distribute information to students and families about vaccines. Other state officials from Kentucky and Maryland emphasized the important role of athletic departments in incentivizing vaccinations, as some schools do not allow unvaccinated students to participate in sports and ensuring the ability to take part in school athletic events is highly motivating.
State public health agencies can also engage more individuals by integrating vaccine efforts into the healthcare system. State health departments partner with primary care providers (PCPs), pharmacists, Medicaid agencies, and managed care organizations (MCOs) to educate individuals about COVID-19 vaccines and incentivize vaccinations. For example, one state’s Medicaid agency sent a fax blast to Medicaid-participating pharmacies to help encourage vaccinations. Another state official cited their state’s partnership with MCOs, where the MCOs helped organize community vaccination events and partnered with providers to increase vaccine availability. Other MCOs are offering financial incentives to their patients who get the COVID-19 vaccine. Trusted medical providers have a unique role in counseling and educating individuals about the safety of vaccines. Several states are leveraging this trust in doctors and creating initiatives that encourage providers to administer both COVID-19 and routine immunizations at doctor’s visits. For example, Wyoming is organizing a series of webinars for providers, giving them the opportunity to ask questions and work through challenges together.
Consistent Outreach and Messaging is Critical
States highlighted the value of a governor’s role in messaging through use of the bully pulpit including publicly vaccinating their eligible children. Still, most noted that effective outreach to those who remain unvaccinated requires tailored messaging to specific audiences and thoughtful assessment of population-specific barriers to vaccine information and uptake. Wyoming, for example, launched a multi-pronged messaging campaign to address vaccination holistically (including COVID, influenza and routine vaccinations). The campaign is tailored to the needs of various populations such as American Indians and residents in the most rural parts of the state. Intentional use of “choice” language through their provider and consumers educational campaigns has been key. Notably, early in the pandemic, some individuals were getting information about vaccine (and testing) opportunities across state lines which challenged state-specific messages around resources. The state responded through multiple messaging media to bring the right information to state residents.
Maryland is focusing outreach efforts to pockets of the state with a high rate of unvaccinated individuals. They are rolling out a voluntary screening/testing program at schools (reaching approximately 80% to date) with the hope of integrating mobile vaccination clinic opportunities into the program. The state is also aiming to reach areas with high need by leveraging multiple messaging strategies, such as door-to-door canvassing, pop up activities, digital communications, and partnerships with local employers and court systems.
Using an Equity-driven Approach
Given the disparate impact of the pandemic on communities of color, specifically Black, LatinX, and Indigenous groups, states are working to make sure their vaccine distribution strategy is equitable to these populations. Research shows that even though children may not have been impacted by the pandemic at the same rates as adults, the socio-emotional and developmental implications are staggering. And, children are experiencing similarly disproportionate levels of vaccine distribution, highlighting the importance of using an equity-driven approach to close the gaps in vaccine distribution in advance of and during the school year, and to mitigate the effects of the COVID-19 virus, especially with the emergence of the highly contagious Delta variant.
State officials cited their focus on areas with high numbers of unvaccinated people, as well as those vulnerable to infection. States use various data, such as the CDC’s Social Vulnerability Index (SVI), to identify these pockets of need and bring vaccinations to these areas, using a combination of mobile vaccination teams and local providers. Ensuring providers have appropriate educational materials and support to build vaccine confidence with their patients is critical.
State officials acknowledged efforts to engage community-based organizations and faith leaders to support vaccine intent. Kentucky created a COVID-19 vaccine communication toolkit for local trusted leaders to use when engaging with community members. There has also been an increased push from the federal level to address equity in COVID-19 response, including vaccination efforts. For example, the White House has increased public messaging and created the COVID-19 Health Equity Task Force and there has been an increase in equity-related funding from the CDC and HRSA to aid states as they work to use an equity lens on targeted approaches to vaccinate individuals.
Considerations for the Evolving Landscape
Several key themes were discussed without clear policy solutions and represent areas of continued opportunity as the school year begins and the vaccine landscape will continue to evolve:
- Navigating the issue of parental consent: Maintaining policies around consent for vaccination emerged as a major challenge in some states. A small subset of states allows minors 14 and older to consent for their own medical care through policies developed in partnership with provider organizations, such as the American Academy of Pediatrics. Political and policy disagreements with respect to exercising this option around the COVID-19 vaccine has resulted in clearer guidance from some states that parental consent is needed for COVID-19 vaccination separate from routine use of the minor consent option for other services.
- Incentivizing provider participation: Provider reimbursement approaches continue to evolve to incentivize vaccination and engage various provider types and locations. State officials noted further that provider reimbursement approaches should reflect the extended counseling sessions often occurring with unvaccinated people uncertain about their intention.
- Planning for the next milestones in vaccine approval: Several anticipated milestones will renew discussions around vaccine intent, access, and planning, including emergency use authorizations (EUA) for use of vaccines in children under 12 as well as full approval of those vaccines under EUA for adults and older children.
- Integrating pharmacists into vaccination efforts: Many states were eager to identify ways to include pharmacists in the Vaccines for Children (VFC) program specifically (and new adult immunization programs) to broaden the network and reach of vaccine providers, particularly in rural, frontier and otherwise underserved areas.
Participating state officials expressed their interest in increasing access to oral health care by sustaining or building on new teledentistry flexibilities introduced during the pandemic. According to the ADA, teledentistry, like other telehealth services, involves “the use of telehealth systems and methodologies” in dentistry, such as live video interaction, asynchronous or “store and forward” communication, and remote patient monitoring. Adoption of these methods and reimbursement for teledentistry approaches varies by state. Teledentistry can greatly increase access to oral health care, particularly for underserved populations such as communities of color and those living in rural areas.
During the pandemic, 17 states updated their Medicaid teledentistry guidance to allow new provider types to deliver virtual services, expand the scope of services that can be reimbursed through Medicaid, and ease consent restrictions that limited access to teledentistry, among other policy modifications. Considering telehealth policy revisions made during the COVID-19 pandemic, twenty-three states currently have policies in place to allow for delivery and reimbursement of teledentistry, however, challenges remain. For example, state leaders shared concerns about reimbursement for teledental services and limited guidance for providers about scheduling teledentistry visits in tandem with in-person visits. Some states, such as Pennsylvania and Rhode Island, seek to maintain or enhance teledentristry policies enacted during the pandemic to increase access to care for low-income children and adults.
In March 2020, Pennsylvania established guidance defining teledentistry as “two-way, real-time interactive communication” between a patient and dental provider. Accordingly, the Pennsylvania Medicaid program dental fee schedule was updated with billing codes D9995 (“teledentistry – synchronous”) and D0140 (“limited oral evaluation – problem focused”). (The D9995 code is not reimbursable, rather it is used to document teledental visits and must be used in conjunction with D0140 to provide services to patients experiencing dental emergencies). This policy lasted for the duration of the state of emergency in Pennsylvania, ending June 10, 2021. Now, officials seek to make permanent these Medicaid policies for preventive teledentistry through developing guidance on:
- virtual supervision of fluoride varnish application,
- tobacco cessation counseling,
- oral hygiene instructions and nutritional counseling,
- limited problem-focused evaluations,
- integration of different settings of care delivery, and
- care coordination for follow up to in-person visits as needed.
Rhode Island is in the process of establishing Medicaid guidance for teledentistry to expand dental services, particularly for children. At the beginning of the COVID-19 pandemic, the Rhode Island Department of Health released guidance allowing providers to bill telehealth services to Medicaid. This allowed dental providers to bill for a care coordination phone call (D9992) and schedule emergency video consultations with patients (D9310). This guidance expired on July 6, 2021, but the Rhode Island legislature recently passed an update to the Telemedicine Coverage Act, which expands telemedicine coverage requirements for Medicaid and private insurers, requires reimbursement rates for telemedicine services to match in-person rates, and ensures that dentists providing teledentistry services be held to the same standards of care that would apply in an in-person setting. Work to communicate reimbursable services to dental providers is in progress.
As states identify approaches to expand the use of teledentistry, many are creating pathways for patients and their caregivers to administer certain preventive procedures under virtual supervision from dental practitioners. As part of a pilot project, Nevada allows parents to apply fluoride varnish for their children under virtual supervision from a licensed dental provider. The Nevada Board of Dental Examiners approved virtual provision of fluoride varnish for individuals under the age of 21 in October 2020. A forthcoming fact sheet will provide more information on Nevada’s fluoride varnish program.
School-linked and School-based Programs
States also are considering how to leverage schools to fill dental care gaps among children. School-based dental sealant programs (SBSPs) provide critical primary and preventive dental care and disproportionately serve low-income students and those living in rural areas. However, according to a 2015 survey, 39 states and the District of Columbia do not have sealant programs in most of their high need schools, and only 5 states have sealant programs in at least 75 percent of high need schools. The Centers for Disease Control and Prevention (CDC) published considerations for SBSPs during the COVID-19 pandemic that includes information on restarting SBSPs. Still, state leaders cited concerns that reestablishing school-based programs will be challenging due to safety concerns, changing guidance, and workforce shortages, and they are searching for other strategies to increase access to dental care for students from low-income households.
To encourage children to visit dental providers in advance of the 2021-2022 school year, Smile, California, the California Medi-Cal Dental Program’s campaign, is partnering with the Office of Oral Health and Local Oral Health Programs to carry out a Back Tooth School Activation. Campaign partners can access Back Tooth School resources on the Oral Health and School Readiness website. Additionally, although the pandemic has limited students’ ability to receive oral care at school, California is pursuing strategies to screen children at school and refer them to dental providers using an electronic referral system. California’s Dental Transformation Initiative created a pilot program to improve dental health for Medicaid-eligible children. More LA Smiles, run through UCLA, is the largest of these pilot projects and created the LA Dental Registry and Referral System (LADRRS) to connect medical providers in clinical settings with dental providers. To implement a school-linked program, a platform like LADRRS can be modified to include referrals from schools. This system will enable state leaders to target low-income schools and gather data on students’ health.
Acknowledgement: The authors thank state officials from California, Rhode Island, Colorado, Pennsylvania, Minnesota, and North Carolina who reviewed a draft of this publication. Additionally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number U2MOA394670100, National Organizations of State and Local Officials. This information, content, or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
Following the May 10, 2021 approval from the Food and Drug Administration (FDA) authorizing the Pfizer COVID-19 vaccine for adolescents aged 12-15, approximately 17 million adolescents are now able to get vaccinated, about half of whom are adolescents of color. States are using lessons learned from earlier vaccination efforts and adapting the planning and implementation process of vaccinating individuals aged 16 and older against COVID-19 to inform the process for those 12 and older and ensure an equitable and efficient approach.
This authorization raises new considerations for states as they work to increase vaccination rates among their populations, including where children and adolescents will get vaccinated, how to build vaccine confidence among parents and adolescents, what the consent process looks like, and appropriate messaging strategies.
To reach adolescents ages 12-15, states are both drawing on existing vaccination locations, from mass vaccination clinics and pharmacies to medical offices, as well as setting up new vaccine sites in a variety of settings. For example, Alaska changed its vaccine allocation for evening drive-thru sites to Pfizer to increase access for adolescents after school and work hours. Some states are also newly engaging pediatricians. Washington State is working to get the Pfizer vaccine into pediatricians’ and primary care providers’ offices so trusted and familiar providers can educate children and their parents about the vaccine together, and family members can receive their vaccinations at the same time.
Many states are also leveraging schools as a critical vaccination setting and are developing plans for pop-up vaccination sites at summer camps and other recreational programs. In Virginia, the Department of Health began reaching out to school systems and meeting with superintendents prior to the FDA’s authorization. The state was able to help educate and prepare the schools to hit the ground running so that they could immediately schedule vaccine clinics upon FDA approval. This process was especially important given the short window of time before the school year ends. Earlier in May, South Carolina announced plans to hold vaccination events at schools intended for both students and their parents, with an added incentive of school supply giveaways for those who receive the vaccine. Additionally, some high schools in Maine are hosting vaccine clinics at the end of May, which provides just enough time to administer second doses before the school year ends. Oregon state officials are encouraging schools to provide the venue and help with outreach and scheduling, while facilitating partnerships with federally qualified health centers, pharmacies, and local public health authorities to provide the vaccination services on campus.
As states roll out the vaccine to new providers and locations, providers are also identifying a need for smaller vaccine packaging to avoid any potential vaccine waste. Vaccine waste has varied among states. Some state officials noted that they removed previous requirements for providers to use a certain percentage of doses within a given timeframe to ensure all opportunities to administer the vaccine are taken and to reduce barriers to vaccination, especially in areas with lower vaccination rates.
Requirements for parental consent to vaccinate minors vary among states, and even across vaccination sites. In Maine, parents or guardians do not have to be on site to provide consent. Rather, Maine allows parents to sign a form and either mail or email the form to the provider in advance, or have the child bring a hard copy to the vaccine site. Maine parents can also provide verbal consent over the phone. A small number of youth in Maine may provide their own consent for the vaccine, including those who are living separately from their parent/legal guardian, are legally married, are a member of the armed forces, or have been emancipated by the court. The state has already used this process for 16- and 17-year-olds.
In Alabama, adolescents aged 14 and older can consent for themselves in clinics, like mass vaccination sites or provider offices, but require parental consent for vaccinations in school. The state has existing processes in place to obtain consent for children to receive other routine childhood immunizations through the school; it is using the same process for the COVID-19 vaccine. Other states, like Kentucky, are also using existing processes for obtaining consent for routine immunizations and adapting them for the COVID-19 vaccine.
Vaccine Outreach and Messaging
Because studies have shown children have a lower risk of serious illness and death from COVID-19, polling has indicated that parents are confused about the benefits and risks of vaccination and hesitant to vaccinate themselves and their children. However, over the first two weeks of May, there was a 3 percent increase in the total number of COVID-19 cases in children, and a jump of over 20 percent of new cases in children under 19. The CDC is emphasizing that vaccinating eligible children is of the utmost importance to help protect both children and families, and move towards the goal of herd immunity to protect vulnerable community members who cannot get vaccinated.
Vaccinating children and adolescents brings an additional challenge for states and providers, who are tasked with building vaccine confidence among both parents/guardians and their children. State officials note that one important strategy is providing the vaccine in familiar settings with trusted providers, who can engage in conversations with families to understand their concerns and educate about the vaccine’s safety and efficacy. State officials also note the importance of messaging to both youth and adults, because children can be effective health advocates for their parents as well.
States are using trusted messengers and venues to communicate with adolescents. For example, the Louisiana Department of Health circulated flyers to the Department of Education encouraging vaccinations for adolescents 12 and above and providing relevant information. Some health departments are capitalizing on parents’ motivation to ensure their children can continue to play sports by messaging through sports teams that getting vaccinated eliminates the need for students to quarantine (thereby missing practices and games) if there is a school exposure. Other states are using football games that draw large crowds of teens as an opportunity to educate about the benefits of vaccination.
The Oregon Youth Authority (OYA) created resources in different languages tailored to adolescents from different populations and those in OYA custody. The flyers include first-hand accounts of COVID-19 vaccination experiences from individuals who identify as Latino, Black, and Native American, and information about the Indian Health Services’ involvement in the vaccine planning and development process. The Michigan Department of Health & Human Services is using social media advertising designed for parents and children, including Snapchat, Instagram, and TikTok. The Alaska Department of Health and Human Services has created opportunities to ensure adolescents can communicate with each other using peer-to-peer platforms to give unvaccinated teens the opportunity to ask questions of vaccinated teens and share why they chose to get vaccinated.
As states vaccinate more adolescents and adults against COVID-19, they continue to use multi-pronged strategies in order to reach the greatest number of people in the most efficient and equitable way. With more populations now eligible, states are figuring out how to tailor vaccination strategies developed for adults to younger children and adolescents. As the vaccine distribution progresses, NASHP will continue to share promising strategies and support states in these efforts.
By leveraging federal Medicaid funding and state investment while simultaneously clarifying complex billing procedures and enhancing engagement with providers, Arizona has made remarkable progress in increasing student access to critical school-based behavioral health services.
Arizona’s efforts to improve school behavioral health services began in 2018 when its state legislature allocated $3 million from the state’s general fund to expand these services. The state’s Medicaid program, the Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of Education (DOE) used $1 million of this funding to provide schools with mental health training, and the remaining $2 million was matched with federal Medicaid funds, resulting in a total $10 million in Medicaid funding to increase the number of behavioral health providers in schools.
To obtain Medicaid reimbursement for school-based services under the Medicaid School-Based Claiming (MSBC) program, Arizona’s local education agencies (LEAs) use two school-based claiming programs, the Direct Service Claiming (DSC) program and the Medicaid Administrative Claiming (MAC) program. LEAs seek Medicaid reimbursement through the DSC program to cover the cost of providing medical and behavioral health services to Medicaid-eligible students with an Individualized Education Program (IEP). The MAC program provides LEAs with reimbursement for administrative outreach services for Medicaid that are conducted in school settings. The state contracts with a third-party administrator, Public Consulting Group (PCG), to process Medicaid school-based claims.
In addition to claims processed through the MSBC program for students with IEPs, Medicaid services delivered by behavioral health providers contracted through one of AHCCCS’ managed care organizations can be reimbursed by Medicaid regardless of whether the student has an IEP.
Challenges and Solutions
Improving partnerships and coordination between schools and providers: While Arizona provided school behavioral health services before 2018, the additional state funding helped prioritize these services and facilitated the development of new relationships between behavioral health providers and schools. State officials reported that prior to the initiative to promote school-based behavioral health services, there were some challenges related to establishing relationships between schools and providers.
For example, some school administrators were skeptical if they could bill for school-based services or were concerned about the logistics of providing appropriate space to conduct behavioral health services without interrupting usual school activities. Many of these issues have been addressed through extensive and ongoing training sessions with both school administrators and provider groups. State officials also credited the cross-sector workgroup meetings that are held on a regular basis with helping improve interagency relationships.
Another key factor in Arizona’s success was incentivizing partnerships between schools and behavioral health provider agencies to create a differential adjusted payment for behavioral health providers. The enhanced payment became effective in October 2019, and provides a 1 percent rate increase for providers that have a memorandum of understanding with three or more schools to provide behavioral health services, and a 3 percent rate increase for providers that are autism Centers of Excellence.
State officials at AHCCCS also are in the process of improving data sharing with the DOE. By matching school identifier numbers on claims for services provided on a school campus, or as the result of a referral from an educational entity, the state will be able to obtain a better understanding of where and which services are delivered. Improving these data-matching processes will also provide information about where students are being referred for additional services and help identify where future focus should be directed within the state to enhance school-based behavioral health services.
Another key partnership to support students’ behavioral health needs is AHCCCS’ collaboration with the Arizona DOE on several grants, including Project Aware, which is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA). Project AWARE works with three school districts to provide suicide prevention and behavioral health resources.
Addressing lack of behavioral health providers and service delivery challenges: Arizona state officials identified the lack of behavioral health providers, particularly in rural regions, as an issue faced by many states. However, Arizona officials are pleased and encouraged by the number of providers who are participating in the state’s expansion of school-based behavioral health services. One factor that likely incentivized greater provider engagement was the implementation of the differential adjusted payment, although state officials indicated that there had already been a growing interest among behavioral health providers to develop new school partnerships to reach more students due to the statewide focus on the issue.
School districts in Arizona have also developed creative solutions to connect their students to behavioral health services. One school district in Arizona responded to provider shortages and space limitations by setting up a dedicated mobile unit in the school parking lot for behavioral health services. Prior to bringing in the mobile clinic, providers did not have financial incentives to travel to the school because it was difficult to secure an appropriate office during the school day. With the mobile unit, the district can provide consistency for their providers as well as a private space for students to receive behavioral health care. However, because the care is not technically provided in the school building, the district needed to work with the state Medicaid agency to find a way to appropriately bill under school-based behavioral health services.
Clarifying qualifying services and billing procedures: The state’s increased focus on the provision of behavioral health services in schools also helped to improve the accuracy of billing code processes. When efforts to expand school-based behavioral health services were initially launched, state officials at AHCCCS actively worked to address some of the existing misunderstandings about the allowability for those services to be provided at a school campus outside of the MSBC program. State officials recognized that due to errors in coding related to where services are provided, some school-based behavioral health services were not being correctly captured, resulting in the state not having a clear picture of the scope of services being provided to students.
To address these issues, AHCCCS coordinated and led many informational learning sessions throughout the state for both educators and provider agencies, including trainings about billing procedures. Once providers learned how to assign the correct place of service code, state officials reported a notable increase in the quantity of behavioral health services provided. State officials attributed the increase not only to the coding improvements that more accurately captured completed work, but also due to new services provided as a result of the state’s overall emphasis and investment in school behavioral health services.
Like many states, Arizona uses a Random Moment Time Study (RMTS) to assess the amount of time providers spend engaged in Medicaid-reimbursable activities. Each LEA has a RMTS coordinator who facilitates the administration of the program. As the third-party administrator, PCG manages the overall RMTS process, and provides program-specific introductory trainings for new coordinators and LEAs as well as recurring trainings to provide program updates and address areas of concern. AHCCCS coordinates with PCG to improve the RMTS process, and at present, AHCCCS consistently meets RMTS compliance standards, despite having to transition to virtual trainings during the COVID-19 pandemic.
Effect of COVID-19: The transition to mobile learning due to COVID-19-related school closures has presented an opportunity for schools to provide behavioral health services through virtual platforms. State officials report there has been a reduction in the number of claims that use place-of-service codes, which indicate when services are provided at an educational institution, most likely due to the decrease in the number of students attending school in person because of the pandemic. However, officials indicated that they have observed a dramatic increase in the amount of behavioral health services currently delivered through telehealth as more students have had to operate within a remote learning environment.
For districts without local providers, the ability to work with students without travel has helped connect more children to care. According to one Arizona state official, many behavioral health providers have gone above and beyond to connect with children whose need for care has been exacerbated by stress and isolation resulting from the pandemic.
State officials said there is anecdotal evidence that the pandemic has caused an increase in the number of parents expressing concern that their children are exhibiting depression and/or suicidal tendencies. However, officials also noted they have observed a greater willingness among parents to discuss issues concerning mental health, which could result in parents more actively advocating to ensure that schools continue to offer behavioral health services.
Since the start of the state’s efforts to expand behavioral health services in schools in 2018, officials report progress has been remarkably successful throughout 2019 and into early 2020, and there has been a substantial increase in the number of students who have received behavioral health services from an educational entity or institution. While declines in the number of youth suicides cannot be directly correlated with the state’s expansion of behavioral health services — and data from the effect of the pandemic is not yet available — there was a 41 percent decrease in youth suicides from 2018 through 2019.
State officials report their efforts have been so successful that in 2020 the state legislature passed SB 1523, which established and allocated $8 million to a new Children’s Behavioral Health Services Fund that will further enhance school-based behavioral health services. The fund will be administered by AHCCCS and provides behavioral health services to students who are not Medicaid-eligible but are uninsured or under-insured and who receive a referral for services from an educational institution.
In reflecting on lessons from Arizona’s expansion of school-based behavioral health services that might be used by other states, officials explained that determining how to handle nuanced billing situations, such as telehealth and the state’s mobile unit, was an important factor in ensuring that all provided services were accurately captured and reimbursed. They commented, “If Arizona can do it, anyone can do it — we are ranked 51st in [the nation for] education funding, and we have the poorest counselor-to-student ratio in the nation…that said, we have this great state Medicaid agency, and we’ve been able to figure out how to reach more kids with the dollars given to us. And so, if Arizona can figure out how to do this sort of work and get these partners on school campuses, then any other state can do this.”
The National Academy for State Health Policy (NASHP) would like to thank state officials from Arizona for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.
The COVID-19 pandemic has negatively impacted the mental health of many children and adolescents and reduced students’ access to comprehensive school mental health systems (CSMHS) as schools shifted to remote learning.
In recent years, states have implemented policies that have successfully expanded access to CSMHS. Lessons learned from these initiatives can help address students’ growing mental health needs and may help reduce states’ health care costs by decreasing mental health-related emergency department visits, which have escalated during the pandemic.
The availability of a comprehensive behavioral health system is critical to a child’s health and well-being. Nearly 17 percent of children and adolescents have a mental health condition, yet almost half of these children do not receive needed treatment. This is more pronounced among children and youth who are Black, Latinx, and come from other racial and ethnic minority groups, which disproportionately face barriers to accessing quality mental health care. These disparities have been amplified by the COVID-19 pandemic. A lack of regular, accessible mental health programs, services, and supports may lead to greater use of emergency departments, which are costlier and often lack appropriate policies to serve children with mental health needs, such as how to transition children and adolescents to other services and provide appropriate care coordination.
Schools are a primary source of mental health services for children and have been shown to improve students’ access to mental health programs, services, and supports. This is true for an increasing number of students, as the percentage of adolescents receiving mental health services and supports in educational settings has grown from 12 percent in 2011 to 15 percent in 2019.
A CSMHS approach is a best practice identified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Medicare & Medicaid Services (CMS). Schools can use this approach to support:
- Prevention of mental health needs among all students;
- Early identification of students and intervention for those who are at risk; and
- Services and treatment for those who have mental health needs.
A CSMHS also supports adherence to treatment, decreased stigma, and improved educational attainment. Implementing and expanding a CSMHS may also help to reduce racial and ethnic disparities in school responses to students’ behavior by encouraging mental health services over punishment. Children and youth with mental health needs who are Black and Latinx are more likely to receive punishment instead of mental health care services in comparison to White children.
A CSMHS is one component of a system of care for children and youth with special health care needs (CYSHCN) and behavioral health needs, and can be considered within a broader framework of policies to support mental health of children and adults.
There are a variety of federal initiatives that support state efforts to develop and expand these critical school programs, including:
- The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) provides funding at state and local levels to promote health and well-being through schools, including programs and services to support students’ mental health;
- SAMHSA’s Project Advancing Wellness and Resilience in Education (AWARE) provides funding to state education agencies to partner with state mental health agencies to increase awareness of mental health in schools, provide training to school staff, and connect students with behavioral health needs to services; and
- The School-Based Mental Health Services Grant Program, authorized by the 2020 Department of Education budget, provides $10 million to six states to increase the number of mental health service providers in schools.
The Biden Administration has underscored the importance of behavioral health services for students by setting a goal to double the number of mental health professionals in schools. The day after his inauguration, President Biden issued an executive order stating that the federal government will support states in promoting mental health and social-well-being in schools, and the American Rescue Plan Act of 2021 that was signed into law in March 2021 allocates more than $120 billion in grants to states through the Elementary and Secondary School Emergency Relief Fund. The majority of this funding will be distributed to local education agencies, which could use these subgrants to provide mental health services and supports and to implement interventions that address learning loss while responding to students’ emotional needs, among other purposes.
State Policy Considerations
Schools have adapted to shifting priorities over the past year and continue to implement innovative strategies to meet students’ growing mental health needs. During the pandemic, several states have introduced legislation to support schools in various ways to enhance their mental health programs during and after the pandemic.
- Implementing statewide task forces. Schools face a variety of barriers to developing CSMHSs for students, including allocating adequate funding, adhering to data privacy regulations, and identifying and implementing best practices. To support school districts’ diverse needs, states are forming committees to review existing approaches and make recommendations to improve mental health programs. This process may be particularly helpful to identify and address emerging challenges and strategies during and after COVID-19.
In 2017, North Carolina created the Superintendent’s Working Group on Student Health and Well-Being to produce recommendations to support students’ mental health, which were released in a report in May 2018. In October 2020, Illinois introduced legislation that would create a similar mental health task force consisting of mental health providers, school nurses, state General Assembly members, school board members, principals, parents, and students to produce recommendations in 2021.
- Developing mental health policies in schools. Clear policies at the state and local level can support comprehensive, consistent, and appropriate approaches to addressing students’ mental health needs in schools. State policies can provide guidance for local school districts regarding expectations and best practices, while allowing flexibility for schools to meet their students’ specific needs while considering the local context.
On June 8, 2020, North Carolina enacted SL 2020-7 S476, which implemented recommendations from the state task force. This law requires the Department of Public Instruction to adopt a statewide, school-based mental health policy, and requires each school to adopt its own policy following task force recommendations.
- Supporting universal screening practices. Widespread screening for children’s behavioral health needs is a recommended best practice. While schools have a unique opportunity to screen a high proportion of their students for behavioral health needs, less than 15 percent of schools have implemented a universal screening process. States are supporting schools by issuing recommendations for schools to increase mental health screening among students and guidance for funding for these services.
New Mexico requires in its administrative code that schools screen all students for health and well-being, including behavioral health needs. The state has developed guidance on funding sources for screening services, which may include operational funds, Title I and Title III funds, and Coordinated Early Intervening Services funding through the Individuals with Disabilities Education Act. In January 2020, New Jersey introduced legislation that would require schools to provide annual depression screening for students in grades seven through twelve.
- Expanding the availability of mental health services in schools. Few schools meet the recommended student-to-staff ratios for counselors, psychologists, nurses, and social workers due to a lack of funding and workforce shortages. States are enhancing CSMHSs through policies that provide funding to increase the availability of mental health professionals in schools and support partnerships with community-based behavioral health agencies.
Washington, D.C. has made significant efforts to support the expansion of behavioral health services to all students by earmarking local and federal funding and increasing funding over time for schools to develop partnerships with community-based mental health services. In October 2020, New Jersey introduced legislation that would require all public school districts to have at least one school counselor and to meet a maximum student-to-school counselor ratio of 250 to 1 – the national recommended ratio.
- Improving mental health training and education. School staff who are frequently in contact with students are an important resource to support students’ mental health. States are providing guidance and support to train these staff to identify indicators of mental health needs among students and facilitate appropriate referrals. States also advise on school curricula and education that support mental health awareness among students.
North Carolina’s SL 2020-7 S476 requires the state’s mental health policy to include a model mental health training program for school staff that local school districts must adopt. All school staff who work with students in grades K-12 must be trained in youth mental health, suicide prevention, and other mental health-related topics. Pennsylvania introduced similar legislation in September 2020 that requires schools to train school staff in identifying signs of depression and referring students and their families to mental health services.
Comprehensive school mental health systems are an important component of systems of care for CYSHCN and behavioral health needs. The National Standards for Systems of Care for CYSHCN, which were developed by a national work group of state and national health policy leaders, is a valuable resource that states can use to guide improvements to systems of care for CYSHCN, including considerations for mental health systems. States can implement systems based on the following standards to improve care for CYSHCN during and after COVID-19, including:
- Improve mental health care access, especially for marginalized communities;
- Increase the use of medical homes serving individuals with chronic and complex conditions;
- Improve coordination of care across behavioral health, social and health systems; and
- Improve access to CSMHS.
Schools have played an important role in supporting students’ mental health, but often face challenges in implementing CSMHS. Mental health needs among children and adolescents have been rising for several years, and this trend has been exacerbated by the pandemic. One way that states can address this is through policies that strengthen CSMHS to support students during and after the pandemic. The National Academy for State Health Policy will continue to track state policies that support CSMHSs during and after the COVID-19 pandemic.