Cross-Cutting/Systems Building Overview

Public health can play a key role in mental health promotion and providing linkages to systems of intervention and treatment. Recognizing that physical and mental health are closely related at the individual and population levels, Michigan is working toward integration of these systems. An issue brief from the Kellogg Family Foundation (February 2021) entitled “The Implications of COVID-19 for Mental Health and Substance Use” indicated that the mental health of women with children and people of color were disproportionately impacted during the pandemic. The COVID-19 pandemic has impacted mental health across population domains and has underscored the need to create mental and behavioral health systems that are accessible and meet the needs of all Michiganders.

In March 2022, MDHHS announced a restructuring so that services are supported across community-based, residential, and school locations. The changes make addressing the needs of children and families a priority, while benefitting people of all ages. As part of the restructuring, the MDHHS Health and Aging Services Administration was renamed to the Behavioral and Physical Health and Aging Services Administration (BPHASA). This administration, in addition to current responsibilities administering Medicaid and services for aging adults, now oversees community-based services for adults with intellectual and developmental disabilities, serious mental illness, and substance use disorders. The Substance Use, Gambling and Epidemiology Section within the Bureau of Specialty Behavioral Health Services in BPHASA is responsible for clinical services within the Substance Use Disorder Treatment System. Services include those specifically for women, adolescents, and young adults.

The restructuring also created the Bureau of Children’s Coordinated Health Policy and Supports to improve and build upon the coordination and oversight of children’s behavioral health services and policies. The Bureau of Children’s Coordinated Health Policy and Supports will manage the implementation of the Infant Mental Health program, a home visiting model that is a needs-driven, relationship-focused intervention for perinatal women, infants, and toddlers and coordinates with public health home visiting programs. MDHHS and the Michigan Department of Education have partnerships related to early childhood mental health, adolescent/school mental health, and Infant and Early Childhood Mental Health Consultation (IECMHC) in childcare.

Intensive Crisis Stabilization Services (ICSS) for Children is a current Medicaid service in the Medicaid Provider Manual. MDHHS identified ICSS for Children as a key service in the MI Kids Now Service Array, and MDHHS will work towards expanding and ensuring access to this service on a statewide basis. MDHHS established a new grant program to provide funds to each Community Mental Health Service Program (CMHSP) to expand ICSS for Children to address crisis situations for young people. MDHHS awarded grants to 18 CMHSPs and will provide ongoing funding opportunities in FY 2024 and FY 2025. MDHHS also established a learning community to support grantees in implementation and to encourage peer-to-peer sharing of best practices. This program will allow CMHSPs to test different models (e.g., rural service delivery, 24/7 coverage, collaboration with other child-serving systems, etc.) using state general funds, and the “lessons learned” will be integrated into Medicaid policy as permissible under federal law and regulations.

In addition, MDHHS is supporting the development of Certified Community Behavioral Health Clinics (CCBHCs) in several locations. The CCBHCs will provide integrated services with an array of mental health services across ages (adults and children) regardless of ability to pay or type of insurance. These changes are intended to streamline and coordinate resources and improve policies and processes.

As described above, the MDHHS infrastructure and core funding mechanisms for behavioral health are primarily located outside of the Title V program. However, many Title V and MCH program areas coordinate and intersect with behavioral health initiatives. Additionally, the Title V 2020 needs assessment identified gaps in behavioral health services across MCH population domains. To be responsive to the findings and the needs of the MCH population, a new cross-cutting state performance measure (SPM 6) was created in 2020. The role of Title V in addressing behavioral health needs across population domains is discussed in the SPM 6 state action plan.

The Title V plan focuses on providing local health departments with funding to implement a range of behavioral health supports for women, children, and adolescents in their jurisdictions; supporting the work of Regional Perinatal Quality Collaboratives in addressing behavioral and mental health in their respective Prosperity Region; strengthening collaboration and engagement between Title V and behavioral health partners for children with special health care needs; and supporting children’s health through the trauma-informed Handle with Care initiative. Within this work, Title V recognizes the importance of and need for a diverse workforce that is representative of the communities being served and will support behavioral health partners in working towards equity and diversity in the workforce. The need to increase diversity within the public health workforce is also discussed in the “Title V Needs Assessment Update 2022-2023: A Review of Emergent Literature Concerning the Public Health Workforce and Broadband Access” which is included as a Supporting Document in this application.

Behavioral/Mental Health (FY 2022 Annual Report)

Through the 2020 Title V needs assessment, a new state priority need was identified to “Expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.” To align with this priority need, a new SPM was created for the 2021-2025 cycle to “Support access to developmental, behavioral, and mental health services through Title V activities and funding.” The annual objective in this state action plan signifies the ongoing commitment to mental and behavioral health initiatives within Title V systems work and community-based work that is funded by Title V. The annual yes/no objective was chosen to capture and reflect, in one state action plan, the array of work across Title V programs, population domains, and local initiatives. This approach (i.e., the use of a yes/no objective) is an option in the Title V Information System (TVIS) and is used by other states for cross-domain or systems-focused SPMs.

In FY 2022, this SPM and the objectives in the state action plan focused on work across population domains that was directly supported or funded by Title V: the work of local health departments (LHDs) in addressing behavioral and mental health needs in their communities; the efforts of Regional Perinatal Quality Collaboratives (RPQCs) in addressing behavioral and mental health; and increased engagement between Children’s Special Health Care Services (CSHCS) and behavioral health partners. A new objective for Handle with Care was added in FY 2022.

The COVID-19 pandemic continued to impact this SPM in FY 2022. For example, LHDs were still involved in COVID-19 response and vaccination efforts, which impacted their capacity for other work including MCH. Despite the continued pandemic challenges, efforts to expand behavioral and mental health services in Michigan achieved some progress and success. For example, RPQCs continued to support expansion of the universal screening tool and Pregnancy Checkup app in prenatal clinics throughout the state. The High Touch, High Tech (HT2) team at Michigan State University (MSU) made enhancements to the app, including a new narrating avatar and a public-facing feature to make the app accessible to more individuals. Strong partnerships and commitment to the work, as discussed below, continue to be key drivers in these efforts.

Objective A: Support the work of local health departments in addressing developmental, behavioral, and mental health needs in their jurisdictions through 2025.

This objective helps to illustrate how behavioral/mental health is being addressed at the local level with the support of Title V funding. Of the 45 local health departments (LHDs) in Michigan, six LHDs addressed some aspect of mental health as a performance measure in their FY 2022 annual plans through the Local Maternal Child Health (LMCH) Program. Every LHD completes an annual LMCH plan which gives an overview of the jurisdiction; an MCH Needs Assessment update; description of the involvement of families, consumers and stakeholders in ongoing needs assessment activities; and a work plan detailing objectives, activities and deliverables for each selected performance measure. Of the six LHDs in FY 2022 selecting the behavioral/mental health performance measure, work plan activities completed and reported in the agencies’ LMCH Year-End Report included: mental health education to school youth through virtual and face-to-face presentations and to women, pregnant women and adolescents during home visits; staff attendance at suicide prevention, perinatal mood disorder and mental health workgroups, mental health trainings for staff and the community; gap-filling depression screening/referrals; and suicide risk assessment. Agencies provided community educational resources through social media on behavioral/mental health. In total, these LHDs served 3,878 individuals (women, pregnant women, children 1-21 and others) and expended $180,222 in LMCH funds. Notably, since Title V funding is often used as a gap-filling funding source by LHDs, if an LHD does not choose a behavioral health measure for their Title V work plan it does not mean they are not doing meaningful work on this issue in their community.

The COVID-19 pandemic impacted LHDs’ ability to deliver services in FY 2022. Progress toward anticipated goals was halted as staff were needed for pandemic response activities; some clinics were closed for all or part of FY 2022. For school-based activities, educational presentations were delivered virtually until COVID conditions improved and an in-person format could be resumed at the end of the school year. Within LHDs, secondary trauma and staff burnout have impacted mental health. Staff turnover has been high, including among LHD leadership, with at least 16 new Health Officers appointed since March 2020. Hiring new staff has also been challenging and has halted or delayed planned activities. An unanticipated consequence of the pandemic was the increase in youth mental health needs.

In FY 2022, the LMCH program planned to provide support, guidance, and technical assistance to health departments. As part of this plan, LMCH created an “Evidence-Based Strategies by Performance Measures for Local MCH” document to provide guidance and technical assistance to LHDs as they created their action plans. The LMCH action plan contains a column to identify evidence-base/informed strategies. The document provides some potential evidence-based/informed or promising practice strategies that may be used in action plans, including SPM 6. As discussed, the pandemic stretched resources at local health departments, and agencies were overwhelmed with COVID-19 response activities. The MDHHS LMCH team provided support when able and avoided inundating agencies with requests that may have further overburdened LHDs during the pandemic. As planned, the LMCH program tracked count/expenditures for Title V spending on behavioral and mental health activities.

Objective B: Support the work of Regional Perinatal Quality Collaboratives in addressing behavioral and mental health in their respective Prosperity Region through 2025.

Behavioral and mental health outcomes continue to impact Michigan’s maternal and infant populations. In 2021, 10.6% of birthing individuals in Michigan with a live birth indicated they smoked while pregnant; in 2020, the most recent year available, the Neonatal Abstinence Syndrome (NAS) rate in Michigan was 624.1 per 100,000 live births with individual regions ranging from 2,691.8 per 100,000 live births to 292.8 per 100,000 live births; and in the years 2014-2018, 36.1% of pregnancy-associated, not related deaths were attributed to accidental poisoning/drug overdose and 4.5% were attributed to suicide.[1]

Michigan supports the Regional Perinatal Quality Collaboratives (RPQCs) through direct consultation; overall leadership of the Michigan Perinatal Quality Collaborative by a designated coordinator; and financial support through Title V federal funds, which serve as gap-filling funds for the RPQCs. In FY 2022, three RPQCs and the High Touch High Tech (HT2) team supported the expansion and ongoing implementation of a universal electronic behavioral and mental health screening tool and app in 13 prenatal care clinics and three family planning sites. Overall management is through Michigan State University (MSU) and supported through State Opioid Response funds. The app, called the Pregnancy Checkup app (previously known as the Mom’s Checkup app), utilizes evidence-based Screening, Brief Intervention and Referral to Treatment (SBIRT), as well as evidence-based screening tools for depression and trauma. Specific screening tools are based on clinic preference. The app offers patients the opportunity to share their screening results with their provider. If the patient agrees, results are sent via encrypted email to the clinic. This allows providers/clinics to make further referrals to treatment and resources. If patients decide not to share their screening results, they still can receive a brief intervention, which is consistent with best practice recommendations. Approximately 90% of patients agree to share their screening results.

Access to the Pregnancy Checkup app through personal devices continues to be an efficient option for clinics, especially as some clinics have adapted to shorter times spent in waiting rooms. The link and QR access code were created in response to restrictions put in place during the COVID-19 pandemic in which patients were waiting in their vehicles prior to their appointment. Clinics continue to utilize the QR code and link to the app as an option for patients as they streamline the check-in process upon arrival for appointments. At the conclusion of every screening session, patients are asked to complete an evaluation, providing an opportunity for feedback on the screening tool and app. Patients consistently rate the app ‘easy to use’ and are satisfied with the methodology used.

Continued funding allowed the MSU team to expand implementation of the Pregnancy Checkup app and universal screening tool, provide continued support to clinics after initial implementation, and build enhancements to the app. At the end of FY 2022, 16 clinics were utilizing the Pregnancy Checkup app, with additional clinics having expressed interest. Implementation of these additional clinics will be pursued in FY 2023. Based on feedback received in FY 2022, the team worked to create an avatar for the app that would resonate with a broad audience. While the previous avatar, a parrot, was appealing, individuals shared they would like the option for a human avatar to lead them through the app. The new avatar was created so that individuals of any race, ethnicity or gender could associate with it. The team also worked to create a chat feature in the app that could be staffed by a community health worker, social worker, etc. who would link patients to resources in real-time. Planning also began for a public facing feature of the app. This feature would make the app accessible to patients not currently linked to a prenatal care clinic or for patients of a clinic that is not currently utilizing the Pregnancy Checkup app. The intention is that these patients could complete the screening tool, receive a brief intervention, and be linked to resources. As mentioned, this is still in the planning stages and will be more fully developed in FY 2023. 

Prenatal clinics from a large health system in a fourth RPQC region have also implemented universal behavioral and mental health screening but are utilizing a different evidence-based screening tool. The HT2 team has met with representatives from this health system and is hopeful that as the use of the Pregnancy Checkup app expands into this region, the health system utilizing the previously mentioned screening tool will transition to the electronic universal screening program on the app.

In collaboration with the implementation of the Pregnancy Checkup app universal screening tool, one RPQC contracted with an outside vendor to provide tele-behavioral and mental health services to patients who are unable to utilize local resources, or who live in areas without resources nearby. Other prenatal care clinics utilizing the Pregnancy Checkup app continue to evaluate the resources available in their respective regions and will connect patients to telehealth services as available and appropriate.

The Michigan Child Collaborative Care (MC3) is a virtually based program that provides psychiatry support to primary and prenatal care providers in Michigan who are managing patients with behavioral and mental health concerns. Through the Governor’s Healthy Moms, Healthy Babies initiative, MC3 has expanded engagement of perinatal providers in the program, as well as offers short-term remote consultation and care coordination between patients and remote behavioral health consultants. In FY 2022, 213 perinatal providers enrolled in the program, and since late FY 2021, 262 patients have been referred for consultation, of which 90% became in engaged in the program and 73% enrolled. MDHHS and the RPQCs support MC3 through sharing program information, hosting program presentations and promoting informational MC3 webinar opportunities.

As a result of the COVID-19 pandemic, many in-person childbirth education and breastfeeding classes were canceled. Many pregnant and postpartum people were left without options for education and support. The Region 8 PQC (Southwest Michigan) recognized this need and began offering virtual childbirth and breastfeeding education and support classes for pregnant and postpartum individuals and families in this region. The feedback received was positive and many individuals indicated that these classes were either their only option for education based on their geographic location, or the classes were convenient since they didn’t have to arrange for transportation or childcare. The Region 8 PQC has continued to offer and support these courses in FY 2022 based on the feedback received from the community. In FY 2022, 10 childbirth series (three classes per series) and 22 breastfeeding education and support sessions were held. These courses provide opportunities for participants to review pregnancy and childbirth education, ask questions of the course instructor, and connect with other pregnant and postpartum people in their cohort.

Objective C: Support increased collaboration and engagement between Title V and behavioral health partners.

In FY 2022, MDHHS restructured how behavioral health services are delivered across community-based, residential, and school locations, as well as other settings. This included the creation of the Bureau of Children’s Coordinated Health Policy and Supports (BCCHPS) to improve the coordination and oversight of children’s behavioral health services and policies. BCCHPS will emphasize the critical importance of including families in addressing the health needs of children. In addition, the Bureau will work with other MDHHS administrations to address children’s behavioral health crises and expand dedicated partnerships. CSHCS and BCCHPS leadership meet monthly to discuss barriers to behavioral health care for CYSHCN and best practices for collaboration.

CSHCS continues to facilitate the Children’s Special Health Care Services, Behavioral Health and Intellectual and Developmental Disabilities Collaborative. The goal of the collaborative is to identify opportunities and implement activities to better support families with children who are receiving services through both CSHCS and the community mental health system. Due to COVID-19 and the behavioral health redesign, activities of the collaborative were on hold for FY 2022.

CSHCS and the Michigan Developmental Disabilities Council continued their strong partnership in FY 2022. CSHCS Division Director continues to serve by gubernatorial appointment on the Michigan Developmental Disabilities Council (DD Council), representing Title V. This provides an opportunity for the CYSHCN Director to ensure the DD Council focus includes children and adults with special health care needs. In addition, the CYSHCN Director can establish and maintain relationships with many organizations, as well as family and self-advocates who support Michigan residents with a developmental and/or intellectual disability. The CSHCS Policy Specialist continues to represent CYSHCN on the DD Council Policy workgroup. In FY 2022, CSHCS partnered with the DD Council and BCCHPS to create plans for a video series to help families of CYSHCN navigate systems more effectively and provide education to local behavioral and developmental service providers. Work will continue for this strategy in FY 2023.

Objective D: Support students’ mental health and wellness through implementation of Handle with Care (HWC).

Handle With Care (HWC) programs promote safe and supportive homes, schools and communities that protect children, and help traumatized children heal and thrive. HWC first came to Michigan in 2014 with the establishment of a HWC program in Jackson County, Michigan. Since that time, 49 communities have taken on this work at the local level with more expressing interest each year. Due to this rapid program expansion, MDHHS was approached by local HWC implementors seeking statewide infrastructure and staffing support for this initiative. The Division of Child and Adolescent Health (DCAH) took on this role in 2019 using existing staff support. Since that time, a state-level advisory committee was formed, a state website created, and a formal implementors guide and training approach developed. Through feedback on the HWC Advisory, a need was expressed by local communities for a statewide online application that would streamline the submission of HWC notices from Law Enforcement Agencies and the receipt of notices from designated HWC school personnel. Thanks to the support of the Title V MCH Block Grant, funding was designated for the development of this online portal in 2021 and 2022.

Planning for this process began in the Spring of 2021 with assistance and support from colleagues at the Department of Technology, Management and Budget (DTMB) who solicited bids from AI design firms. After reviewing the bids, the HWC state team opted to use Blue Vector Consulting to design and build the HWC portal. This began an ongoing weekly meeting with Blue Vector, DTMB and HWC state staff for a 9-month period in which the system was designed, built, and tested. The online portal also had to undergo a lengthy internal testing process to validate its use and compatibility with the state’s overall system and security standards. The HWC online application received final approval to “go live” in the Spring of 2022 which led to the final stage of development, a pilot process. Two HWC communities agreed to be trained on the new online system and pilot it over a 3-month period. Due to timing of the school calendar, the official pilot did not begin until September 2022. Since that time, 114 HWC notices have been submitted by Law Enforcement Agencies to schools in both Jackson and Eaton Counties which involved a total of 185 students. A total of 125 schools and 11 law enforcement agencies are currently utilizing the system. Bi-monthly calls with the pilot communities have also been convened during the pilot process to receive real time feedback on the application.  In FY 2022-2023, the team will move from the pilot to broader onboarding of additional communities.

[1] Source: Division for Vital Records and Health Statistics, Michigan Department of Health and Human Services