Behavioral/Mental Health (FY 2024 Application)

The findings from the Title V needs assessment led to a new state priority need in 2020 to “Expand access to developmental, behavioral, and mental health services through routine screening, strong referral networks, well-informed providers, and integrated service delivery systems.” While work that aligns with this priority is evident within other state action plans, a new SPM was also created for the 2021-2025 cycle to “Support access to developmental, behavioral, and mental health services through Title V activities and funding.”

Creation of this new SPM was intended to better capture existing and new work across population domains related to behavioral and mental health and to identify opportunities for expanded work in the future. For the state action plan, the Title V program initially focused on three specific areas that are either directly supported or funded by Title V: 1) the work of local health departments in addressing developmental, behavioral, and mental health needs through Title V funding; 2) the work of Regional Perinatal Quality Collaboratives in addressing behavioral and mental health; and 3) increased engagement between the Title V CSHCN program and behavioral health partners. In FY 2022, a fourth objective was added for the Handle with Care (HWC) initiative. HWC focuses on students’ mental health and well-being and is supported by Title V 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 that created cross-domain or systems-focused SPMs (e.g., utilization of an MCH database, development of a social marketing/awareness campaign, advancing racial equity in the MCH workforce). Michigan’s SPM 6 state action plan is not an exhaustive reflection of efforts to better integrate or expand mental and behavioral health access or services. Other MCH initiatives and partnerships are underway but are not discussed in this state action plan, as the intent is to capture cross-domain work related to Title V activities and/or funding.

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

Mental health was a strategic priority identified by approximately one-third (12) of Michigan’s local health departments (LHDs) in the 2017 Local Maternal Child Health (LMCH) needs assessment. Mental health challenges continue to impact women, children and families across the lifespan. One in seven women will experience a Perinatal Mood and Anxiety Disorder[1].Twenty percent of Michigan women experience depression before pregnancy, 18.9% of women experience depression during pregnancy, and 16.1% experience depression following pregnancy[2]. The COVID-19 pandemic exacerbated stressors that many women and families faced prior to the pandemic. It also led to new stressors such as social isolation, job loss, housing insecurity, and poverty. Therefore, supporting behavioral health work within local health departments remains critical in FY 2024.

The CDC Youth Risk Behavior Survey Data Summary & Trends Report[3] includes the first data collected since the start of the COVID-19 pandemic. As seen in the decade before the COVID-19 pandemic, mental health among students overall continues to worsen. Findings indicate that more than 40% of high school youth felt so sad or hopeless that they could not engage in their regular activities for at least two weeks during the previous year.

There were significant increases in the percentage of youth who considered suicide, made a suicide plan, and attempted suicide. The data also reflect stark disparities in outcomes for female and LGBTQ+ students. Some providers are noting dramatic increases in depression and anxiety among patients, including at younger ages. Additionally, mental health service needs in Michigan outweigh the number of providers available, especially in rural areas, leading to long wait times for treatment.

Simultaneously, the LHD workforce is experiencing high levels of stress as many public health employees have faced harassment and pushback regarding pandemic mitigation efforts such as masking, social distancing, and vaccination. LHDs have noted an unprecedented rate of staff turnover and multiple staff vacancies.

The objective in this FY 2024 state action plan helps to illustrate how behavioral/mental health needs are being addressed through the Local Maternal Child Health (LMCH) program which provides Title V funding to all 45 of Michigan’s local health departments. Each health department has the flexibility to use Title V funds to align with their local MCH strategic priorities. Some LHDs work on mental/behavioral health with Title V funds; other LHDs may work on mental/behavioral health with other funds or in broader MCH program areas and therefore their activities may not be captured in their Title V LMCH workplans.

Many LHDs report having a long and rich history of being active partners with established community groups, advisory boards, collaboratives, and coalitions such as Community Mental Health, Child Abuse and Neglect Prevention Councils, child advocacy, school nurses, county courts, and law enforcement. LHDs describe receiving family feedback on services through paper and telephone surveys. LHDs value and elevate parent and adolescent voices by recruiting and promoting consumer involvement in decision making on collaboratives, councils, and advisory boards.

Seven LHDs are addressing some aspect of mental health as a performance measure in their current annual LMCH plans such as depression, adverse childhood experiences and suicide prevention within the women/maternal health and adolescent health domains. For example, SPM 6 was utilized in the women/maternal health domain by two LHDs that used LMCH funds to provide gap-filling universal stress/depression screening for pregnant and postpartum home visiting clients using the Edinburgh Postpartum Depression Scale and abbreviated Perceived Stress Scale. The LHDs educated pregnant/postpartum clients on stress, depression prevention and management, and created treatment goals with clients during case management. Women who scored as high risk for depression were referred for mental health treatment. The COVID-19 pandemic continued to impact access due to closures and fear related to meeting in person. Within the LMCH plans, outcome measurements include the number of women screened for depression, the number of women receiving case management for depression, and the number of referrals for treatment.

An example of SPM 6 in the adolescent health domain is a LHD that provides education to middle and high school students on mental health topics such as stress management, depression, body image, and substance use during health education classes. Another LHD teaches suicide prevention gatekeeping training to students. One LHD describes having high school students and a teacher on their reproductive health advisory board, and the health educator uses age-appropriate health education strategies. This LHD measures the number of adolescents who receive the education and knowledge gained through pre/post-test evaluations. Other LHDs conduct gap-filling depression and suicide risk assessments for adolescents.

State strategies to support LHD work on this measure in FY 2024 will include provision of guidance and technical assistance from the MDHHS LMCH consultant. To support the Title V pillars, LHDs will be encouraged to use a health equity lens in the formation of workplans and to involve families and clients as partners in their work. Sample LMCH workplans and webinars will be provided to LHDs to demonstrate inclusion, equity, and family engagement strategies. A specific workplan that integrates SPM 6 was created as part of a FY 2024 sample LMCH Plan.

The LMCH program will continue to track Title V spending on behavioral and mental health activities in FY 2024. LMCH data gathered from this performance measure will provide a local perspective, which will be important for informing future Title V behavioral/mental health strategies and 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 has a significant impact on maternal and infant morbidity and mortality. Poor behavioral and mental health outcomes in Michigan, especially in pregnant people, are illustrated through several indicators. For example, in 2021, 10.6% of individuals in Michigan with a live birth indicated that they smoked while pregnant; in 2020, the Neonatal Abstinence Syndrome (NAS) rate for Michigan was 624.1 per 100,000 live births; and from 2015-2019, 37.9% of pregnancy associated injury deaths were attributed to accidental poisoning/drug overdose and 4.5% were attributed to suicide[4].  Furthermore, 68.5% of individuals with a live birth in 2020 stated they had experienced one or more life stressors (i.e., homelessness, close family member sick or died, loss of job, etc.) in the 12 months prior to delivery and 18% stated they had one or more unmet basic needs (i.e., skipped meals because there was not enough money for food; did not have safe housing; could not keep basic utilities on; etc.) during pregnancy.[5]

Michigan is working to address behavioral and mental health concerns through the work of the Regional Perinatal Quality Collaboratives (RPQCs). The aim of the RPQCs is to develop innovative strategies to regionally address the drivers of adverse birth outcomes. Several RPQCs have begun addressing perinatal substance use through implementation of universal prenatal screening, increasing treatment capacity in their respective region, supporting nonpharmacological treatment of infants born substance-exposed, and offering educational opportunities in unconscious bias and stigma reduction. Depending on the availability (or lack) of other funding sources, Title V funding is used as a gap-filling funding source for RPQCs. Title V MCH leadership is also closely involved in the work of RPQCs.

Strategies to achieve Objective B focus on providing resource supports to the RPQCs to implement and expand universal screening, as well as other services and resources to improve care and treatment of mental and behavioral health in pregnant people and their infants. Previous surveys of prenatal care clinics illustrated a lack of consistent or universal screening of patients for perinatal substance use and/or mental health conditions such as depression and anxiety. Universal screening of all pregnant people is the first step in addressing behavioral and mental health in this population, as well as the related stigma that surrounds these conditions in general. Subsequent linkage to behavioral and mental health professionals, treatment, and other supportive services is the essential next step for those identified through universal screening, or otherwise.

As of Spring 2023, five RPQCs have implemented prenatal screening at clinics that serve residents within their respective regions. West Michigan’s major health system has built their preferred evidence-based screening tool into their electronic medical record. The screening tool is being utilized for both inpatient and outpatient care. Northern Lower Michigan, the Upper Peninsula, Saginaw/Bay area, and the Thumb area are working with clinics to implement an electronic screening tool that is based on evidence-based Screening, Brief Intervention and Referral to Treatment (SBIRT). Initial results have shown success in both patients completing the screening tool (upwards of 80-95% of patients) and in identifying pregnant people with behavioral and/or mental health concerns that might not otherwise have been assessed or addressed. Patients utilizing the screening tool have expressed their overall satisfaction and commented on the ease of use. Expansion of universal screening throughout the state is expected to continue in FY 2024.

Three RPQCs have implemented nonpharmacological care and rooming-in at birthing hospitals within their respective region for treatment of infants born substance-exposed. The programs encourage a family-centered approach where infants remain with their birthing person in a quiet, calming environment in which breastfeeding, skin-to-skin and bonding techniques are encouraged instead of the infant immediately being admitted to the Neonatal Intensive Care Unit (NICU). The RPQCs continuously seek feedback from families that have utilized the program; one RPQC has an advisory team that includes families with infants born substance exposed. These families were vital in the design and implementation of the rooming-in program at the regional hospital. Families are linked to supportive services and resources prior to discharge from the hospital. It is expected that as the hospitals continue implementation and garner patient feedback, they will grow and expand their programs.

Stigma and bias can impede care and treatment for pregnant people with mental and behavioral health concerns, leading to adverse health outcomes. RPQCs will be encouraged to continue providing educational opportunities in bias, equity, and stigma reduction for Collaborative members, as well as prenatal care providers. These opportunities are intended to be arenas for personal growth to increase awareness and knowledge, while reinforcing the need to be conscious of personal biases to prevent them from affecting clinical judgement. Ideally, the opportunities will also stimulate the desire to create systemic and cultural change within the provider’s facility, creating a safer and more inclusive space for prenatal, postpartum, and infant care.

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

In FY 2022, MDHHS launched a behavioral health restructuring process to support services across community-based, resident and school locations as well as other settings. Changes to this system of care will benefit people of all ages, with addressing the needs of children and their families as a top priority. These changes will streamline and coordinate resources and improve policies and processes to make them more effective.

The first strategy for this objective is to reflect the unique challenges of CYSHCN and their families in the decisions related to the behavioral health restructuring. This is accomplished through CSHCS participation on various workgroups and consistent meetings with leadership from the Bureau of Children’s Coordinated Health Policy and Supports (BCCHPS). The CSHCS Advisory Committee (CAC) receives regular updates on the restructuring project and has opportunities to provide feedback to the MDHHS behavioral health leadership team. The CSHCS leadership team meets monthly with BCCHP to discuss important topics that impact a shared population of children with behavioral health and special health care needs. In addition, CSHCS will re-envision a collaborative committee with key stakeholders, BCCHP, and community mental health providers. The committee will identify and explore solutions for challenges in accessing services by populations served by mental/behavioral health, intellectual and developmental disabilities (I/DD), and physical health systems.

The second strategy is to continue providing CSHCS, Family Center, and CSN Fund educational sessions at the Home and Community-Based Waiver Conference, the Michigan Council for Exceptional Children Conference, and Community Mental Health Association seasonal conference series. These educational sessions provide general information on the CSHCS program, describe how to access services, explain the relationship between CSHCS and the community mental health system of care, and introduce the Family Center. The CSN Fund presentation shares important information on how the CSN Fund helps families and the best way to approach the CSN Fund for support.

The final strategy for this objective is for CSHCS to evaluate opportunities to better address the needs of CSHCS clients who are at higher risk for developmental delays due to their CSHCS-qualifying medical condition. The CSHCS program is intended to cover acute/specialty care that is directly related to the CSHCS qualifying diagnosis. Since the program’s inception, CSHCS has not covered mental health related care. Historically, neurodevelopmental testing and neuropsychiatric testing has been considered mental health related. In FY 2024, CSHCS will continue the process of evaluating coverage of neurodevelopment assessments for infants with critical congenital heart disease (CCHD). CCHD refers to a group of infants with serious heart defects that are present at birth and are critical enough that heart surgery is required in their first year of life. Neurodevelopmental disorders are the most common, and potentially the most damaging, sequelae in children with CHD. The prevalence and severity of developmental delay increases with the complexity of CCHD and is associated with several genetic syndromes. CSHCS is evaluating the impact of an operational change to provide coverage for neurodevelopmental assessment for infants with CCHD.

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

Handle with Care (HWC) is an initiative designed to promote communication between local law enforcement and schools. When law enforcement is on the scene of an incident that was experienced or witnessed by a school-aged child, they determine what school the child attends and a “Handle with Care” notice is sent to the child’s school before the school bell rings the next day. School staff are encouraged to handle that child with care and look for potential signs that the trauma the child experienced is affecting his or her behavior in school.

The goal of HWC is to help students succeed in school. Regardless of the source of trauma, the common thread for effective intervention is the school. Research shows that trauma can undermine children’s abilities to learn, form relationships, and function appropriately in the classroom. A national survey of the incidence and prevalence of children’s exposure to violence and trauma revealed that 60% of American children have been exposed to violence, crime, or abuse; 38% were direct victims of two or more violent acts[6]. Prolonged exposure to violence and trauma can impact a child’s ability to focus, behave appropriately, and learn in school. In turn, this can lead to school failure, truancy, suspension or expulsion, dropping out, or involvement in the juvenile justice system.

HWC promotes school-community partnerships so that children who are exposed to trauma in their home, school, or community receive appropriate interventions to help them achieve academically despite experiences of trauma. HWC is a partnership between law enforcement, schools, and mental health providers, and connects students and families to mental health services. Schools that participate in HWC are encouraged to implement individual, classroom, and whole school trauma sensitive strategies so that traumatized children are “Handled with Care.” If a child needs more intervention, on-site trauma-focused mental healthcare is available at the school, or a referral is made to a community provider.

Strategies to help achieve Objective D in FY 2024 include the enhancement, expansion and tracking of a centralized online notification system that streamlines and automates HWC notices from law enforcement to the appropriate school liaisons. In FY 2022, the system was developed and piloted in two counties with expansion planned for four additional sites in FY 2023. The overarching goal is to serve all 83 counties in the future. Prior to development of the online notification system, each site was tasked with manually creating, tracking, and responding to notifications. Local HWC partners expressed a need for a centralized system for reporting notices. Initial feedback from implementing counties has indicated that the notification system is simple to use, efficient and has streamlined communication for law enforcement to submit the HWC notice and for the local school entity to receive the information. The system also stores all data about notices sent for law enforcement and schools to access at any time and to provide reports and data to community partners.

Title V block grant dollars are being used to fund the expansion, maintenance, and enhancement costs associated with the online notification system. After the successful pilot, comprehensive training videos and user guides are available for each of the key roles utilizing the HWC notification system including Law Enforcement Administrators, Law Enforcement Officers, and School Administrators. Monthly check-in calls with system users in addition to collected data have been used to make quality improvements for system modifications, training, and to generate a list of future enhancements to consider. The system will assist in the expansion of the HWC program over time, as it will decrease the amount of work needed when creating a HWC program in a new county by streamlining communication and creating efficiencies. It is anticipated that this notification system will be an incentive for additional counties to adopt the HWC program and allow for more widespread trauma-informed supports in Michigan’s schools. Current plans are for the online system to be available in FY 2024 to all interested counties and to have the necessary supports to onboard them seamlessly.

[1] Children’s Hospital of Philadelphia. Perinatal or Postpartum Mood and Anxiety Disorders

[2] 2020 Birth Year: Michigan PRAMS Maternal and Infant Health Summary Tables

[3] Centers for Disease Control and Prevention. 2011-2021 Youth Risk Behavior Survey Data Summary & Trends Report

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

[5] 2020 Birth Year: Michigan PRAMS Maternal and Infant Health Summary Tables

[6] Finkelhor D, Turner H, Ormrod R, Hamby SL. Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics. 2009 Nov;124(5):1411-23. doi: 10.1542/peds.2009-0467. Epub 2009 Oct 5. PMID: 19805459.