Cross-Cutting Overview

Public health can play a key role in mental health promotion and the prevention of mental illness, as well as 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 better integration between these systems. Additionally, the COVID-19 pandemic has had a significant impact on 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.

Within the organizational structure of MDHHS, the Behavioral Health and Developmental Disabilities Administration (BHDDA) and the Public Health Administration (PHA) fall under the leadership of the Chief Deputy for Health. Additionally, there are close working relationships between BHDDA staff who work with children and families and PHA staff. For example, BHDDA’s Division of Services to Children and Families leads the implementation of the Infant Mental Health program, a home visiting model that coordinates with public health home visiting programs. BHDDA’s Division of Recovery Oriented Systems of Care supports a network of substance use treatment programs designed specifically for pregnant women and women with young children. Similar partnerships exist between MDHHS and the Michigan Department of Education related to adolescent mental health. MDHHS is also working toward better integration of mental and physical health care through a behavioral health redesign effort that involves establishing specialty integrated Medicaid health plans for those with significant behavioral health needs.

Although efforts have occurred at the state and local level to coordinate and integrate promotion, prevention, intervention, and treatment strategies across physical and behavioral health, the Title V needs assessment found that gaps remain across population domains. The system assessment found that programs and services are often siloed which creates gaps in assessment, surveillance, planning, coordination, and referral. The forces of change assessment found that sociocultural phenomena such as systemic racism, implicit bias, trauma, political polarization, and social media play a role in creating a climate that fosters anxiety and depression. It also highlighted the intergenerational impact of mental illness. The community themes and strengths assessment found that stigma continues to play a role in preventing people from seeking treatment and that the mental health system does not have the capacity to treat everyone who needs treatment. This was especially true for individuals seeking providers who accept Medicaid. The assessment also noted the linkages between maternal mental health and developmental outcomes for children, as well as the impact of chronic stress and trauma on mental health.

The health status assessment also identified behavioral and mental health concerns across multiple population domains. For women and maternal health, serious and increasing mental health needs were found in the preconception period and during and after pregnancy. For example, women ages 18-44 years showed an increase from 2013 (14.1%) to 2019 (23.1%, BRFS) in reporting two or more weeks of poor mental health over the previous month. From 2016 to 2018 the percentage of Michigan women who reported treatment for anxiety or depression in the year prior to their pregnancy rose from 35.8% to 38.4% (PRAMS). Similarly, major postpartum depression symptoms rose from 2014 (12.6%) to 2018 (16.3%, PRAMS). While there are fewer sources of data regarding mental health among children in Michigan, they are more likely than children nationwide to be diagnosed with an autism spectrum disorder (3.2%, NSCH 2017-2018) or attention deficit disorder (10.0%). Over a third of Michigan children ages 6-11 years who had a diagnosed mental or behavioral health condition did not receive treatment in the previous year (36.8%, NSCH 2017-2018). Adolescents in Michigan have experienced a higher suicide mortality rate than adolescents nationwide since at least 2012 despite increases in both rates. In 2019 for adolescents ages 10-19 years, the suicide rate in Michigan was 7.3 per 100,000 and 6.6 per 100,000 for the US (WISQARS). 37.3% of Michigan high school students reported two or more weeks of sad or hopeless feelings over the previous month in 2019, a major increase from the 26.0% in 2011, and this metric was even higher among Hispanic students (46.5%, YRBS). Michigan adolescents have also increasingly reported considering suicide, from 15.7% in 2011 to 18.7% in 2019 (YRBS). Parents report that 59.3% of children with special health care needs experienced bullying, compared to 43.2% of non-CSHCN (NSCH 2018), which is linked to adverse mental health outcomes. These data indicate that Michigan has unmet needs for mental and behavioral health services across Title V populations.

The COVID-19 pandemic has resulted in economic and social challenges that are having a significant impact on the mental health and well-being of mothers, children, adolescents and families. According to the “Kids, Families and COVID-19: Pandemic Pain Points and the Urgent Need to Respond” report, 22% of Michigan households with children reported feeling down, depressed, or hopeless during the pandemic. The report states, “Mental health, already a pressing issue for young people, has become an acute concern for millions in 2020, as they deal with everything from uncertainty and isolation to the profound grief associated with the coronavirus-related deaths of family and friends.” Additionally, the Child and Adolescent Mental Health as a Result of COVID: a Michigan Perspective report states that in Michigan “trends show increased isolation, fear of contagion, political and racial unrest along with economic uncertainty have resulted in increased anxiety and depression.” The report notes other stressors that compound the effects of the pandemic, including financial stressors such as job loss and eviction. The report includes links to several studies that highlight the significant negative impact of the pandemic on children’s emotional well-being and mental health—and in turn, the increased demand for mental health services.

Behavioral/Mental Health (FY 2022 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 on this priority is evident across many domains and state action plans, for the purpose of Title V the priority formally links to the state performance measure (SPM) on childhood lead poisoning prevention (that was continued from the 2016-2020 five-year cycle) and a new SPM that was 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 Title V and behavioral health partners. For the FY 2022 state action plan, a fourth objective was added for the new Handle with Care initiative that will support students’ mental health and receives Title V funding.

The annual objective in this state action plan is “yes” to signify the ongoing commitment to mental and behavioral health initiatives within Title V systems work and community-based work that is funded by Title V. This annual objective was intentionally chosen to capture and reflect, in one state action plan, the array of work across Title V programs, population domains, and local initiatives. Notably, this 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 of the plan 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. 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. Some providers are noting dramatic increases in depression and anxiety among patients, including at younger ages.

The objective in this state action plan helps to illustrate how behavioral/mental health is being addressed at the local level with the support of Title V funding. The 45 LHDs in Michigan receive approximately one-third of Michigan’s total Title V allocation through LMCH. Each health department has the flexibility to use Title V funds to align with their local MCH strategic priorities. Local needs vary across the state. 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 Title V LMCH workplans. Additionally, some activities that tie with mental/behavioral health and wellness may be captured in other areas of the Title V application (such as NPM 9 on bullying).

Currently, eight LHDs are addressing some aspect of mental health as a performance measure in their annual plans such as depression, adverse childhood experiences and suicide prevention within the women/maternal health and adolescent health population domains. 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 workplan it does not mean they are not doing meaningful work in their community on this issue.

For example, SPM 6 was utilized in the women/maternal health domain by an LHD that used Title V funds as gap filling to provide universal stress/depression screening for pregnant and postpartum home visiting clients using the Edinburgh Postpartum Depression Scale and abbreviated Perceived Stress Scale. The LHD educated pregnant/postpartum clients on stress, depression prevention and management, and created treatment goals with clients during case management for stress/depression. Women who scored as high risk for depression were referred for mental health treatment. Some families faced access challenges due to the COVID-19 pandemic, particularly during the statewide closures, while others adapted to using telehealth visits when possible. 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 an LHD that provides education to middle and high schools students on mental health topics such as stress management, depression, body image, and substance use during health education classes. This LHD measures the number of adolescents who received the education and measures knowledge gained through pre/post-test evaluations. A second example is an LHD that uses funds in a nurse-led medical service clinic to screen for adolescent depression using PHQ2 with follow up with PHQ9 when indicated. The measure is the count of adolescents served.

State strategies to support LHD work on this measure include provision of support, guidance, and technical assistance from the MDHHS LMCH consultant. Training webinars will be offered to provide information on evidence-based and evidence-informed strategies and activities for behavioral/mental health access. 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 as partners in their work. In 2021, the LMCH consultant provided a sample LMCH workplan that demonstrates some initial strategies to integrate inclusion and equity and to promote family engagement. The state Title V program recognizes that given the significant and ongoing demands on LHDs in response to the COVID-19 pandemic, LHDs may not have the capacity to make significant adjustments to workplans for FY 2022.

The LMCH program will also track Title V spending on behavioral and mental health activities. Data gathered from this performance measure will provide a local perspective, which will be important for strengthening 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. Michigan is plagued by poor behavioral and mental health outcomes, especially in pregnant people, as illustrated through several indicators. For example, in 2019, 13.6% of women in Michigan with a live birth indicated that they smoked while pregnant; in 2018, the Neonatal Abstinence Syndrome (NAS) rate for Michigan was 721.2 per 100,000 live births; and from 2013-2017, 32.0% of pregnancy associated injury deaths were attributed to accidental poisoning/drug overdose and 5.1% were attributed to suicide[1]. 

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 and offering educational opportunities in unconscious bias and stigma reduction. Building on these efforts, the RPQCs will work to implement and expand telehealth services, focused on behavioral and mental health, for pregnant and postpartum people living in areas with limited in-person options for this type of specialized care. 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 and telehealth services in their region. Previous surveys of prenatal care clinics illustrated a lack of consistent or universal screening of patients for perinatal substance use 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 is the essential next step for those identified through universal screening, or otherwise. Behavioral and mental health professionals are a limited resource in Michigan, especially in rural areas. Residents in rural Michigan often encounter barriers to care that include the physical distance to clinics and reliable and consistent transportation. Telehealth services are a logical option in overcoming these barriers.

Four RPQCs have implemented prenatal screening at clinics that serve residents of 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 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. It is anticipated that these results will lead to expansion of universal screening within their regions, as well as in other regions.

Most clinics that have implemented universal prenatal screening have an embedded social worker or behavioral health professional in their clinic. This serves as a great resource for initial contact with patients, but in terms of ongoing support, it may not fully meet patient needs or may only benefit those patients who live near the clinic and have adequate transportation. West Michigan, Northern Lower Michigan, the Thumb area and the Upper Peninsula are comprised of largely rural areas. Patients in these areas often travel long distances for prenatal care appointments; some struggle with reliable transportation or having money for gas; and some are unable to take the time from work for additional appointments. It is these situations and barriers which necessitate tele-behavioral/mental health services. Clinics in the Upper Peninsula have begun piloting tele-behavioral/mental health services for prenatal patients through a state-based vendor. Successful results are anticipated and will be used as a model to expand tele-behavioral/mental health services both within and outside the regions. Utilizing telehealth services for behavioral and mental health care will greatly increase the capacity of care, especially in rural areas of Michigan.

The effects of the current pandemic led many health care provider offices to, at least temporarily, offer care via telehealth services. Many providers, clinics and patients are now familiar with the technology, which should ease the introduction of tele-behavioral/mental health services within this population. It could also prove beneficial in coordinating care for patients who may not have stable or reliable internet access. For example, the telehealth appointment could be coordinated with their prenatal appointment and accessed from the prenatal care clinic.

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

In FY 2019, the CSHCS Division and the Behavioral Health and Developmental Disabilities Administration (BHDDA) formed a collaborative committee to explore and identify challenges in accessing services by populations served by mental/behavioral health, intellectual and developmental disabilities (I/DD), and physical health systems. The collaborative committee includes members from the Family Center, Family to Family Health Information Center, MDHHS CSHCS, MDHHS Behavioral Health and Development Disabilities Administration (BHDDA), local Community Mental Health (CMH), local health departments (LHDs), ARC of Michigan, CMH Association, MDHHS child welfare and juvenile justice, family members, and Medicaid Health Plans. The purpose of the collaborative workgroup is to develop tools to assist families in communicating their needs and accessing appropriate services; develop tools to assist CMH staff in understanding CSHCS youth and their families; and develop tools to assist LHDs in understanding mental health and I/DD services and how to assist families in accessing these services.

Building on prior accomplishments, in FY 2022 the collaborative workgroup will finalize and publish a toolkit for families needing assistance from CSHCS and mental/behavioral health and I/DD systems. In addition, the workgroup will update, publish, and promote a series of webinars describing the mental/behavioral health, CSHCS, and I/DD services for families. The workgroup will continue to provide outreach and education sessions for both mental health and I/DD staff regarding CSHCS and services available through the program. Finally, work will continue in FY 2022 to explore high-level policy priorities (such as respite physical and behavioral health integration) and to improve systems of care for this shared population.

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 or ability to succeed 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. According to the U.S. Department of Justice, 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; approximately 40% were victims of two or more violent acts. 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 aimed at ensuring that children who are exposed to trauma in their home, school or community receive appropriate interventions to help them achieve academically at their highest levels 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, class 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 include the design, development, pilot testing, implementation and tracking of a centralized online notification system that streamlines and automates HWC notices from law enforcement to the appropriate school liaison. Currently, no such system exists in Michigan to support the 49 counties currently implementing HWC. Each site has been tasked with manually creating, tracking and responding to these notifications. Local HWC partners have expressed a need for a centralized system for reporting notices. A centralized online portal will create efficiency across the state and will provide an efficient process for law enforcement to submit the HWC notice and for the local school entity to receive the information.

Once the system is established, it will allow the state to monitor HWC notices among counties participating in the initiative. This statewide data will be used to help with quality improvement and to make informed decisions regarding the program. The online portal will also assist with the expansion of HWC over time, as the streamlined system will decrease the amount of work needed when creating a HWC program in a new jurisdiction.

Title V block grants dollars are being used to fund the development, design, pilot and maintenance costs associated with the online portal. It is anticipated that the development of this portal will be an incentive for additional counties to adopt the HWC initiative and allow for more widespread trauma sensitive supports to be provided in Michigan’s schools.

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