Count children with mental health problems among those facing obstacles to care during the pandemic.
After spending several months focused on COVID-19, the Oregon Health Authority has delayed a program for low-income families to help children with mental health problems stay in their homes and out of institutions or the troubled foster care system.
The delay marks another setback for Oregon, a state that struggles to provide adequate behavioral health care services to residents of all ages and has come under scrutiny in recent years for its foster care system.
The program, called Intensive In-Home Behavioral Health Treatment, is intended to be part of the solution. Therapists go to the homes of children to offer counseling, parenting advice and support to help youth before their situation becomes so dire that officials feel they need to be taken out of the home and placed in foster care, a residential program or in juvenile detention.
The program’s emphasis on prevention marks a new strategy for Oregon, one that the state projects will actually cost less in the long term. Officials predict the in-home visits will keep 300 youth out of psychiatric residential treatment in its first year. The ultimate goal: address problems earlier before they turn into a full-blown crisis that will cost taxpayers more and send youth to a residential setting.
Now Oregon children have been put on hold. The program was supposed to start in July, but state officials have pushed back the start until January to save money and give coordinated care organizations and the health authority more time to prepare. COVID-19 put the state behind schedule, said Sarah Kelber, spokeswoman for the authority.
The delay will save the authority a pittance: $3.5 million.
The decision represents how priorities have shifted amid the pandemic. In 2019, the Legislature passed a package of child welfare reforms, including the program. Brown backed the legislation, signing it into law on Sept. 23 in a publicized event at the Corvallis Boys and Girls Club. She declared at the time: “Oregon’s system of care has been overburdened.”
But then the pandemic hit, slamming state revenues. State economists project a shortfall of $2.7 billion in the upcoming year following the close of businesses, restaurants and bars that put hundreds of thousands of Oregonians out of work. Lawmakers expect to go into a special session later this summer to balance the budget, an unpredictable scenario that depends on whether Congress will send states more federal relief to offset deep cuts.
Delaying the program won't save much in the needed budget reductions that hang over the health authority. The agency drafted plans for a possible 17% cut to its budget for the next year, representing more than $370 million with federal matching dollars. The $3.5 million trim is less than 1% of that total. The authority suggested delaying the program in its list of possible budget cuts, and Brown included the item in an initial round of nearly $150 million in reductions across all agencies.
When the program was crafted in 2019, the financial outlook was different. The Legislature gave the Oregon Health Authority $6.6 million to roll out the program and make it eligible for federal Medicaid matching funds through coordinated care organizations, said Sarah Kelber, a spokeswoman for the authority.
People in Medicaid who are on the so-called open card plan, which gives them a choice of providers, will have access to in-home therapist visits starting this month because it is required by law as part of the Oregon Health Plan. Most Medicaid recipients belong to a coordinated care organization, which won’t start the program until January.
Oregon Health Authority officials acknowledge that the state needs the program.
“When children get the access to the right behavioral health services when they need them and for as long as they need them, children get better,” Kelber said in a statement. “When they get better, they are able to stay at home, be in school and be successful in their communities.”
State Starts Groundwork
In 2018, Brown convened a working group to look at the children’s behavioral health system and come up with recommendations for the 2019 session. Andrew Grover, executive director of Youth Villages in Oregon, chaired the group, which included the insurance industry, coordinated care organizations and providers.
Youth Villages, a nonprofit provider based in Memphis, Tennessee, is a model for the program. It has offered intensive in-home behavioral health services to children in Oregon since 2011, serving nearly 930 children in the Bend, Salem and Portland areas, according to its 2019 report.
The organization tries to bridge the gap between regular outpatient therapy and residential treatment programs offering more expensive around-the-clock care.
“For most of my experience in the Oregon system, there's never really been that middle level of care that's more than outpatient but doesn't require the out-of-home removal, and that's where in-home services come in,” Grover said. “Therapists go into homes, see the families and help them identify issues and goals.”
The visits are frequent, often at least three or four times a week, and they last four to six months. As a result, most therapists at Youth Villages work with just four or five families at any given time, Grover said.
The program receives referrals from a variety of sources, including child welfare workers, schools and families. The families often may be one step away from their child entering a residential program or foster care because of neglect or drug or alcohol abuse in the home. Or maybe the children had trouble with police and risk entering juvenile detention without a change in behavior.
Before enrolling a family, a therapist meets with the parents and child at their home to determine whether the environment is safe and the child can be helped.
The providers tailor their approach to the situation, working with both parents and the children. For example, the therapists work with parents to develop skills they may need in parenting and correcting their children. They also work with children to address past trauma, which may include abuse or bullying. The therapists help youth develop goals for life skills and good behavior, with an eye toward staying in school, out of trouble and with their families.
Success stories include children who become willing to attend school after chronic absenteeism or youth who learn how to have healthy relationships with friends and family.
At any given time, Youth Villages works with about 100 families in Oregon. Each year, the group serves between 250 and 300 families in Oregon.
“Demand for our services has grown incrementally as people have become familiar with it,” Grover said, adding that the families are drawn to the concept of an intense and structured program in their homes.
The kinds of behavioral issues can vary from acting out to a threat of suicide. Children may want to avoid school, have behavior problems or want to harm themselves.
“Some of the most common things that we see (children) struggling with are the level of depression and anxiety that are leading them to want to harm themselves or take their own life," Grover said. “We also see young people who have experienced significant trauma.”
Youth Villages follows up after the program ends to gauge success. A national survey of its participants one year after leaving the program found that 95% were in school, graduated or employed and 89% had avoided trouble with the law.
The state expected the new program and its initial funding to provide services to about 1,500 children up to age 18, budget documents show. That projection also included another $13 million in matching federal dollars. The state expected those costs would save the expense of putting 300 young people in expensive psychiatric residential care, records show.
Like other providers, the program has adapted to the pandemic. Therapists use video conferencing technology to visit with families but they still make in-person visits in high-risk situations, Grover said, and they respond directly when families have a crisis and need help. “We're all thinking about what part of this new way of working with families will survive post-pandemic,” Grover said. “There are some staff that are itching to get back out and engage with families.”
Advocates Tout Prevention
Advocates support the program’s approach. It addresses problems before they grow into larger issues for children and families, said Chris Bouneff, executive director of the Oregon chapter of the National Alliance on Mental Illness.
Intervening early can keep children out of the institutional system which is what happens now, he said.
“By the time the state intervenes, the damage is done” under the current system, he said.
He would like the program to begin on time but acknowledges that the state has to cut somewhere and that it’s easier to delay a program rather than cut an existing one.
“There’s a certain logic to not spending money that hasn’t been spent yet,” he said. “It’s a tricky position the state’s in. I don’t envy the way they have to do decision-making.”
Like Brown, he hopes the federal government will step in and help the state plug at least part of its budget gap as a pandemic relief measure.
“This is an actual approach to care that would pay long-term dividends,” he said. “My hope is the federal government will do a type of rescue package that allows the state to fill critical holes.”
CareOregon, which has more than 375,000 people on Medicaid with three coordinated care organizations, pushed hard for the program and funding in the 2019 session. Jill Archer, vice president of behavioral health at CareOregon, told lawmakers in testimony that coordinated care organizations have seen the impact of a fragmented system that serves children. Coordinated care organizations in 2018 asked Brown to form a cabinet to address children’s issues, which helped spur the working group.
In a statement to The Lund Report, Archer said change in the timeline “will put the CCOs and their service areas in a better position to launch this new program which is home based.” Disability advocates see potential in the program. Tom Stenson, deputy legal director of Disability Rights Oregon, said intensive in-home behavioral supports can help children, reduce trauma and save money.
“These services could help many children stay in their family home, maintain connections to their family and community, live richer lives and achieve better life-long outcomes,” Stenson said in a statement. “This program is necessary to reverse long-standing failures to provide behavioral supports to children. In the absence of these simple supports, children have been forced into locked detention facilities, homeless shelters, and out-of-state facilities. We hope these supports can be put in place as soon as they can be safely provided.”