Oregon’s Medicaid providers are preparing for a top-to-bottom look at how well the state’s health infrastructure is addressing young children’s social and emotional health leading up to kindergarten.
The review comes in response to research pointing to how important the first five years of a child’s life are to their development, affecting their ability to regulate emotions and form relationships. But the state’s medical and behavioral health system hasn’t always served children’s social and emotional health.
If all goes according to plan, Oregon’s coordinated care organizations will have a better picture of what social and emotional health services are available for kids and what needs are going unmet.
“This is the first in the country and there are alot of people watching Oregon,” said Colleen Reuland, director of the Oregon Pediatric Improvement Partnership, a group that seeks better health outcomes for children and developed the new policy. “This is pretty transformative because it’s asking the system to do things it hasn’t done before.” she said.
Children’s social and emotional development in the first few years of life has lasting impacts. Research shows that poverty, parental substance abuse and other environmental factors can lead to children having long term behavioral, social and emotional difficulties.
Reuland said signs of concern could be a child that’s overly shy or anxious, doesn’t eat, struggles with transitions, can’t self-regulate in a community setting or read the emotions of another child. Interventions could include parenting classes or therapy, she said.
The social and emotional health of children is an important part of being ready for kindergarten, where language skills and peer interaction matters, said Elisabeth Wright Burak, a senior fellow at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families.
“Everything that you are expected to do in kindergarten relies on psychological abilities,” she said.
The widely used Bright Futures pediatric guidelines now include a focus on children’s social and emotional health and kindergarten readiness. Oregon’s early learning plan calls for more social and emotional health services.
But a 2020 Oregon secretary of state audit found that the state’s fragmented behavioral health system is leaving children and families in crisis.
Wright Burak said identifying kids with emotional-regulation problems, signs of autism or untreated mental health conditions and intervening early can help them be ready for kindergarten. The Medicaid system is the logical place to reach these kids and their families before they enter school, she argued in a 2018 report.
Forty percent of children in Oregon get health coverage through Medicaid or another government program. Over half of children receiving government insurance have at least one “social complexity factor,” such as living in poverty, a language barrier, a parent who is incarcerated or a parent who is enrolled in substance use disorder treatment.
But Reuland said that just 5% of publicly insured children get a social-emotional health assessment. Fewer than 6% of these children receive a service related to their social or emotional health.
“We want to improve, but that’s a hard place to start,” said Reuland.
Over the summer, the Oregon Health Authority adopted a policy giving coordinated care organizations an incentive to start addressing the gaps in social and emotional health services for young children.
Oregon’s 16 CCOs are at the center of the state’s unique Medicaid system that’s structured to improve health outcomes while reducing costs.
They contract with the state to provide Medicaid services and can flexibly spend money on services that aren’t directly related to patients’ health but result in fewer trips to emergency rooms or other costly medical services. CCOs are financially rewarded if they meet metrics showing patients are getting cancer screenings, quitting smoking, seeing their doctors for follow-up visits and meeting other targets.
Under a new Oregon Health Authority metric, CCOs in January will begin reviewing data and mapping out what social-emotional health services and resources are available.
They’ll also engage preschools and other early learning programs, behavioral health providers and other community stakeholders on what social and emotional health services are available for children up to age 5, said Reuland. In particular, CCOs will have to engage with populations that have challenges accessing services, she said.
“What Yamhill County will do will look very different from what Portland or eastern Oregon will do,” she said.
From there, CCOs will develop action plans. By 2023 or 2024, CCOs will have to prove their plans are improving children’s social and emotional health.
She said the COVID-19 pandemic has made this work even more urgent because it’s created more stressful environments for kids who’ve missed out on social development at preschools, play dates or storytime at the library.
Over the spring, an Oregon Health Authority committee that signed off on the metric heard from the medical community about how it could drive bigger changes.
Dr. R.J. Gillespie, a pediatrician at The Children’s Clinic and affiliated with the Oregon Pediatric Society, said in a letter to the committee that CCOs should look into the capacity of behavioral health providers and ability of primary care practices to address social and emotional wellness of kids.
She said she hoped the metric would go beyond a checklist and address the larger system that impacts kindergarten readiness and child wellness.
Dr. Suzanne McClintick, a physician at Childhood Health Associates of Salem, also said in a letter to the committee that the metric could be a “powerful tool for transformational changes in the delivery of services in primary care to promote positive long term outcomes for all children.”
Earlier this year, 11 CCOs participated in a pilot project to test out how they would measure kindergarten readiness. They’re all on board.
Josh Balloch, vice president of government affairs and health policy at CCO AllCare Health, said it makes sense that education would eventually be linked to health. He said Oregon’s Medicaid system seeks to address social determinants of health, meaning environmental or social factors that impact an individual’s well-being.
“Getting those upstream investments are part of that long term goal,” he said. “This isn’t some new-fangled idea. This was part of a very long term process.”
You can find Jake Thomas at @JakeThomas2009 on Twitter.