“When my daughter started kindergarten this August, she quickly noticed a classmate who was struggling to settle in. She told me about a boy who often cried, laid on the floor, and yelled at teachers. But my daughter also told me the boy was kind to her, and funny. She felt sad he was having so much trouble. A few weeks later, the boy was gone—transferred to another school.”
Haley McCrary
As professionals working in behavioral health and school-based services, not only have we encountered this situation ourselves, but we’ve heard stories like this from many others. We can’t help but wonder if more accessible mental health supports could have helped this boy—and others like him—stay in his community school.
The Urgent Need for School-Based Mental Health Services
At a time when one in six U.S. students has a mental health disorder and less than 20 percent receive adequate mental health care, expanding Comprehensive School Mental Health Systems (CSMHS) has never been more urgent. CSMHSs provide an array of supports and services that promote positive school climate, social and emotional learning, and mental health and well-being, while reducing the prevalence and severity of mental illness. It is a powerful tool for addressing students’ mental health struggles early on. If supported, CSMHSs offer evidence-based mental health care to students in an accessible environment: their schools.
Making these services available in schools is vital because schools are where youth spend most of their time. This approach normalizes seeking support, reduces stigma, and addresses access challenges caused by barriers such as a lack of transportation and parents’ ability to take time off for medical appointments. Students receiving care in schools are also more likely to engage in treatment than those referred elsewhere and have shown reduced absenteeism, higher academic achievement, and fewer disciplinary incidents. As the youth mental health crisis grows and funding opportunities expand, investing in CSMHSs is critical.
Navigating the Real-World Challenges of Implementing School-Based Services
Although the potential for CSMHSs is immense, schools and providers often struggle with implementation due to persistent workforce, administrative, and funding problems. One of the most common issues is the continued shortage of qualified mental health providers, which can keep schools from meeting rising behavioral health needs. When schools do bring behavioral health professionals on board, they then struggle to clearly define the roles of and expectations for established school personnel versus the new behavioral health hires, which can create confusion and hinder collaboration.
Fragmented funding structures and tricky coordination between Medicaid and educational systems also pose problems for schools. Regulatory barriers further complicate implementation as schools attempt to navigate data-sharing regulations, such as the Health Insurance Portability and Accountability Act and the Family Educational Rights and Privacy Act, which can hinder care coordination with students’ community-based providers.
On the financing side, perceived administrative burden and differing school and Medicaid regulations often impede federal reimbursement. Schools typically lack Medicaid-specific knowledge, sufficient staff, or infrastructure to navigate this complicated system. The challenges of de-coding state policies and reimbursement methodologies, executing contracts with payers, and following documentation requirements can quickly overwhelm them.
Agencies Can Take the Lead
State education agencies, state Medicaid agencies, and local education agencies (LEAs) play a key role in overcoming these obstacles by giving schools the guidance and support needed to navigate these complexities and deliver effective services. They can help schools expand their CSMHS programs and better meet the mental health needs of students by offering clear direction, including drawing on the recently released State Health Official letter about Early and Periodic Screening, Diagnostic, and Treatment requirements from the Centers for Medicare & Medicaid Services.
Some states have used policy, training, and technical assistance to tackle workforce, funding, and administrative challenges. The Colorado Department of Education supports school districts by funding mental health professionals through the School Health Professional Grant Program and providing technical assistance to streamline service delivery. California’s Children and Youth Behavioral Health Initiative provides incentives for managed care plans to partner with LEAs to implement behavioral health supports in schools and coordinate care across settings. Michigan collaborates with LEAs to simplify Medicaid billing for schools, providing comprehensive training on documentation requirements and offering tools that streamline administrative claiming. State and local agencies can look to these examples for ways to help schools handle issues such as recruiting qualified behavioral health professionals, navigating complex Medicaid funding streams, and simplifying administrative processes for documentation and billing.
Solutions to Support Implementation
Mathematica works closely with state and local agencies to offer scalable, sustainable solutions for implementing school-based services. Through our work on initiatives such as the Medicaid School-Based Services Technical Assistance Center (SBS TAC), California’s Children and Youth Behavioral Health Initiative, and a recent study for the Office of the Assistant Secretary for Planning and Evaluation on school-based behavioral health services in a post-COVID-19 era, we have seen firsthand the challenges that states and LEAs face in expanding CSMHSs. But we’ve also witnessed the innovative approaches and solutions they are using to overcome them.
To learn more about these solutions, visit the SBS TAC resource page, review resources from our past events, or join one of our upcoming ones. Register for the SBS TAC webinar on November 14, where we will discuss practical strategies for using Medicaid to support preventive school-based behavioral health services. And keep an eye out for our second blog post with key insights from the recent National Alliance for Medicaid in Education conference, showcasing how states are overcoming challenges and launching CSMHSs and other school-based services across the U.S.
School-based mental health services offer an unparalleled opportunity to improve child and community mental health. Although setting up these services can feel intimidating, solutions are available. State and local agencies can build on successful strategies to ensure that every school is equipped to deliver the mental health services their students need to thrive.
