Continuum of care
Overview
Coverage of a robust continuum of care tailored to the unique needs of children, youth and families is foundational to meeting EPSDT requirements and ensuring states have a well-functioning behavioral health system.
CMS has articulated key categories of services that must be covered as a result of EPSDT, including behavioral health screenings and assessment, early intervention programs, community-based behavioral health services at varying levels of intensity, crisis care, and inpatient treatment when necessary.* However, the federal government has not detailed specific services that must be covered as a result of EPSDT, reflecting a determination that such decisions are more appropriately left to states, clinical experts, and other key partners. To begin to fill this gap, in this section CHA offers a description of a comprehensive continuum of behavioral health services that can and should be available to children and youth under 21.
CHA’s continuum below describes key behavioral health services and supports that are aligned with EPSDT requirements. The 13 key categories in the continuum range from prevention and early intervention to more acute inpatient and residential treatment. The continuum also includes “cross-cutting” categories with services and supports that can be integrated at any level of care. These cross-cutting categories include behavioral health services and supports provided in school-based setting, family supports, and services to address health-related social needs. It also includes services and supports that are tailored specifically to the needs of children and youth living with complex or co-occurring needs, including physical health conditions, substance use disorders (SUDs) and neurodevelopmental disabilities. All services included in a robust behavioral health continuum should be accessible, non-stigmatizing, trauma-informed, and integrated across a variety of settings, such as schools, health care and community-based settings.
In developing the continuum, CHA and member hospitals looked to:
- CMS guidance on EPSDT requirements and implications for child and youth behavioral health care;*
- Existing resources and literature on what comprises a comprehensive array of behavioral health services, including the American Society of Addiction Medicine criteria for adolescents, assessment tools such as the Child and Adolescent Level of Care Utilization System, Child and Adolescent Needs and Strengths and Child and Adolescent Service Intensity Instrument, and SAMHSA frameworks on child and youth behavioral health crisis care and a comprehensive mental health and SUD service system;*
- The outcomes of recent EPSDT, ADA and Section 504 litigation requiring coverage of specific intensive home and community-based care options such as intensive care coordination, intensive home-based services and mobile crisis services for children and youth; and
- Clinical expertise on the array of services that are necessary for children and youth from members of CHA’s BHLC and national experts.
CHA’s continuum is not intended to be the definitive source of behavioral health services and supports for children and youth; instead, it provides a framework that hospitals can use to help assess what services are available to Medicaid-enrolled children, youth and families consistent with EPSDT requirements.
While CHA’s continuum offers an important starting point that children’s hospitals can use to assess the benefits available in their state, it is important to note that under EPSDT, states must offer children and youth any services coverable under 1905(a) authority that are necessary to correct or ameliorate their condition. Moreover, the example services and supports in CHA’s continuum are not exhaustive of all behavioral health services and models that a state may provide or that a young person might need. States have discretion to determine the specific therapeutic models that they will cover to meet children’s needs. Finally, CHA’s continuum only describes services that can be covered under Medicaid’s EPSDT benefit: some key services for children and youth with complex conditions are not coverable under EPSDT but are nonetheless important in a robust continuum of care and can be covered using other federal Medicaid authorities (see Strategy 3 for a discussion of how and why to cover these additional services).
Prevention & Early Intervention
Description
A core tenant of EPSDT is to identify health issues early. EPSDT covers services that promote health and wellbeing by averting the onset of or lessening the progression of a behavioral health condition. CMS and the legal system have made it clear that EPSDT requires regular behavioral health and developmental screenings and comprehensive assessments, including through use of a standardized assessment tool.* Prevention and early intervention programs covered under EPSDT also include health education and services that reduce the risk of developing a behavioral health condition and support early identification and treatment. Many prevention and early intervention services take an integrated, whole-child approach to support overall emotional and behavioral wellbeing. Prevention and early intervention services can also be provided as part of integrated primary care and behavioral health practices.
Example Services and Supports
- Behavioral health promotion and prevention services, such as early childhood programs, family education, dyadic programs that support the child and parent/caregiver together and community-based prevention programs
- Behavioral observations
- Behavioral health well visits
- Behavioral health and developmental screenings in the Bright Futures periodicity schedule*
- Inter-periodic behavioral health and developmental screenings as needed
- Comprehensive assessments that provide the foundation for individualized care planning
- Targeted prevention services for young people and families at high risk of a behavioral health condition, such as skill-building programs, parent/caregiver counseling, pediatric occupational therapy, crisis prevention and safety planning, and youth peer support programs
- Brief, short-term counseling for children and families with emerging behavioral issues
- Behavioral health service navigation
- Linkages to ongoing behavioral health care
Outpatient Services
Description
Outpatient services are the way that the majority of children, youth and families with less intensive or complex needs interact with a state’s behavioral health system. EPSDT requires coverage of all necessary individual, group, and family-based therapy, as well as case management and medication support. A comprehensive set of outpatient services also includes evidence-based therapies and modalities for children, youth and families that are research-backed. Outpatient services may be delivered in a provider’s office or clinic, or at home, school, or via telehealth.
Example Services and Supports
- Individual, group, and family therapy, including dyadic therapy and evidence-based psychotherapies such as cognitive behavioral therapy, dialectical behavioral therapy, and parent-child interaction therapy
- Youth and family/caregiver peer support services
- Specialized therapies for children and youth with co-occurring needs, such as eating disorder therapy
- Specialized services for children and youth with co-occurring behavioral health and neurodevelopmental disabilities, including behavioral therapy, social skills training, speech therapy, occupational therapy, educational counseling, and aides or paraprofessional supports for skill-building and personal care
- Case management
- Skill building services
- Psychosocial rehabilitation
- SUD services, including individual, group and family counseling and co-occurring treatment for children and youth with mental health and SUD needs
- Medication support services, including medication for addiction treatment for young people with SUD
- Risk and safety assessments and other psychiatric services when needed
Intensive Care Coordination
Description
In addition to outpatient case management, when interpreting EPSDT, the legal system generally has found that states must cover intensive care coordination (ICC) for children and youth living with complex behavioral health needs.* ICC services are often team-based and include assessment and service planning, support accessing services, and support coordinating service delivery, including during transitions of care. In some instances, the courts specifically have required the provision of High Fidelity Wraparound, a model of ICC that uses a team-based, collaborative process to support children and youth with complex needs who may otherwise need out-of-home placement.
Example Services and Supports
- ICC, which may be delivered using a High Fidelity Wraparound model
- Tailored ICC for children and youth with complex needs, such as specialized ICC for early childhood, youth in child welfare, youth who are justice-involved, or youth with neurodevelopmental disabilities
Intensive Home-Based Services
Description
EPSDT-related litigation has also resulted in states being required to cover IHBS. These individualized, strengths-based services help a child or youth build the skills to successfully function in their home or community. IHBS – in concert with ICC and community-based crisis services – can reduce the need for hospitalization, residential treatment, or out-of-home placement. IHBS are often delivered alongside ICC using a team-based approach that includes provision of crisis services, skill-building activities, intensive therapeutic services and youth and family peer support services. While many of these services are also part of other categories in the continuum of care, IHBS refers to delivering such services in a high-intensity, coordinated way for children and youth otherwise at risk of residential or inpatient treatment.
Example Services and Supports
- Individual and family therapy provided at home, including intensive, evidence-based therapies like Multisystemic Therapy, Functional Family Therapy, Therapeutic Foster Care and Coordinated Specialty Care for first episode psychosis
- Youth and family/caregiver peer support services
- Crisis planning, crisis intervention and crisis stabilization provided at home
- Skill-building activities
- Family/caregiver support services (see “family supports” below)
Intensive Outpatient Programs
Description
EPSDT covers necessary intensive outpatient programs (IOPs) that are more intensive than traditional outpatient therapy but less restrictive than inpatient or residential treatment. IOPs are designed for children and adolescents who need frequent, structured support for their mental health or SUD needs, but who may not require 24-hour supervision. IOPs may include individual and group therapy, skill-building activities, case management and medication support.
Example Services and Supports
- Mental health IOPs that support children and youth with emotional and mental health issues
- SUD IOPs that focus on treatment for alcohol and/or drug use
- Specialized IOPs for children with co-occurring mental health and SUD needs, complex trauma, or other complex needs
Partial Hospitalization Program
Description
Partial hospitalization programs (PHPs) are structured, intensive behavioral health programs that provide day-long treatment for children and youth who need a higher level of support than outpatient or IOP services, but who do not require 24-hour supervision. PHPs often combine therapy, skill-building and family support to facilitate step-down from an inpatient or residential setting or divert a child or youth from facility-based care.
Example Services and Supports
- Mental health PHPs that provide structured support for children and youth with emotional or mental health conditions
- SUD PHPs that focus on SUD treatment
- Specialized PHPs for children with co-occurring mental health and SUD needs, complex trauma, or other complex needs
Crisis Services
Description
EPSDT requires coverage of crisis services to assess, stabilize and treat children and youth experiencing acute distress and help divert young people in crisis from the emergency department. Crisis services can be part of IHBS and available as standalone services when a child or youth is experiencing a mental health or SUD emergency. A robust set of crisis services includes initial crisis response, treatment, and ongoing stabilization. Mobile Response and Stabilization Services (MRSS) are a best-practice crisis model for children and youth that emphasizes community-based crisis response and ongoing stabilization. The MRSS model also supports ongoing relationships between the young person and family and the crisis team.
A robust crisis continuum also includes elements that cannot be entirely covered by Medicaid, such as a coordinated response system that utilizes the 988 Suicide and Crisis Lifeline or local crisis hotlines to facilitate access to crisis services.
Example Services and Supports
- Community-based mobile crisis services, including MRSS
- Crisis intervention services
- Crisis stabilization services, including crisis stabilization units, urgent care or walk-in crisis centers, and crisis observation units
- Crisis follow-up and ongoing stabilization services
Inpatient Services
Description
EPSDT requires coverage of intensive clinical services provided in a secure hospital setting when a young person is at immediate risk of harming themselves or others or cannot be safely stabilized in the community and requires 24/7 monitoring and support.
Example Services and Supports
- Inpatient services to stabilize a child or youth and provide intensive therapeutic supports
- Psychiatric Residential Treatment Facilities (PRTFs) for young people living with significant behavioral health needs who require 24/7 clinical oversight
- Specialized inpatient units with tailored clinical expertise, such as inpatient units for eating disorders, for children and youth with neurodevelopmental disabilities, or trauma-focused units
- Medical-psychiatric inpatient units that treat youth with co-occurring medical and behavioral health needs
Residential Treatments
Description
When necessary, EPSDT covers intensive treatment provided in a structured residential setting focused on therapeutic support and skill development. Residential treatment settings vary in intensity and focus and may include Qualified Residential Treatment Programs (QRTPs) for children and youth in child welfare, specialized residential programs for children and youth with co-occurring needs, and transitional settings to support stabilization or step-down to community-based care.*
Example Services and Supports
- Residential treatment provided in a smaller, home-like setting such as a therapeutic group home
- QRTPs that provide short-term, clinical focused residential treatment for children and youth involved in child welfare
- Specialized residential programs with tailored expertise, such as trauma-specific programs, SUD residential programs, and culturally specific programs like indigenous youth residential treatment centers
School Based Services
Description
Schools are important settings for delivering EPSDT services, as young people spend a majority of their time at school. While these services are also part of other categories of the continuum of care, CMS has identified use of school-based services as a key way for states to meet EPSDT obligations.* Services that are especially important in school-based settings include screenings and assessments, individual counseling and therapy, case management, and referrals and linkages to behavioral health care outside of school when needed.
School-based services may be needed at any level on the continuum of care.
Example Services and Supports
- School-based prevention and early intervention services, including behavioral and developmental screenings and assessments
- Individual and small group counseling and therapy for students at high risk of a behavioral health condition or with emerging behavioral issues
- More intensive individual counseling, therapy, skill building, psychosocial rehabilitation, and case management for students with significant or ongoing behavioral health needs
- Services for students with neurodevelopmental disabilities, including social skills training, speech therapy, occupational therapy, educational counseling, and aide or paraprofessional supports for skill-building and personal care
- Linkages to ongoing behavioral health care
Family Services and Supports
Description
CMS has made it clear that EPSDT covers services and supports for family members for the direct benefit of the child, including health education, family therapy, skills training, and case management.*
Outside of EPSDT, states can cover additional family supports like respite care and home visiting programs using other Medicaid authorities and robust behavioral health services for Medicaid-enrolled parents and caregivers (see Strategy 3 below).
Family services and supports may be needed at any level on the continuum of care.
Example Services and Supports
- Behavioral health service navigation
- Family therapy, including dyadic evidence-based practices that treat the child and family together
- Family/caregiver peer support services, including peers with tailored experience with SUD, eating disorders, and the juvenile justice and child welfare system
- Linkages to family education programs, such as the NAMI Family-to-Family program
- Linkages to housing, food and other supports
- Ongoing family involvement in treatment planning, transitions of care, school-based services, in-home services, and crisis planning and stabilization services
Services to address health-related social needs
Description
EPSDT covers referrals and linkages to services and supports to address health-related social needs such as physical health, housing, food, legal services and transportation services.
Outside of EPSDT, states may be able to use other Medicaid authorities to cover supported employment and supported education, flexible funds, community events and activities, and food, housing and other services that address health-related social needs (see Strategy 3 below).
Services to address health-related social needs may be needed at any level on the continuum of care.
Example Services and Supports
- Linkages to physical health, housing, food, legal services, transportation services
- Linkages to supported employment and education, flexible funds, and community events and activities when available
Specialized treatment for young people living with complex needs
Description
EPSDT requires coverage of necessary specialized services for young people living with complex behavioral health needs, such as those who have co-occurring mental health conditions and neurodevelopmental disabilities, SUDs or physical health conditions. Specialized services can be integrated at every level of the continuum of care and can include specialized treatment centers for young people with co-occurring SUDs or physical health conditions, and evidence-based therapies to support children and youth with behavioral health needs who are involved in multiple systems.
Specialized treatment for young people living with complex needs may be needed at any level on the continuum of care.
Example Services and Supports
- Specialized therapies for children and youth with complex needs or who are involved in multiple systems, such as Multisystemic Therapy and Functional Family Therapy
- Specialized services for children and youth with co-occurring needs including eating disorder therapy
- Specialized services for children and youth with co-occurring behavioral health and neurodevelopmental disabilities, including behavioral therapy, social skills training, speech therapy, occupational therapy, educational counseling, and aides or paraprofessional supports for skill-building and personal care
- Therapeutic foster care services
- Tailored ICC for children and youth with complex needs
- Specialized IOPs, PHPs, residential facilities and inpatient units with tailored clinical expertise for eating disorders or children and youth with co-occurring mental health conditions and neurodevelopmental disabilities or SUDs
- Family peer partners with tailored experience with SUD, eating disorders, and the juvenile justice and child welfare system
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Section 04
Advocacy Strategies