Scaling California’s School-Based Mental and Behavioral Health Infrastructures

November 20, 2023

A new report examines the need for new funding pathways to scale mental and behavioral health infrastructures that support students and teachers.

State and local education agencies nationwide will soon arrive at the sunset of availability of ESSER funding—a substantial amount of federal aid dedicated to mitigating the detrimental effects of the COVID pandemic. This deadline raises the need for states and local education agencies (SEAs and LEAs) to identify and secure new funding pathways that would effectively support behavioral health and well-being in schools for both students and educators at unprecedented scales. However, for any state to accomplish this task, certain complex practical implementation challenges must first be overcome in the context of their long-run available resources, says Lupita Alcalá, project lead at the Region 15 Comprehensive Center (R15CC), a federally funded capacity-building technical assistance partner to SEAs in the Western United States.

A report drafted by R15CC, in partnership with the California Department of Education, describes some of those challenges and provides guidance to help leaders in California make informed decisions about allocating resources and optimizing technical assistance. The report, Improving Coordination and Access to California School-Based Mental Health Services, provides a landscape analysis that starts with identifying what is needed and by whom.

“We looked at where concerns were greatest and who needed to be served, plus demand and supply,” says Alcalá. This involved exploring student demographics, school climate survey data, and staffing ratios; conducting interviews with district, county, and state leaders; and performing a document scan of existing research, tools, and guidance.

One clear finding was that education leaders had varied understanding of how different funding streams could be leveraged to maximize programs and services and to plan for sustainability of a new mental and behavioral health infrastructure. The report offers insight into how to resource such efforts over the long term, and outlines potential opportunities presented by blending and braiding funds, as well as the limitations of those opportunities.

“Interestingly, we are seeing more states lean into understanding how they can better leverage Medicaid funds to support behavioral health supports over the long term. Medicaid, currently, is one of the few ongoing resources, across states, that can underwrite these services,” says Lisa Eisenberg, Child & Youth Health Financing Project Director at WestEd.

In California, approximately half of all LEAs participate in a school-based Medicaid reimbursement program known as the Local Educational Agency Medi-Cal Billing Option Program (LEA BOP). Under this program, participating LEAs leverage Medicaid funding to pay for direct health and behavioral health services for their students. Some LEAs partner with community-based organizations, while others hire individual providers in-house, to provide services and supports to students. The ability to maximize the use of Medicaid dollars for mental and behavioral health services differs across LEAs, depending largely on the capacity of the LEA to secure and use this funding. The report discusses the strategic use of Medicaid and other funding sources to support school-based and mental health programs.

In addition to guidance around funding, the report lays out important considerations for those looking to build comprehensive school-based mental health systems. Those key entry points are:

First, retain state-level staff to establish and maintain a system of ongoing cross-agency collaboration that effectively aligns accountability and support systems.

According to the report, state health and education systems typically serve LEAs and mental health providers separately, in parallel.

“Health and education systems are often attempting the same or related work siloed from one another,” says report co-author Amber Valdez, project lead at R15CC. “For example, they may have completely separate accountability systems and support structures, both aiming to continuously improve comprehensive mental and behavioral health programs that support children and youth.”

Alcalá adds, “They need to start with how each system can leverage the others’ strengths to shore up school-based mental health supports. What is the state’s responsibility, as they administer funding for state systems to interact with each other? And where are the gaps?”

In California, as elsewhere, significant funding is now available to support such cross-agency coordination, specifically $4 billion in Community Schools grants and another $4.7 billion in Children, Youth and Behavioral Health Initiatives.

Second, provide LEAs with training and technical assistance focused on cross-agency collaboration.

“Just as SEAs may not have cross-agency coordination mechanisms,” says Valdez, “the same thing exists at the local level. The infrastructure and technical support for collaboration need to be created at every system level. It’s not enough to mandate collaboration through policy; support systems must be in place to help build the conditions for collaboration.”

The report authors note that coordination across and within agencies can be achieved by putting local teams in place and providing them with training and technical assistance.

The report suggests that state-level training and guidance for LEAs and health providers—and subsequently from them to schools—include:

How to implement school-based health programs to maximize billing and reimbursement on health-care expenditures and to expand access to health care services for Medicaid-eligible students.

How to identify and coherently blend, braid, or otherwise pull together other available funding sources.

How to diversify each workforce to be representative of and responsive to the state population, including thinking differently about how to recruit people, ensure that people feel supported, train people in developing cultural competencies, and additionally, how to serve rural areas well.

How schools and districts can support the mental health referral process. The report describes four sample scenarios describing common partnership models—including better training on what is required by law (FERPA and HIPAA) and relationship building—so that referral pathways and services can be equitably and consistently offered.

What privacy laws and regulations say can and cannot be done.

Third, root local comprehensive school mental health approaches in the strengths, needs, and aspirations of the students, families, and local communities being served.

The report found that places with established referral pathways have strong partnerships between LEAs and community-based organizations, in addition to other practices that include partnerships and coordination with other system providers. “Community-based organizations are often trusted partners because they are known to the community and are likely to have staff with linguistic and cultural competencies that are relevant to the community,” says Alcalá.

For example, in California, according to survey data, ​the counties with the five highest percentages of 11th grade students responding that they missed a day of school in the last month due to feeling sad, hopeless, anxious, stressed, or angry, had, on average, a 51% Latinx population.

“Knowing who we need to serve—culturally and linguistically—and how, as well as deeply unpacking workforce demands, geography, remoteness, and barriers, is key,” says Alcalá. “Of the more than 1,000 districts in California, a majority are small, which poses a structural challenge with respect to providing mental health equitably.”

---

Related resources for SEAs and state health agencies

• Working Paper: California’s Children & Youth Behavioral Health Ecosystem
• Webinar series explaining the School Medicaid program to district and school audiences (Part One and Part Two), developed by California’s Department of Health Care Services and R15CC.
• California recommendations on expanding School Medicaid to address student health needs, particularly mental health.

Forthcoming this winter is a webinar on covering student mental health services through California’s state program.

The Region 15 Comprehensive Center works with SEAs in Arizona, California, Nevada, and Utah to improve outcomes for all children and better serve communities through capacity-building technical assistance. Visit the R15CC website for more information.

The contents of this post were developed by the Region 15 Comprehensive Center. The Region 15 Comprehensive Center is funded by a grant from the U.S. Department of Education. However, the contents of the post do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal government.