1. Financing Strategies for Early Childhood Comprehensive Systems Deborah F. Perry, PhD Director, Women’s & Children’s Health Policy Center Johns Hopkins School of Public Health and Kay Johnson, MPH, EdM Director, Project THRIVE at NCCP President, Johnson Group Consulting

2. An Early Childhood Systems’ Framework Developed by Roxane Kaufmann, GUCCHD; design by: Lucia Foley, Hampshire Educational Collaborative

3. Continuum of ECMH Services and Supports  Promotion  Prevention  Intervention

4. Promotion  Developmental and social-emotional screening in primary care and early care and education programs  High quality child care  High quality training on social-emotional development  Use of an evidence-based early childhood curriculum  Dissemination of information promoting healthy social- emotional development

5. Prevention  Home visitation programs  Mental health consultation  Family mentors  Social skills curricula  Family supports  Caregiver supports

6. Intervention  On-site mental health consultation  Crisis teams  Wraparound services  Relationship-based therapy  Hotline for families  Behaviorally-based programs in a variety of settings  In-home treatment

7. Level 1. Services to strengthen caregiver skills and relationship with child. Level 2. Services for families and children with identified social risks, delays, special health needs, and disabilities. Level 3. Services to families of children diagnosed with serious emotional disorders or severe mental/ behavioral health problems. Source: Infant Mental Health Services for Young Children and Families. Florida State University, Center for Prevention and Early Intervention Policy. © 2000 Florida’s Model for IMH

8. Examples of Services  Screening to detect social-emotional delays and risks.  Child development advice from pediatric care providers.  Mental health support through home visiting programs.  Mental health consultation for child care and other early childhood learning programs.  Interventions to repair parent-child relationships.  Treatment for children with significant mental health problems.  Substance abuse treatment for parents, which includes a child-centered component. See: Neurons to Neighborhoods; Bright Futures; Zero to Three Policy Center.

9. Successful Efforts  Making new investments  Using multiple public financing streams  Financing a wide array of interventions  Maximizing resources through collaboration and planning  Building on early childhood initiatives

10. Finance Strategies Grounded in Research & Best Practices  Use research evidence about what children need and how to deliver it.  Benefit from experience in other states.  Aim to finance intentional, research- informed intervention strategies.  Conduct cross-system fiscal and program analysis and planning. Source: Jane Knitzer. NCCP. 2006.

11. Do we know what works?  Early detection and prompt interventions can improve outcomes (i.e., “shift the odds”) for both children living in high-risk environments and those with biologically based disabilities. (IOM)  Preventive interventions have been shown to be effective in reducing the impact of risk factors for mental disorders and improving social and emotional development. (Surgeon General)  Interventions tailored to specific needs have been shown to be more effective in producing optimal outcomes than services that provide generic advice and support. (IOM)

12. Typical ECMH Challenges System Challenge Insufficient focus on early identification Failure to intervene for early risks Approaches not family centered, age-appropriate Children fall through gaps between systems Limited provider capacity Program fragmentation Finance Challenge Unbundled financing for S/E screening & diagnosis How to finance services for child without diagnosis No coverage for parent-child services, for age appropriate interventions Eligibility definitions and overlap for dually eligible young child Adequacy of provider reimbursement; training dollars Interagency turf battles; gaps in financing

13. Opportunities within Each Program  Improve screening and diagnostic evaluation.  Do more outreach and monitoring for high-risk.  Improve access to appropriate services.  Develop clear, functional eligibility definitions.  Enhance professional training and capacity.  Overcome fiscal, administrative and policy barriers.

14. Spending Smarter Using Federal Programs and Policies to Promote Healthy Social and Emotional Development Among Our Most Vulnerable Young Children Kay Johnson and Jane Knitzer NCCP, 2006.

15. Financing Early Childhood Mental Health Services

16. Reflect before Deciding Among Financing Options  Mission: Does the finance strategy enable the initiative to follow its mission?  Results Focus: Does it fit with desired results?  Accessibility: Does the strategy enable service delivery to target populations?  Fairness: Does it distribute costs fairly?  Adequacy/Stability: How much revenue does this generate? How stable is the potential revenue?  Efficiency: Do the benefits outweigh the administrative costs? What are the opportunity costs?  Politics: Does the strategy help the initiative gain allies and partners, or does it create opponents and turf battles? Source: The Finance Project. H. Stebbins & C. Hayes

17. Maximize Medicaid/EPSDT  Recommend age appropriate screening and diagnostic tools in EPSDT.  Separate billing for development screening and diagnostic evaluation (unbundle).  Cover services delivered in a range of settings.  Reimburse for parent-child (family) therapy.  Match funds for child care MH consultation.  Use age-appropriate diagnostic codes.

18.  Use ECCS planning to assess fiscal resources.  Include children with developmental, behavioral, or emotional challenges in definition of “special needs” (CSHCN).  Spend on services not covered by Medicaid.  Include social-emotional services in “medical home” initiatives. Title V MCH Block Grant Source: Spending Smarter. Johnson and Knitzer. NCCP. 2005.

19. Other Health & Mental Health Programs  Coverage for mental health in SCHIP.  Explicitly include Community Health Centers.  Use children’s mental health grants.  Use community mental health centers as a hub for early childhood mental health consultation. Source: Spending Smarter. Johnson and Knitzer. NCCP. 2005.

20. Child Care  Blend child care quality funds to finance early childhood mental health consultation (e.g., quality set aside)  Use CCDF to support training on social- emotional and school readiness.  Target funding to ensure highest risk get high- quality child care. Source: Spending Smarter. Johnson and Knitzer. NCCP. 2005.

21. Head Start & Early Head Start  Support mental health consultation.  Finance training to enhance the skills of parent-involvement coordinators, parent educators, etc.  Fund additional support services and referral for vulnerable children and their families. Source: Spending Smarter. Johnson and Knitzer. NCCP. 2005.

22. IDEA Special Education Programs  Finance appropriate social-emotional screening, evaluation, and services in Part C.  Extend Part C eligibility to infants and toddlers with social-emotional conditions and risks.  Build a continuum of services from 0-5, focusing state expenditures. Source: Spending Smarter. Johnson and Knitzer. NCCP. 2005.

23. Finance Strategies to Give Kids a “Leg Up”

24. Characteristics of Effective Systems  Involve different catalysts and different leadership  Involve partnerships and many stakeholders  Emphasize prevention and early intervention, not only “treatment”  Involve different entry points  Develop creative fiscal strategies  Build on existing early childhood programs  Work toward policy and systems change

25. State and Local Responsibilities  STATE: Clear point of responsibility/ accountability Committee on interagency collaboration at senior level Regular feedback from community and families Policy shifts related to funding and HRD State family organization/coalition  COMMUNITY: Local cross-system team responsible for planning, policy development, resource identification, training,monitoring Strong family involvement on this management committee Interagency review mechanism System for referrals Local family supports

26. State Leadership:  Adopt clear guidance & billing codes for :  Developmental checklists & screens (SCREENING) EPSDT periodicity schedules based on AAP recommendations State may choose to recommend several tools Broad range of providers may screen and bill Link Part C Early Intervention “child find” to your approach  Developmental assessment (DIAGNOSIS) Specific types of providers, consider qualifications Use age appropriate diagnostic codes (e.g., DC:0-3) Decide what happens when child has no clear diagnosis Clarify rules & regulations

27. State and local leadership:  Model behavior desired  Develop MOU/MOA to clarify agreements  Issue joint guidance & publications  Host meetings for cross-training  Develop and finance service strategies that bridge the gap between medical and non- medical services Interagency Coordination

28. State leadership:  Request / appropriate targeted dollars for early childhood projects  New appropriations to use for Medicaid state share  Small amounts of grant funding to jump start local pilots  Call for increased federal funding to states  IDEA Part C and Part B Preschool programs  Medicaid federal share  Expansion to children with disabilities Request additional funding

29. Spending Smarter means:  Capturing dollars that already exist in federal funding streams.  Maximizing efficiencies through systems approaches.  Blending and braiding funds.  Leveraging both smaller grant funds and entitlement dollars.  Using flexible funds to fill gaps in systems of care.  Paying for appropriate services.

30. Top Ten – things you could do now 1.Convene a group to review current funding. 2.Support strategies with interagency plans and written agreements. 3.Adopt a statewide definition of risk factors and mobilize resources to serve at- risk. 4.Blend dollars for “cross-training” professionals. 5.Maximize flexibility in smaller federal grant programs. 6.Clarify eligibility and payment mechanisms between Medicaid's EPSDT, Part C, Title V, and mental health, etc. 7.Adopt policies and billing mechanisms support developmental services. 8.Target high-risk populations; start with one group. 9.Finance two-generation strategies and parent-child interventions. 10.Monitor (track) children at-risk not yet eligible for entitlements.

31. Recent NCCP Publications: http:// www.nccp.org http:// www.nccp.org  Resources to Promote S/E Heath and School Readiness: A Community Guide  Pathways to Early School Success: Helping the Most Vulnerable Infants, Toddlers & Families  Challenges and Opportunities in Children’s Mental Health: A View from Families and Youth - Unclaimed Children Revisited  Spending Smarter ( Also THRIVE Issue Brief #1 Spending Smarter in ECCS)  THRIVE Short Takes  #1 The Deficit Reduction Act of 2005—Opportunities and Challenges for ECCS Initiatives  #2 Maximizing the Use of EPSDT to Improve the Health and Development of Young Children

32. For more information or questions contact us at Project THRIVE For more information or questions, contact us at Project THRIVE 646-284-9644 ext. 6456 Thrive@nccp.org Kay Johnson, MPH, MEd THRIVE Project Director Jane Knitzer, EdD Executive Director, National Center for Children in Poverty Suzanne Theberge, MPH THRIVE Project Coordinator Leslie Davidson, MD Senior Health Advisor

33. Selected References on Early Childhood Development and S/E Services  American Academy of Pediatrics, Committee on Children and Disabilities. Developmental surveillance and screening for infants and young children. 2001;108(1):192-6.  Glascoe, FP. Early detection of developmental and behavioral problems. Pediatrics in Review 2000; 21(8):272-280.  Institute of Medicine/National Research Council. From Neurons to Neighborhoods: The Science of Early Childhood Development. Shonkoff and Phillips, (eds), Washington, DC: National Academy Press, 2000.  Kauffman Early Education Exchange. Set for success: Building a strong foundation for school readiness based on the social-emotional development of young children. Kansas City: Ewing Marion Kauffman Foundation, 2002.  Knitzer. Building services and systems to support the healthy emotional development of young children:” An action guide for policymakers. New York: NCCP, 2002.  Lavigne JV,et al. Pediatric Practice Research Group. Behavioral and emotional problems among preschool children in pediatric primary care: prevalence and pediatricians' recognition. Pediatric Practice Research Group. Pediatrics 1993;91(3):649-55.  Minkovitz et al. A practice-based intervention to enhance quality of care in the first 3 years of life. JAMA, 2003;290(23):3081-3091.  Raver and Knitzer. Ready to enter: What research tells policymakers about strategies to promote social and emotional school readiness among 3- and 4-year-old children. New York; NCCP, 2002.  Regaldo and Halfon. “Primary Care Services Promoting Optimal Child Development from Birth to Age 3 Years: Review of the literature,” Archives of Pediatric and Adolescent Medicine, 2001; 155:1311-1322.  U.S. Public Health Service, Office of the Surgeon General. Mental Health: A Report of the Surgeon General (2003); and Report of the Surgeon General’s conference on Children’s Mental Health: A national action agenda (2000). Bethesda, MD: National Institute of Mental Health.

34. Selected References on Early Childhood Systems & Financing  Bruner C, Floyd S, and Copeman A. (2003). State Early Childhood Policy Technical Assistance Network - Financing School Readiness Strategies: An Annotated Bibliography. Des Moines, IA: Child and Family Policy Center.  Johnson and Kaye, Using Medicaid to Support Young Children’s Healthy Mental Development, National Academy for State Health Policy, Portland, ME, 2003.  Johnson, Knitzer, and Kaufmann. Making Dollars Follow Sense: Financing Early Childhood Mentla Health Services to Promote Healthy Social and Emotional Development in Young Children. New York: NCCP, 2002.  Johnson and Knitzer. Spending Smarter: A funding guide for policymakers and advocates to promote social and emotional health and school readiness. New York: NCCP, 2005.  Kauffman Early Education Exchange. Set for Success: Building a strong foundation for school readiness based on the social-emotional development of young children. Kansas City: The Ewing Marion Kauffman Foundation, 2002.  Knitzer. Building Services and Systems to Support the Healthy Emotional Development of Young Children: An action guide for policymakers. New York: NCCP, 2002.  Markus A, Rosenbaum S, Stewart A, and Cox M. How Medical Claims Simplification can Impede Delivery of Child Development Services. New York: Commonwealth Fund. 2005.  Rosenbaum,et al. Room to Grow: Promoting child development through Medicaid and CHIP. (Child Development Issue Brief ) New York: Commonwealth Fund. 2001.  Perkins, J. & Olson, K. (1999). Medicaid Early and Periodic Screening, Diagnosis and Treatment as a Source of Funding Early Developmental Services. National Health Law Program.  VanLandeghem K, Curtis D, and Abrams M. (2002). Reasons and Strategies for Strengthening Childhood Development Services in the Healthcare System. Portland, ME: National Academy for State Health Policy.