HOUSE BILL REPORT

HB 2779

As Reported by House Committee On:

Early Learning & Human Services

Appropriations

Title: An act relating to improving access to mental health services for children and youth.

Brief Description: Improving access to mental health services for children and youth.

Sponsors: Representatives Senn, Dent, Eslick, Bergquist, Tharinger, Goodman, Doglio, Pollet, Kloba, Macri and Santos.

Brief History:

Committee Activity:

Early Learning & Human Services: 1/16/18, 1/19/18 [DPS];

Appropriations: 2/1/18, 2/6/18 [DP2S(w/o sub ELHS)].

Majority Report: The substitute bill be substituted therefor and the substitute bill do pass. Signed by 13 members: Representatives Kagi, Chair; Senn, Vice Chair; Dent, Ranking Minority Member; McCaslin, Assistant Ranking Minority Member; Eslick, Frame, Goodman, Griffey, Kilduff, Klippert, Lovick, Muri and Ortiz-Self.

Staff: Dawn Eychaner (786-7135).

Background:

Children's Mental Health Work Group.

The 2016 Legislature established the Children's Mental Health Work Group (Work Group) to identify barriers to accessing mental health services for children and families and to advise the Legislature on statewide mental health services for this population. The Work Group published a final report and recommendations in December 2016 and expired in December 2017.

Medicaid Managed Care for Children.

The Health Care Authority (HCA) administers Apple Health, the state-federal Medicaid program that provides health care for eligible low-income individuals. Apple Health for Kids is available at low or no cost for children whose families meet income eligibility criteria. When purchasing managed care for Medicaid participants, the HCA must ensure that managed care organizations (MCO) demonstrate the ability to supply an adequate provider network. The MCOs must maintain a network of appropriate providers sufficient to provide adequate access to all services covered under the contract. The 2017 Legislature required the HCA and the Department of Social and Health Services (DSHS) to report annually, beginning in December 2017, on issues related to network adequacy for children's mental health.

The DSHS contracts with behavioral health organizations (BHOs) for the provision of behavioral health services in Regional Services Areas (RSA) in the state. The BHOs contract with mental health and substance use disorder treatment programs to provide services to Medicaid enrollees who have a medical need and meet Access to Care Standards established by the DSHS.

By January 1, 2020, behavioral health services must be fully integrated into MCOs that provide mental health services, substance use disorder services, and medical care services to Medicaid clients. Most RSAs are expected to have fully integrated purchasing of medical and behavioral health services ahead of the 2020 deadline.

Home Visiting.

Home visiting programs deliver voluntary services to children and families in the home or community and are designed to alleviate the effects of poverty and other risk factors on child development. The Department of Early Learning (DEL) administers funding for home visiting programs through the Home Visiting Services Account. In August 2017 the HCA delivered a Home Visiting and Medicaid Financing Strategies report to the DEL that included recommendations regarding the potential use of Medicaid funds for home visiting services.

Infant Nurse Consultant.

The DEL requires child care centers licensed to care for four or more infants to work with an infant nurse consultant. Rules adopted by the DEL require such centers to have a written agreement with an infant nurse consultant who visits the center at least monthly. The infant nurse consultant must be a currently licensed registered nurse who has either worked in pediatrics or public health in the past year or has taken or taught classes in pediatric nursing at the college level in the past five years.

Psychiatry Residencies.

The Accreditation Council for Graduate Medical Education accredits medical education and residency programs and associated sponsoring institutions. The University of Washington (UW) Child and Adolescent Psychiatry Residency Program based at Seattle Children's Hospital is an accredited psychiatry residency program.

Parent-Initiated Treatment.

A minor aged 13 and up may consent to outpatient treatment and may initiate inpatient mental health treatment, referred to as minor-initiated treatment, without the consent of a parent or guardian.

When a minor aged 13 or older is brought to an evaluation and treatment facility or a hospital emergency room for immediate mental health services, the provider or facility must notify the parent in writing of the option for parent-initiated treatment (PIT).

The parent or guardian may initiate the PIT process without the consent of the minor by requesting an evaluation for a mental disorder and inpatient psychiatric services. If the minor is found to have a mental disorder and meets medical necessity standards, the minor may be admitted for inpatient treatment.

The evaluation of the minor must be completed within 24 hours unless a medical professional determines that the condition of the minor necessitates additional time for evaluation. The maximum amount of time a minor may be held for evaluation is 72 hours. The Children's Long-Term Inpatient Administration at the DSHS receives notice within 24 hours of all PIT admissions and must conduct a review to determine whether it is a medical necessity to continue the minor's treatment on an inpatient basis. The review is an independent medical review completed within seven to 14 days after the PIT admission.

Beginning April 1, 2018, the PIT process will be expanded to include treatment for substance use disorder.

Educational Service District Mental Health Pilot Sites.

In 2017 the Office of the Superintendent of Public Instruction designated two Educational Service Districts (ESD) in which to pilot a lead staff person for mental health and substance use disorder services. Responsibilities for the lead staff person include coordinating Medicaid billing and ensuring adequate system supports for students with mental health and substance use disorder treatment needs.

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Summary of Substitute Bill:

Children's Mental Health Work Group.

The Work Group is reestablished through December 2020. The membership and duties of the Work Group are substantially similar to the Work Group established in 2016 and members serving on the Work Group as of December 1, 2017, may continue to serve without reappointment. The Work Group must update the findings and recommendations reported to the Legislature by the 2016 Work Group by December 1, 2020. Staff support for the Work Group is provided by the Office of Program Research, Senate Committee Services, and the HCA. The Work Group must select three co-chairs, two from among its legislative membership and one representative of a state agency. The two legislative co-chairs must represent the minority and majority caucuses in the House of Representatives.

Medicaid Managed Care for Children.

The annual report by the HCA and the DSHS to the Legislature on network adequacy for children's mental health is expanded to include data on mental health and medical services provided for eating disorder treatment in children and youth. The data must include the number of diagnoses by county; patients treated in outpatient, residential, emergency, and inpatient settings; and contracted providers specializing in eating disorder treatment, including the overall percentage actively accepting new patients during the reporting period.

The BHOs may allow provider reimbursement for services delivered through partial hospitalization or intensive outpatient treatment programs. Such payment and services are distinct from the state's obligation to deliver Wraparound with Intensive Services. Mental health treatment programs offered through the BHOs may include family support as a component of outpatient services.

The BHOs must allow reimbursement for time spent supervising mental health and social work professionals who are working towards satisfying the number of supervision hours required for licensing in their practice area.

As RSAs adopt fully integrated managed health care systems, the provisions for BHOs regarding reimbursement for partial hospitalization, intensive outpatient programs, and supervision time also apply to RSAs.

Home Visiting.

The HCA must collaborate with the Department of Children, Youth, and Families (DCYF) to identify opportunities to leverage Medicaid funding for home visiting services. The HCA must contract with a third party to build upon the Home Visiting and Medicaid Financing Strategies 2017 report and provide a set of recommendations to the Legislature by December 1, 2018.

By November 1, 2018, the DCYF must:

• develop a common set of definitions to distinguish between home visiting programs and services;

• develop a strategy to expand home visiting programs statewide; and

• collaborate with the HCA to identify how to maximize Medicaid and other federal resources for home visiting and the statewide strategy.

Infant Nurse Consultant.

Beginning July 1, 2018, the DCYF must contract with an infant nurse consultant (consultant) to provide support and consultation to child care providers in at least two regions selected by the DCYF. The consultant must be a currently licensed registered nurse who has either worked in pediatrics or public health in the past year or has taken or taught classes in pediatric nursing at the college level in the past five years. The consultant must visit each child care center licensed to care for four or more infants in the region at least monthly and must provide the DCYF of a signed, written summary of each visit.

Any requirement adopted by the DCYF for providers to have a consultant must be contingent upon an adequate supply of such consultants in the region.

Psychiatry Residency.

Subject to funds appropriated for this purpose, the Child and Adolescent Psychiatry Residency Program at the UW must offer one additional 24-month residency position to a resident specializing in child and adolescent psychology. The residency must include at least 12 months of training in settings where children's mental health services are provided under the supervision of experienced psychiatric consultants and must be located in western Washington.

Parent-Initiated Treatment.

The DSHS must convene an advisory group of stakeholders to review the PIT process and develop recommendations regarding:

• the age of consent for behavioral health treatment of a minor;

• options for parental involvement in youth treatment decisions;

• information communicated to families and providers about the PIT process; and

• the definition of medical necessity for emergency mental health services and options for parental involvement in those determinations.

The advisory group must review the effectiveness of serving commercially sexually exploited children using PIT, involuntary treatment, or other treatment services.

By December 1, 2018, the DSHS must report the findings and recommendations of the advisory group to the Work Group.

Educational Service District Mental Health Pilot Sites.

The duties of the lead staff person in each ESD mental health pilot site are expanded to include delivering a mental health literacy curriculum, mental health literacy curriculum resource, or comprehensive instruction to students in one high school in each pilot site. The curriculum, curriculum resource, or comprehensive instruction must improve student mental health literacy, be designed to support teachers, and be aligned with the state's Health and Physical Education K-12 Learning Standards.

Substitute Bill Compared to Original Bill:

Membership of the Work Group is modified to add a member representing pediatricians located east of the crest of the Cascade mountains and a member representing child psychiatrists. The number of co-chairs of the Work Group is expanded from two to three. Two of the Work Group co-chairs must be legislators representing the minority and the majority caucuses in the House of Representatives. The Work Group must monitor the implementation of specific programs and policies including depression screening for youth and new mothers, consultation services for child care providers caring for children with symptoms of trauma, home visiting services, and streamlining agency rules for providers of behavioral health treatment. Responsibility for developing a common set of definitions, developing a statewide strategy, and maximizing federal resources for home visiting is changed from the HCA to the DCYF.

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Appropriation: None.

Fiscal Note: Requested on January 22, 2018.

Effective Date of Substitute Bill: This bill takes effect 90 days after adjournment of the session in which the bill is passed, except for section 9, relating to the DCYF's duties regarding infant nurse consultation, which takes effect July 1, 2018.

Staff Summary of Public Testimony:

(In support) This year in King County, there was a forum where concerns were heard from adults with mental health needs who wished they had received treatment earlier in their lives. The components of this bill are system-based fixes such as improving network adequacy, improving mental health in schools and early learning, and other systems approaches to address children's mental health across the board. This Work Group has stepped in to consistently engage with these issues. Sometimes the Legislature enacts legislation in one area then moves on and the problem hasn't been dealt with. Home visiting works, and too few families have access. Discussion and direction to explore additional funding sources for home visiting will be a cornerstone of the prevention focus of the DCYF. Most families in crisis don't have the ability to come to the Legislature to share their concerns. Long-term costs are tremendous if early intervention and prevention is not addressed. There is a legislative intent in the children's mental health chapter that has been lost and needs to be restored. The Work Group has been critical in bringing to light issues such as existing laws not being implemented adequately. The PIT advisory group could really assist with that effort. If there is not an ongoing Work Group, ground will be lost in children's mental health. Encouraging BHOs to support partial hospitalization and intensive outpatient treatment is great. Expanding psychiatry residencies will be very helpful, as will the expansion of home visiting. Physician burnout is real and providing de-facto mental health services during primary care visits takes a toll on providers.

(Opposed) None.

Persons Testifying: Representative Senn, prime sponsor; Seth Dawson, Washington State Psychiatric Association, Compass Health, and Washington State Community Action Partnership; Erica Hallock, Fight Crime: Invest in Kids; Peggy Dolane; Laurie Lippold, Partners for Our Children; Robert Hilt, Seattle Children's Hospital; and Julian Ayer, Washington Chapter of the American Academy of Pediatrics.

Persons Signed In To Testify But Not Testifying: None.

Majority Report: The second substitute bill be substituted therefor and the second substitute bill do pass and do not pass the substitute bill by Committee on Early Learning & Human Services. Signed by 25 members: Representatives Ormsby, Chair; Robinson, Vice Chair; MacEwen, Assistant Ranking Minority Member; Stokesbary, Assistant Ranking Minority Member; Bergquist, Caldier, Cody, Fitzgibbon, Graves, Haler, Hansen, Harris, Hudgins, Jinkins, Kagi, Lytton, Manweller, Pettigrew, Pollet, Sawyer, Senn, Stanford, Sullivan, Tharinger and Wilcox.

Minority Report: Do not pass. Signed by 7 members: Representatives Chandler, Ranking Minority Member; Buys, Condotta, Schmick, Taylor, Vick and Volz.

Staff: Kelci Karl-Robinson (786-7116).

Summary of Recommendation of Committee On Appropriations Compared to Recommendation of Committee On Early Learning & Human Services:

The second substitute bill removes the provision requiring the Department of Children, Youth, and Families to contract with an infant nurse consultant and removes the provision establishing a child and adolescent psychiatry residency at the University of Washington.

Appropriation: None.

Fiscal Note: Available. New fiscal note requested on February 8, 2018.

Effective Date of Second Substitute Bill: The bill takes effect 90 days after adjournment of the session in which the bill is passed.

Staff Summary of Public Testimony:

(In support) The lack of children's mental health services is a chronic, pervasive problem without an easy solution.  Continuing the work group with legislators and advocacy groups will create sustained progress in addressing the problem that only one in five children have access to the mental health services they need.  The bill focuses on identifying solutions to address issues early and increasing access to mental health services for children.  Other states have been able to leverage Medicaid funding for home visiting services, and the bill would continue the work to increase funding for home visiting.  Over 1,000 pediatricians in Washington support the bill.  When children lack adequate access to mental health services, it leads to homelessness, substance abuse, criminal activity, school expulsion, hospitalization, etc.  The bill would assist in providing appropriate mental health services when children need it.  The community behavioral health agencies support reimbursement for training and supervision.

(Opposed) None.

Persons Testifying: Seth Dawson, Washington State Psychiatric Association and Washington State Community Action Partnership; Erica Hallock, Fight Crime: Invest in Kids; Laurie Lippold, Partners for Our Children; Ruth Conn, American Academy of Pediatrics-Washington Chapter; and Abby Moore, Washington Council on Behavioral Health.

Persons Signed In To Testify But Not Testifying: None.