Background: The Children's Mental Health Work Group (CMHWG) was established in 2016 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 CMHWG expires in December 2020.

Partnership Access Line. The Partnership Access Line (PAL) is a telephone consultation service for primary care providers to consult with a pediatric psychiatrist. Seattle Children's Hospital delivers PAL consultation services in affiliation with the University of Washington (UW) through a contract with the Health Care Authority (HCA). The PAL for Moms and Kids pilot program provides consultation for health care professionals to assess and treat depression in pregnant women and new mothers. The PAL for Moms and Kids pilot program also facilitates referrals to children's mental health services and other resources for parents and guardians. The PAL for Moms and Kids pilot program will conclude in 2021.

Psychiatry Residencies. The Accreditation Council for Graduate Medical Education accredits medical education and residency programs and associated sponsoring institutions. The UW Child and Adolescent Psychiatry Residency Program based at Seattle Children's Hospital and the Providence Psychiatry Residency located at the Spokane Teaching Health Clinic on the Washington State University (WSU) Spokane campus are psychiatry residency programs. Legislation enacted in 2017 and 2018 required the UW and WSU to each offer a 24-month residency position to a resident specializing in child and adolescent psychiatry. Each residency must include a minimum of 12 months of training in settings where children's mental health services are provided under the supervision of experienced psychiatric consultants. The UW residency must be located in western Washington, and WSU residency must be located in eastern Washington. The UW residency requirement becomes effective July 1, 2020.

Coordinated Specialty Care. The National Institute for Mental Health describes Coordinated Specialty Care (CSC) as a recovery-oriented treatment program for individuals experiencing first-episode psychosis. The CSC is a shared decision-making approach using a team of specialists who work together to develop a patient's treatment plan. Psychosis describes conditions that affect the mind where there has been some loss of contact with reality and often begins in adolescence or early adulthood.

Regional Service Areas. Regional Service Areas (RSA) are geographic boundaries used by the HCA for purchasing health care for Medicaid enrollees through managed care contracts. There are ten RSAs in the state.

Infant and Early Childhood Mental Health Consultation. Infant and Early Childhood Mental Health Consultation (IECMHC) is an intervention that provides early learning professionals and families with consultation from a mental health specialist in order to improve the social, emotional, and behavioral health of children in care.

The Department of Children, Youth, and Families (DCYF) provides infant toddler consultation to early learning providers participating in the Early Achievers (EA) quality rating and improvement system. Referrals for infant toddler consultation are made by EA coaches and are available for children ages birth to age three.

Parent-Initiated Treatment. When a minor age thirteen 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 PIT allows a parent to consent on behalf of a minor aged thirteen through seventeen for behavioral health treatment. A stakeholder advisory group reviewed the PIT process and made recommendations to the CMHWG and the Legislature in December 2018.

Summary of Second Substitute Bill: Legislative Findings. The Legislature finds that:

there is a workforce shortage, and increasing Medicaid rates to a level equal to Medicare rates will increase the number of providers who will serve children and families on Medicaid.
there is a need to increase the cultural and linguistic diversity among children's behavioral health professionals.

Educational Service District Behavioral Health Coordination. Each ESD must coordinate behavioral health in school districts in its region. The coordination must include, at a minimum:

supporting the development and implementation of plans to recognize, initially screen, and respond to emotional or behavioral distress in students;
facilitate partnerships and coordination between school districts, public schools, and regional and local behavioral health systems in order to increase student and family access to services and supports;
assisting school districts and public schools to build capacity to identify and support students in need of behavioral health care services, and to link students and families with community-based behavioral health care services;
identify, share, and integrate behavioral and physical health care service delivery models to the extent practicable;
provide training, technical assistance, and coordination about Medicaid billing;
guide implementation of best practices to respond to, and recover from, the suicide or attempted suicide of a student; and
assist schools and school districts in implementing or expanding social emotional learning programs.

Partnership Access Line. Subject to appropriations, HCA must collaborate with the UW, Seattle Children's Hospital, and OSPI to develop a plan to implement a two-year pilot program called the Partnership Access Line for Schools (PALS). The plan development must begin by July 1, 2019, and PALS must be implemented by January 1, 2020. PALS must support two ESDs selected by OSPI.

Elements of the PALS pilot must include the development of a general behavioral support health curriculum appropriate for school staff, and the delivery of behavioral health trainings for school counselors, social workers, psychologists, nurses, teachers, and administrators. For school staff who have participated in the training, the PALS must provide phone consultations with psychologists and psychiatrists for school staff managing children with challenging behaviors. When assessed as clinically appropriate by PALS clinical staff and when similar support is not immediately available in the local community, the PALS must provide timely crisis management appointments in person or through interactive audio and video technology for school staff.

By December 1, 2022, the HCA must report to the Governor and the Legislature on services delivered through the PALS and recommending whether the PALS should continue or be made permanent.

The University of Washington Certificate Programs in Evidence-Based Practices. Subject to appropriation, UW must establish two certificate programs in evidence-based practices for behavioral health care professionals, as follows:

UW School of Social Work must collaborate with the UW Department of Psychiatry and Behavioral Health Services (UWDPBS) and others to establish a certificate program in evidence-based practices for graduate students pursuing a masters in social work that includes dialectical behavior therapy and the wellness recovery action plan; and
UW Department of Psychology, in collaboration with UWDPBS and others must establish a certificate program for behavioral health professionals in evidence-based practices effective for treatment adolescents and young adults that includes trauma-focused cognitive behavior therapy.

Participants in the certificate programs are eligible to apply for the state Health Care Professional Loan Repayment and Conditional Scholarship program.

Psychiatry Residencies. Subject to funds appropriated, the UW and the WSU must each offer one additional 24-month residency position to residents specializing in child and adolescent psychiatry. The UW residency must be located in western Washington, and the WSU residency must be located in eastern Washington. The implementation of another residency at UW is accelerated from July 1, 2020, to the effective date of this act. The minimum amount of training for these psychiatric residency programs is increased from 12 to 18 months.

Early Identification and Intervention for Psychosis. HCA must collaborate with UW and the Washington Council on Behavioral Health to develop a statewide plan to implement evidence-based CSC programs that provide early identification and intervention for psychosis in licensed or certified community behavioral health agencies. The plan is due to the Governor and the Legislature by March 1, 2020, and must include an analysis of existing benefit packages, payment rates, and resource gaps, including needs for non-Medicaid resources; development of a discrete benefit package and case rate for CSC; identification of costs for statewide start-up, training, and community outreach; determination of the number of CSC teams needed in each regional service area; and a timeline for statewide implementation.

Infant and Early Childhood Mental Health Consultation. Subject to appropriation, DCYF must develop an IECMH consultation model for children ages birth to age five and provide the model to the Governor and the Legislature by November 1, 2019. The model must include a workforce development plan, consultation standards, a program evaluation protocol, and a plan for a data tracking system. DCYF must phase in service delivery starting in at least two regions by July 1, 2020, followed by full statewide implementation by December 31, 2023. DCYF must consult with private and public partners, including tribal representatives, to ensure the model meets community needs in a culturally competent manner.

Trauma-Informed Early Care and Intervention Pilots. Subject to appropriation, DCYF must implement a two-year trauma-informed early care and education pilot in at least two regions, beginning January 1, 2020. The pilot programs must implement a model for professional development in trauma-informed care for child care and early learning providers that provides additional targeted social and emotional supports beyond what is typically provided in these settings. Training and coaching must be provided to family home child care providers in communities of practice. Certain trauma-informed early care and intervention sites must receive increased subsidy rates and supports to enable family engagement and smaller teacher-child ratios. In the pilot areas, DCYF must establish a system to track expulsions from child care and early learning settings. A report is due December 31, 2021.

Professional Learning Days. School districts must use one of their professional learning days to train district staff in mental health first aid, suicide prevention, social-emotional learning, trauma-informed care, and anti-bullying strategies.

Multi-Tiered System of School Supports. Subject to funds appropriated, UW must convene a work group of educators and researchers to develop a statewide multi-tiered system of school supports (MTSSS). The MTSSS must include academic, social-emotional, and behavioral supports. The UW must submit the findings and recommendations of the work group to the Governor and the Legislature by November 1, 2020.

Parent-Initiated Treatment. Subject to funds appropriated, the HCA must conduct an annual survey of parents, youth, and behavioral health providers to measure the impacts of legislation expanding parented-initiated treatment, contingent on the passage of HB 1874 or SB 5904, and provide an annual report. A final report is due November 1, 2022, and must include any recommendations for statutory change.

Other Provisions. OSPI must identify and provide mental health literacy and healthy relationship instructional materials to school districts to use as guidelines for student instruction in these subjects. Subject to appropriation, HCA must provide a free online training for behavioral health providers regarding legal options and best practices for providing treatment to children, youth, and families.

Staff Summary of Public Testimony on First Substitute (Behavioral Health Subcommittee to Health & Long Term Care): PRO: This bill is broad, but not broad enough to cover all the change we need. As a member of the CMHWG I'm proud of the efforts that have been made to dive into the many ways we can improve mental health access. We know more now than we did years ago. The bill should prioritize issues for funding. Brilliant human beings have contributed to the contents of these bills. Mental health and substance use disorders affect one out of five kids. Seventy percent don't get the care they deserve. The recommendations are strong because they bring help to the places where kids are found. In a nearby school district, one counselor serves the needs of over 450 students. This bill would give her access to support and training from psychologists and psychiatrists. Child care providers will be linked to evidence-based practices. This strikes the right balance. I run PAL for primary care providers and expanding the program to pilot on demand crisis evaluations for school personnel will be very helpful. Increasing residency positions will increase our workforce by making the residents more likely to stay in Washington. Increasing rates from Medicaid to Medicare would make a significant positive difference. Replicating and expanding behavioral health coordinators in other school districts will be very important. Providing technical assistance on social emotional learning will add workload and cost. The work of the CMHWG has led to advancements. Access is a huge issue. Focusing on rates is important. There is need to support trauma-informed practices in schools. This bill does a good job in meeting these needs. Educators leave the field at high rates in part because of the stress caused by inadequately addressed behavioral issues. Thank you for adding second residencies for UW and WSU. These residencies are needed in order to be accredited as qualified programs--it takes at least two per location. Consulting for early learning providers is needed to support educators helping kids with emotional and behavioral challenges. It will reduce expulsions that disproportionally affect children of color. Arizona has implemented this strategy and seen positive outcomes for children.

CON: Policy should have accountability. I don't see outcomes measured in these processes. This turns behavior into disease. Diagnostic inflation leaves the population too dependent on medication. Don't label people. Third world countries that don't use drug therapy have better remission rates than countries that treat mental health with medication.

OTHER: It has been an honor and a privilege to support the CMHWG through its many meetings and important accomplishments. This is the next generation of ideas, building off the work done in previous years.

EFFECT OF HOUSE AMENDMENT(S):

Requires DCYF to contract with an organization providing coaching services to Early Achievers Program participants to provide one qualified mental health consultant for each of six designated regions. Consultants must provide resources, information, and guidance regarding challenging behavior and expulsions. DCYF must report activities of consultants to the Governor and Legislature by June 30, 2021.
Delays the addition of additional child and adolescent psychiatry residencies at WSU and UW from the effective date of the bill to July 1, 2020, and July 1, 2022, respectively.
Amends the requirement related to professional learning days to allow schools to focus on one of the following topics: social-emotional learning, trauma-informed practices, recognizing and responding to emotional or behavioral distress, consideration of adverse childhood experiences, mental health literacy, antibullying strategies, or culturally sustaining practices; and delays implementation by one year to the school year starting in 2020.
Codifies provisions relating to the Children's Mental Health Work Group and expands them to allow cochairs to invite additional Legislative members to participate in work group activities without reimbursement, including as leaders of advisory groups; to authorize cochairs to convene advisory group to evaluation specific issues; and to require convening of an advisory group to develop a funding model for PAL, delivering PALS, and expanding PAL to include consultation with health care professionals serving adults.
Removes provisions relating to requiring educational service districts to provide behavioral health coordination; establishing a two-year PALS pilot program; requiring OSPI to provide mental health literacy and healthy relationship instructional materials to school districts; establishing a UW certificate program in evidence-based practices; developing a multi-tiered system of school supports; establishing an infant and early childhood mental health consultation; establishing trauma-informed early care and intervention pilots; providing a free online training for behavioral health providers regarding best practices for providing treatment to children, youth, and families; and establishing an annual survey of effectiveness of changes to family-initiated treatment policy.