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COVID's impact on behavioral health: Solutions for state agencies

By: Melinda Kirrane,

Danielle is a Senior Consultant in the State Government Practice Group. Based in Washington, her expertise includes a variety of aspects of behavioral health, project management, policy analysis, policy development, and stakeholder engagement. Danielle has experience in healthcare and public health, program development, program management, strategic planning, and Medicaid, including the Section 1115 Waiver. In her work with state agencies, she builds collaborative relationships and serves as a trusted partner.

Danielle Stumpf
01.04.22

Read this if you are a behavioral health agency leader looking for solutions to manage mental health, substance misuse, and overdose crises.

As state health departments across the country continue to grapple with rising COVID-19 cases, stalling vaccination rates, and public heath workforce burnout, other crises in behavioral health may be looming. Diverted resources, disruption in treatment, and the mental stress of the COVID-19 pandemic have exacerbated mental health disorders, substance use, and drug overdoses.

State agencies need behavioral health solutions perhaps now more than ever. BerryDunn works with state agencies to mitigate the challenges of managing behavioral health and implement innovative strategies and solutions to better serve beneficiaries. Read on to understand how conducting a needs assessment, redesigning processes, and/or establishing a strategic plan can amplify the impact of your programs. 

Behavioral health in crisis

The prevalence of mental illness and substance use disorders has steadily increased over the past decade, and the pandemic has exacerbated these trends. A number of recently released studies show increases in symptoms of anxiety, depression, and suicidal ideation. One CDC study indicates that in June 2020 over 40% of adults reported an adverse mental or behavioral health condition, which includes about 13% who have started or increased substance use to cope with stress or emotions related to COVID-19.1 

The toll on behavioral health outcomes is compounded by the pandemic’s disruption to behavioral health services. According to the National Council for Behavioral Health, 65% of behavioral health organizations have had to cancel, reschedule, or turn away patients, even as organizations see a dramatic increase in the demand for services.2,3 Moreover, treatment facilities and harm reduction programs across the country have scaled back services or closed entirely due to social distancing requirements, insufficient personal protective equipment, budget shortfalls, and other challenges.4 These disruptions in access to care and service delivery are having a severe impact.

Several studies indicate that patients report new barriers to care or changes in treatment and support services after the onset of the pandemic.5, 6 Barriers to care are particularly disruptive for people with substance use disorders. Social isolation and mental illness, coupled with limited treatment options and harm reduction services, creates a higher risk of suicide ideation, substance misuse, and overdose deaths.

For example, the opioid epidemic was still surging when the pandemic began, and rates of overdose have since spiked or elevated in every state across the country.7 After a decline of overdose deaths in 2018 for the first time in two decades, the CDC reported 81,230 overdose deaths from June 2019 to May 2020, the highest number of overdose deaths ever recorded in a 12-month period.8 

These trends do not appear to be improving. On October 3, the CDC reported that from March 2020 to March 2021, overdose deaths have increased 29.6% compared to the previous year, and that number will only continue to climb as more data comes in.9  

As the country continues to experience an increase in mental illness, suicide, and substance use disorders, states are in need of capacity and support to identify and/or implement strategies to mitigate these challenges. 

Solutions for state agencies

Behavioral health has been recognized as a priority issue and service area that will require significant resources and innovation. In May, the US Department of Health and Human Services' (HHS) Secretary Xavier Becerra reestablished the Behavioral Health Coordinating Council to facilitate collaborative, innovative, transparent, equitable, and action-oriented approaches to address the HHS behavioral health agenda. The 2022 budget allocates $1.6 billion to the Community Mental Health Services Block Grant, which is more than double the Fiscal Year (FY) 2021 funding and $3.9 billion more than in FY 2020, to address the opioid epidemic in addition to other substance use disorders.10 

As COVID-19 continues to exacerbate behavioral health issues, states need innovative solutions to take on these challenges and leverage additional federal funding. COVID-19 is still consuming the time of many state leaders and staff, so states have a limited capacity to plan, implement, and manage the new initiatives to adequately address these issues. Here are three ways health departments can capitalize on the additional funding.

Conduct a needs assessment to identify opportunities to improve use of data and program outcomes

Despite meeting baseline reporting requirements, state agencies often lack sufficient quality data to assess program outcomes, identify underserved populations, and obtain a holistic view of the comprehensive system of care for behavioral health services. Although state agencies may be able to recognize challenges in the delivery or administration of behavioral health services, it can be difficult to identify solutions that result in sustained improvements.

By performing a structured needs assessment, health departments can evaluate their processes, systems, and resources to better understand how they are using data, and how to optimize programs to tailor behavioral health services and promote better health outcomes and a more equitable distribution of care. This analysis provides the insight for agencies to understand not only the strengths and challenges of the current environment, but also the desires and opportunities for a future solution that takes into account stakeholder needs, best practice, and emerging technologies. 

Some of the benefits we have seen our clients enjoy as a result of performing a needs assessment include: 

  • Discovering and validating strengths and challenges of current state operations through independent evaluation
  • Establishing a clear roadmap for future business and technological improvements
  • Determining costs and benefits of new, alternative, or enhanced systems and/or processes
  • Identifying the specific business and technical requirements to achieve and improve performance outcomes 

Timely, accurate, and comprehensive data is critical to improving behavioral health outcomes, and the information gathered during a needs assessment can inform further activities that support programmatic improvements. Further activities might include conducting a fit-gap analysis, performing business process redesign, establishing a prioritization matrix, and more. By identifying the greatest needs and implementing plans to address them, state agencies can better handle the impact on behavioral health services resulting from the COVID-19 pandemic and serve individuals with mental health or substance use disorders more efficiently and effectively.

Redesign processes to improve how individuals access treatment and services

Despite the availability of behavioral health services, inefficient business and technical processes can delay and frustrate individuals seeking care and in some cases, make them stop seeking care altogether. With limited resources and increasing demands, behavioral health agencies should analyze and redesign work flows to maximize efficiency, security, and efficacy. Here are a few examples of process improvements states can achieve through process redesign:

  • Streamlined data processes to reduce duplicative data entry 
  • Automated and aligned manual data collection processes 
  • Integrated siloed health information systems
  • Focused activities to maximize staff strengths
  • Increased process transparency to improve communication and collaboration 

By placing the consumer experience at the core of all services, state health departments can redesign business and technical processes to optimize the continuum of care. A comprehensive approach takes into account all aspects that contribute to the delivery of behavioral health services, including both administrative and financial processes. This helps ensure interconnected activities continue to be performed efficiently and effectively. Such improvements help consumers with co-occurring disorders (mental illness and substance use disorder) and/or developmental disorders find “no wrong door” when seeking care. 

Establish a strategic plan of action to address the impact of the COVID-19 pandemic

With the influx of available dollars resulting from the American Recovery Plan Act and other state and federal investments, health departments have a unique opportunity to fund specific initiatives to enhance the delivery and administration of behavioral health services. Understanding how to allocate the millions of newly awarded dollars in an impactful and sustainable way can be challenging. Furthermore, the additional reporting and compliance requirements linked to the funding can be difficult to navigate in addition to current monitoring obligations. 

The best way to begin using the available funding is to develop and implement strategic plans that optimize funds for behavioral health programs and services. You can establish priorities and identify sustainable solutions that build capacity, streamline operations, and promote the equitable distribution of care across populations. A few of the activities state health departments have undertaken resulting from the strategic planning initiatives include: 

  • Modernizing IT systems, including data management solutions and Electronic Health Records systems to support inpatient, outpatient, and community mental health and substance use programs 
  • Promoting organizational change management 
  • Establishing grant programs for community-driven solutions to promote health equity for the underserved population
  • Organizing, managing, and/or supporting stakeholder engagement efforts to effectively collaborate with internal and external stakeholders for a strong and comprehensive approach

The prevalence of mental illness and substance use disorder were areas of concern prior to COVID-19, and the pandemic has only made these issues worse, while adding more administrative challenges. State health departments have had to redirect their existing staff to work to address COVID-19, leaving a limited capacity to manage existing state-level programs and little to no capacity to plan and implement new initiatives. 

The federal administration and HHS are working to provide financial support to states to work to address these exacerbated health concerns; however, with the limited state capacity, states need additional support to plan, implement, and/or manage new initiatives. BerryDunn has a wide breadth of knowledge and experience in conducting needs assessments, redesigning processes, and establishing strategic plans that are aimed at amplifying the impact of state programs. Contact our behavioral health consulting team to learn more about how we can help. 

Sources:
Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, CDC.gov
COVID-19 Pandemic Impact on Harm Reduction Services: An Environmental Scan, thenationalcouncil.org
National Council for Behavioral Health Polling Presentation, thenationalcouncil.org
The Impact of COVID-19 on Syringe Services Programs in the United States, nih.gov
COVID-19 Pandemic Impact on Harm Reduction Services: An Environmental Scan, thenationalcouncil.org
COVID-19-Related Treatment Service Disruptions Among People with Single- and Polysubstance Use Concerns, Journal of Substance Abuse Treatment
Issue Brief: Nation’s Drug-Related Overdose and Death Epidemic Continues to Worsen, American Medical Association
Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic, CDC.gov
Provisional Drug Overdose Death Counts, CDC.gov
10 Fiscal Year 2022 Budget in Brief: Strengthening Health and Opportunity for All Americans, HHS.gov

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Read this if you use QuickBooks Online.

Let's talk about where records for products and services are used in QuickBooks Online.

To create a product or service record, you hover your mouse over Sales in the left vertical pane on the main page and click Products and services. Click New in the upper right corner and open a blank record for an Inventory or Non-inventory part, a Service, or a Bundle (assembly). Once you complete a record and save it, it will appear in the list back on the Product and services page.

Working with products and services

That’s where we’ll start today, on the Products and services screen. This is a comprehensive table, a dashboard (or home page) for your products and services. It displays real-time information about your items’ pricing and inventory levels, as well as their type and tax status. At the top of the page, you’ll see big, colorful buttons that provide a total of the number of items that are low on stock or out of stock. When you click on one, a list of those products appears.

QuickBooks Online’s Products and services page displays inventory levels and warns you when your stock is low and at zero.

Each row on this screen contains details about the item listed there, like Description, Sales Price and Cost, and Qty On Hand. If you look down at the end of the row, you’ll see options for several types of Actions: Edit, Make inactive, Run report, and Duplicate. Click the gear icon above the table to modify the columns in the table. 

The More menu at the top of the screen contains more options: Manage categories, Run reports, and Price rules. If you want to know what actions you can take on multiple items simultaneously, check the box in front of each and click the Batch actions menu, over to the right (Adjust quantity, Reorder, etc.).

Warning: Be very careful using the Adjust quantity option. There are legitimate reasons for employing it, but you need to make very sure that you understand how this will affect other areas of your accounting. Please ask us if you’re unsure.

Using products and services in transactions

Once you start using product and service records in transactions, you’ll see why we suggested that you create those early on and make them as comprehensive as possible. While you can add products and services in the process of creating an invoice, for example, it’s much easier if you have them ready to go.

Let’s look at a sales receipt to see how this works. Click +New in the upper right corner and select Sales receipt. Select a Customer in the first field and verify that the related fields on the form were filled out correctly. Check and make any changes necessary in the Sales receipt date, Payment method, and Deposit to fields. 

Once you’ve built up a list of products and services, they’ll be available when you create transactions.

Enter the Service Date, and then click the down arrow in the field under Product/Service. The top of the list has an entry labeled +Add new. Click it if you need to add a product or service on the fly, or just select the existing one that you want. QuickBooks Online will fill in the Rate, Amount, and Tax (status). You only have to enter the Qty (quantity) that you’re selling. 

If you have more items or services to add, you can do so on the next line(s). When you’re done, check the numbers in the lower right and save the transaction. QuickBooks Online will adjust your inventory to account for any items you just sold. You can see this change by going back to the Products and Services screen. Or you can run reports, including:

  • Sales by Product/Service
  • Product/Service List
  • Inventory Valuation Detail
  • Physical Inventory Worksheet

Supply chain woes?

It seems that the serious supply chain problems we were experiencing in previous months have eased up some, but you may still be having trouble stocking some items. We hope this isn’t affecting you too much. 

QuickBooks Online, though, can help ensure that you know ahead of time when you must reorder. Its inventory-tracking capabilities can also alert you to items that aren’t selling well, so you don’t get overstocked on anything. And the ability to pull up product and service records when you’re creating transactions saves time and keeps your inventory levels accurate. Please let the Outsourced Accounting team know if you need assistance with this element of your accounting or any of QuickBooks Online’s other tools.

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How QuickBooks Online tracks products and services

Read this if you are responsible for cybersecurity at your organization.

Cybersecurity threats aren’t just increasing in number—they’re also becoming more dangerous and expensive. Cyberattacks affect organizations around the globe, but the most expensive attacks occur in the US, where the average cost of a data breach is $9.44 million, according to IBM’s 2022 Cost of a Data Breach Report. The same report shows that the cost of a breach is $10.10 million in the healthcare industry, $5.97 million in the financial industry, $5.01 million in the pharmaceuticals industry, and $4.97 million in the technology industry.

Cyber threat actors are a serious danger to your company, and your customers, stakeholders, and shareholders know this. They expect you to be prepared to defend against and manage cybersecurity threats. How can you demonstrate your cybersecurity controls are up to par? By obtaining a SOC for cybersecurity report.

What is a SOC for cybersecurity report?

It provides an independent assessment of an organization’s cybersecurity risk management program. Specifically, it determines how effectively the organization’s internal controls monitor, prevent, and address cybersecurity threats.

What’s included in a SOC for cybersecurity report?

The report is made up of three key components:

  1. Management’s description of their cybersecurity risk management program, aligned with a control framework (more on that below) and 19 description criteria laid out by the AICPA.
  2. Management’s assertion that controls are effective to achieve cybersecurity objectives.
  3. Service auditor’s opinion on both management’s description and management’s assertion.

Why should you consider a SOC for cybersecurity report?

A SOC for cybersecurity report offers several important benefits for your organization, which include:

  • Align with evolving regulatory requirements. The cybersecurity regulatory environment is constantly evolving. In particular, the SEC’s cybersecurity guidelines are becoming stricter over time. A SOC for cybersecurity report can demonstrate you’re aligned with these guidelines. If you’re a public company or are considering going public in the future, you need to be prepared to meet not just the SEC’s guidelines of today, but their evolved guidelines in the future.
  • Keep your board of directors informed. Your board is responsible for ensuring the business is effectively addressing and mitigating risks—and that includes cyber risk. A SOC for cybersecurity report offers your board a clear and practical illustration of your organization’s cybersecurity risk management controls.
  • Attract and retain more customers. It’s becoming increasingly common for companies to require that their vendors have a SOC for cybersecurity report. Even for companies that don’t require such a report, it’s important to know their vendors are keeping their data safe. Having this report differentiates you from vendors who have not prepared one.
  • Improve your cybersecurity posture. A SOC for cybersecurity report can identify current gaps in your cybersecurity risk management program. Once you’ve addressed these gaps, you can show your customers, stakeholders, and shareholders that you’re continuously improving and evolving your cybersecurity risk management approach.

How do I prepare for my SOC for cybersecurity assessment?

There are several steps you should take to prepare for your assessment.

  1. Choose your control framework. You have several options, including the NIST Cybersecurity Framework, ISO 27002, and the Secure Controls Framework (SCF). There are multiple online resources to help you choose the framework that’s right for your organization.
  2. Determine who your key internal stakeholders are for your cybersecurity risk management program. You’ll need to select a point person to be responsible for ensuring the independent services auditor has all the documentation they need to complete their assessment and act as liaison across internal and external stakeholders.
  3. Collect all cybersecurity-related documentation in one location. Make sure you have an organizational system that makes sense to your point person so it’s easy for them to pull the appropriate materials to give to the independent services auditor.
  4. Conduct a readiness assessment. You can work with an independent services auditor to conduct such an assessment which will identify gaps you can address before performing the attestation.
  5. Select an independent services auditor to perform the attestation. SOC for cybersecurity services are provided by independent CPAs approved by the AICPA. Ideally, you’ll want to select a firm that is experienced in your industry, has a diverse and robust team of cybersecurity professionals, and is accessible when and where you need them.

As always, if you have questions about your specific situation or would like more information about SOC for cybersecurity services, please contact our IT security experts. We’re here to help.

Article
Yes, you need a SOC for cybersecurity report—here's why

Read this if you are at a Medicaid agency.

After attending this year’s NASHP Conference, I realized Seattle wasn’t the only gem I found. The city welcomed a record number of NASHP attendees, including many first timers, who brought with them a passion for the vital work they do to support Medicaid and health and human services agencies across the nation. Executive Director Tewarson led her first conference with finesse, and the entire conference exemplified her team’s passion and dedication to state health policy. 
 
The 35th annual conference was full of fresh ideas and a collaborative spirit. As I reflect over the three days of the conference, some ideas I am taking back to my team include:

  • Workforce challenges are here to stay—and are only becoming more severe, requiring states to rethink hiring, training, and staffing among healthcare providers at all levels. Actions to consider:
    • Work to help ensure we allocate appropriate funding for behavioral health and clinical staff. 
    • Encourage more diversity in the field. This means having more representation in the workforce for new hires to identify with, including recruiting and training staff, so they feel welcome and encouraged to join.
    • Increase support for highly skilled jobs like CNAs and childcare workers. Our system cannot work without these staff, and the skills they bring to the table are crucial to the field, developed over time, and indispensable.
    • Start planning now to address the potential loss of childcare dollars to avoid exacerbating the workforce shortage challenges.
    • Identify other ways to help the workforce with benefits and support that can go a long way toward recruiting and retaining experienced caregivers. 
  • Disparities in health equity were always there, and the pandemic laid them bare. 
    • We need to assess the impact of all initiatives to help ensure they aren’t creating additional health inequities and develop strategies to rectify existing barriers.
    • We should bring those experiencing health inequities to the table, listen to their struggles, and let them lead us to solutions.
    • We need to build a diverse workforce that will bring more voices and ideas into the room in this arena.
  • There is a lot of innovative work going on in child behavioral health that can impact outcomes:
    • Providing youth mental health first-aid training and trauma-informed training to school-based, nonclinical staff is crucial to addressing the children’s behavioral health crisis. Children spend so much time at school and build trust in teachers, bus drivers, custodians, and administrative staff.
    • Training school staff on the use of mobile crisis units to avoid children inappropriately becoming involved in the juvenile justice system or being treated in emergency rooms.
    • Putting clinical staff in schools, even via telehealth or part-time, has shown positive outcomes for child behavioral health.
  • We may not know when the Public Health Emergency will end. Still, we can spend this time developing and improving our plans for unwinding, setting consistent expectations with our members and meeting them where they are, developing strategies to make successful emergency provisions permanent, and engaging our legislatures now to prepare for the upcoming federal funding gap.
  • The most significant success factor in every session I attended was breaking down silos across health and human services agencies. We need to continue working across programs, agencies, and states to help ensure we are innovating, growing, and providing the best care for those our policies and programs serve.
  • Lastly, as a foster-adopt mom, I was heartened to hear the speakers consistently bring the topic back to focus on some of our most vulnerable youth: children in foster and kinship care and our justice-involved youth. The call to collaboration and partnerships across child welfare, juvenile justice, public health, county health departments, and Medicaid agencies to impact change was not lost on me, and I found my passion for improving our foster care system invigorated by the passion of those around me.

I am thankful for organizations like NASHP that help us come together to innovate and collaborate on the biggest problems facing our industry today. NASHP’s mission to support the development of policies that promote and sustain healthy people and communities, advance high-quality and affordable health care, and address health equity is needed now more than ever. The 2022 conference allowed us to collaborate and share innovations that can be used to help propel us in our essential work to improve the health and lives of the individuals we serve.
 
My biggest takeaway was that we are stronger when we work together. I’m excited to hear what your biggest takeaways were this year. It has energized me to continue this critical work to help Medicaid agencies improve the health and lives of our residents. I do not doubt that this group will take back all the lessons and work to improve the lives of the residents of their states, and we will all gather in Boston next year, excited to hear of all the new successes. See you next year!

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NASHP meets the Emerald City

Read this if you are a community bank.

The Federal Deposit Insurance Corporation (FDIC) recently issued its second quarter 2022 Quarterly Banking Profile. The report provides financial information based on call reports filed by 4,771 FDIC-insured commercial banks and savings institutions. The report also contains a section specific to community bank performance. In second quarter 2022, this section included the financial information of 4,333 FDIC-insured community banks. BerryDunn’s key takeaways from the report are as follows:

Community banks see quarterly growth in net income despite year-over-year decline.

Community bank quarterly net income increased to $7.6 billion in second quarter 2022, despite being down $523.0 million from one year ago. Higher noninterest expense, lower noninterest income, and higher provision expense offset growth in net interest income. Nearly three-quarters of community banks reported higher net income than one quarter ago. More than two-thirds of community banks reported an increase in net interest income from the year-ago quarter.


Loan and lease balances continue to show widespread growth in second quarter 2022.

Community banks saw a $82.3 billion increase in loan and lease balances from first quarter 2022. All major loan categories except commercial & industrial (C&I) and agricultural production grew year over year, and 69.9% of community banks reported annual loan growth. Total loan and lease balances increased $125.4 billion, or 7.7%, from one year ago. Excluding Paycheck Protection Program loans, annual total loan growth would have been 14.0% and annual C&I growth would have been 21.9%.

Community bank net interest margin (NIM) increased to 3.33% due to strong interest income growth.

Community bank NIM increased eight basis points from the year-ago quarter and 22 basis points from first quarter 2022. Net interest income growth exceeded the pace of average earning asset growth. The average yield on earning assets rose 25 basis points while the average cost of funding earning assets rose three basis points from the previous quarter. The quarterly increase in NIM was the largest reported since second quarter 1985. However, NIM remains below the pre-pandemic average of 3.63%. 

Slightly more than half of community banks reported quarter-over-quarter reductions in noncurrent loan balances.

The allowance for credit losses (ACL) as a percentage of total loans and leases decreased six basis points from the year-ago quarter to 1.25%. The coverage ratio for community banks is 46.4 percentage points above the coverage ratio for noncommunity banks. The coverage ratio increased 54.1 percentage points from the year-ago quarter to 245.4%, a record high since Quarterly Banking Profile data collection began in first quarter 1984.

It has been a time of momentous change for the banking industry; this has been the case since the pandemic but continues to hold true. The Federal Open Market Committee (FOMC) had already risen the target federal funds rate by 225 basis points in 2022 at the time of writing this summary, with further increases throughout the remainder of 2022 anticipated. Although rising rates have been the largest contributor to strengthening net interest margins, the impact these rate increases will have on the long-term economy is still to be seen.

Inflation also continues to run rampant, with rate increases thus far seeming to be ineffective in slowing inflation. The continued inflation has many wondering if rate increases are not the answer and that there may be other, inalterable forces at play. If this is the case, the FOMC’s target rate increases could have the effect of worsening an economic slowdown. Furthermore, although loan growth remained relatively strong in quarter two, deposit growth waned. Community banks saw only a 0.4% increase in deposits from a quarter ago. This has put some institutions in a liquidity crunch, having to rely more heavily on wholesale funding to fund loan growth. However, making funding decisions has proven to be difficult, given the economic uncertainty and potential target rate increases.

Community banks will have to continue to remain vigilant and remain a resource to their customers. Banks’ customers are facing many of the same challenges that banks are facing—interest rate uncertainty, rising costs, staffing shortages, etc. Therefore, as we’ve previously mentioned, it continues to be important for banks to maintain open dialogue with customers. As always, please don’t hesitate to reach out to BerryDunn’s Financial Services team if you have any questions. You can also visit our Ask the Advisor page to submit your questions.

Article
FDIC Issues its Second Quarter 2022 Quarterly Banking Profile

Read this if you are at a state agency looking to implement or improve your 988 Suicide & Crisis Lifeline. 

Between 2015 and 2020, one in four fatal police shootings involved a person with a mental illness, and an estimated 44% of people incarcerated in jail and 37% of people incarcerated in prison had a mental health condition. In addition, the recent COVID-19 pandemic has adversely impacted the mental health situation in the country. 

Many people experiencing mental health distress call 911 because it is a widely known emergency number and easy to use. Recent data has shown that people using 911 to get help with serious mental illness do not get the right care at the right time and some even end up in law enforcement custody, rather than being seen by a mental health professional.

The 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) is the new three-digit, nationwide phone number that is locally operated and offers 24/7 access via call, text, and chat to trained crisis counselors who can help individuals experiencing mental health-related distress. Mental health-related distress can include substance use crisis, suicidal thoughts, depression, or any emotional distress. The 988 Suicide & Crisis Lifeline is also available for individuals worried about a loved one who might need crisis support services. Its goal is to provide accessible and immediate crisis intervention and support to every individual in need. 

988 state implementation and top challenges

As of August 2022, 23 states have passed legislation to facilitate the implementation of the 988 Suicide & Crisis Lifeline. Colorado, Nevada, and Washington enacted legislation with user fees to support 988 operations and provide financial sustainability for the system. Several states have established advisory groups or planning committees with representatives from state agencies, health providers, law enforcement, emergency medical services, and other partners to better coordinate the system and identify policy levers. 

Implementing a three-digit number for behavioral health emergencies in every state and providing 24/7 primary coverage through in-state call centers have presented certain challenges to states across the nation. As states prepare to launch the 988 hotlines, they have encountered key issues around infrastructure, workforce, 911 integration, readiness of the crisis care continuum, cultural competence, and performance management.  

Solutions for state agencies

To address these key issues, states should consider the following to aid in the successful implementation of the 988 Suicide & Crisis Lifeline:

Assess the states’ needs to successfully implement the 988 Suicide & Crisis Lifeline

Despite meeting baseline requirements for the implementation of the 988 Suicide & Crisis Lifeline, state agencies are struggling to implement the 988 Suicide & Crisis Lifeline. 

By performing a structured needs assessment, state agencies can evaluate their infrastructure, policies and procedures, funding, and workforce needs to better understand their readiness to implement and capability to sustain the 988 Suicide & Crisis Lifeline. This assessment provides insight for state agencies to understand their strengths, challenges, and areas of opportunity, and it should evaluate: 

  • State infrastructure
    Behavioral health leaders acknowledge that infrastructure supports are necessary to make the 988 Suicide & Crisis Lifeline work across the continuum of care. It is important to assess the infrastructure across the crisis care continuum to help ensure a smooth transition for individuals who need care quickly. Successful implementation should take certain considerations into account during the planning process, such as including all the interested parties representing diverse populations.
  • Workforce
    In the current labor market, workforce availability and retention are top concerns for sustainable and effective 988 Suicide & Crisis Lifeline operations. States are struggling to hire the extra staff needed to launch the 988 Suicide & Crisis Lifeline as well as to recruit qualified persons. To realistically implement the system, innovative workforce development and supporting wages to recruit and retain a specialized workforce are critical considerations for the states. Critical components to include in the assessment should include, but are not limited to:
    • Training
      Staff training and proper supervision will be crucial to effectively manage the 988 Suicide & Crisis Lifeline, and states need best practices models for how to best train crisis responders and the call center staff. States should assess the existing training infrastructure to identify ways early on to support the mental health of their 988 Suicide & Crisis Lifeline counselors to reduce the risk for burnout and post-traumatic stress disorder. 
    • Capacity
      Adequate capacity is a key factor to workforce. The assessment should identify the number of qualified workforce available for in-person staffing. In the current labor market, it will also be important to consider including the identification of the number of qualified staff able to work remotely. If states would like to consider remote capabilities for the call centers, it will also be important to assess the available technology necessary, as well as the development of standards and expectations, including strong communication. 
  • Readiness of the crisis care continuum
    Apprehension about the readiness of the crisis care continuum (e.g., mobile crisis teams through diversion services and lower levels of care) exist. Federal officials have stated they expect up to 12 million calls/texts/chats in the first year of the 988 Suicide & Crisis Lifeline, and research suggests approximately 20% of those calls/texts/chats will require some level of in-person response. States are questioning whether mobile crisis teams are prepared for the increased demand while also identifying connections and access to upstream services. In addition, states can consider the needs and experiences of the system’s end users to help address equity. The assessment can help to assess the readiness of the various components across the crisis care continuum.

Establish a strategic plan of action to implement the 988 Suicide & Crisis Lifeline 

With the implementation of the 988 Suicide & Crisis Lifeline, state agencies have an opportunity to strengthen crisis care. The best way to begin strengthening crisis care is to develop and implement strategic plans that optimize the 988 Suicide & Crisis Lifeline and the following services. Building on the strengths and opportunities identified in the needs assessment and the associated recommendations, strategic plans can establish priorities and identify sustainable solutions that build capacity, promote equitable access to care, and promote continuous quality improvement. Collaborating with key stakeholders to develop a strategic plan can help identify a roadmap for how the state should approach the implementation, maintenance, and sustainability of the 988 Suicide & Crisis Lifeline, including, but not limited to, the following areas:

  • Data and performance management
  • Stakeholder engagement
  • Health equity
  • Voice of the customer
  • Financial sustainability

Maximize available funding streams

Historically, behavioral health has not had sufficient funding to adequately address mental health and substance use disorder prevention, treatment, and recovery services across the continuum of care. The COVID-19 pandemic exacerbated behavioral health challenges for many individuals struggling and highlighted the challenges with the infrastructure and workforce. In the last couple of years, the federal administration has continued to allocate additional funding to supplement existing and ongoing federal funding. States should begin by evaluating the existing federal funding opportunities to support the implementation of the 988 Suicide & Crisis Lifeline. According to the Substance Abuse and Mental Health Services Administration’s (SAMHSA) 988 Convening Playbook for States, Territories, and Tribes, below are a few examples of funding sources that can be leveraged for the implementation of the 988 Suicide & Crisis Lifeline. 

  • SAMHSA 
    • Transformation Transfer Initiative
    • Community Mental Health Services Block Grant
    • Substance Abuse and Treatment Block Grant
    • Mental Health Block Grant Set-aside
    • State Opioid Response Grant
    • Tribal Opioid Response Grants
  • American Rescue Plan Act (ARPA) of 2021—for Mobile Crisis and Crisis Line Services
  • Medicaid
    • Early, Periodic, Screening, Diagnosis, and Treatment (known as EPSDT)
    • 1915(a) waivers
    • 1915(b) waivers
    • 1115 SMI/SED Service Delivery Waiver

The implementation of the 988 Suicide & Crisis Lifeline is critical to supporting the community and meeting their needs at a time where they need community support the most. If you have any questions, please contact BerryDunn’s behavioral health consulting team. We’re here to help.

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Components of successful implementation of the 988 Suicide & Crisis Lifeline

Read this if you are at a state Medicaid agency.

The uncertainty surrounding the end date of the COVID-19 Public Health Emergency (PHE) has made it difficult for state Medicaid agencies to plan and prepare to transition to pre-pandemic operations. Upon the federal declaration of the PHE, states and territories were forced to react quickly to reduce the impact on the Medicaid program and its enrollees. Many states and territories took advantage of the emergency authorities through the Centers for Medicare and Medicaid Services (CMS) to implement temporary policy changes such as the removal of prior authorization requirements, increased payments to providers, removal of cost-sharing, and the expansion of telehealth services. 

While many of the emergency authorities will terminate on or around the end of the PHE, states and territories may elect to make those temporary changes permanent due to the positive impact for both enrollees and providers. Take telehealth, for example. The broad flexibilities allowed during the PHE permitted providers to meet the healthcare needs of enrollees in a time where in-person visits were not recommended, nor available. To increase access to testing and vaccinations in pharmacies, pharmacy technicians and interns were permitted to administer COVID-19 vaccinations when supervised by an immunizing pharmacist.

So what comes next for states and territories once the PHE ends? Taking a proactive approach to plan out next steps will assist states and territories to be better prepared upon conclusion of the PHE. The US Department of Health and Human Services (HHS) has committed to providing at least a 60-day notice prior to the official end date of the PHE. CMS encourages states and territories to communicate changes to enrollees, managed care plans, counties, providers, and other stakeholders.

As we await the declared end date of the PHE or notification of another extension, states and territories can begin taking actions to prepare for the resumption of normal operations. We have learned new ways to prevent disruptions in meeting the needs of enrollees, developed enhanced methods of communication to stay in touch, and used technology to its fullest capacity. While our new normal is very different than pre-pandemic times, we can all use what we have learned to strengthen our tactics for any future PHEs. BerryDunn is here to assist and support states and territories as they prepare for the eventual end of the PHE.

If you have questions or would like to discuss further, please contact the Medicaid consulting team. We're here to help. You can also read more BerryDunn articles on the PHE unwinding here.

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Looking beyond the Public Health Emergency: What's next for states

Read this if you are a Medicaid agency or attended MESC 2022.

As I depart Charlotte and fly home and MESC 2022 closes out, I understand why Charlotte is referenced as the Queen City. The people make it so, as we were welcomed with open arms in this beautiful place. Our appreciation and gratitude go out not only to Charlotte, but also to NESCSO for providing us with a place to meet, share ideas, get inspired, and deepen our relationships.

In the coming months, our team can sift through what we learned during our four days at MESC. It will be up to us to transform the ideas spawned from presentations and conversations into tangible action, and grow the new relationships we developed. Here are my key takeaways and themes from the conference that I will continue to ponder:

  • The conference is in full swing on the other side of the pandemic. MESC was sold out, as 1,700 people attended.
    • MESC established a new annual award for collaboration. This year the award went to the Public Sector Technology Group's (PSTG) Medicaid Information Technology Architecture (MITA) workgroup. CMS is optimistic that the MITA workgroup's efforts will help improve Medicaid and that the resulting toolkit will be the future of MITA. Thank you to this group, and congratulations on a well-deserved award!
  • Modernization efforts:
    • The reality of managing modernization efforts is settling in. States and territories are beginning to get clear on their approach, acknowledging that each has unique needs, and consequently, can customize their approach. It will be a long haul requiring good upfront strategizing, planning and execution.
    • Many states and territories recognize a need to examine and adjust their internal structures to manage multiple procurements and strategies.
    • Data and data governance is foundational to the modularization and modernization effort.
  • Unwinding is weighing on everyone's mind, but participants discussed other forward-looking topics. 
  • CMS continues to solicit input from states, territories, and vendors
    • This was CMS' first in-person conference since the pandemic's start—it was so great to have their energy and participation.
    • It was fantastic to be in sessions where CMS asked: How can they do better? 
    • Efforts on outcomes, streamlining certification, consistency, and accountability continue to be CMS themes
    • Brent Weaver, CMS' new Data and Systems Group Director, outlined four of CMS' goals at MESC:
      • Strengthen state and territory partnerships
      • Get input from vendors on unwinding
      • Identify ways to improve data quality
      • Find ways that will help CMS become better partners
  • Ensuring health equity and leveraging social determinants for health is a priority for states and territories.
  • New solution vendors are coming into the Medicaid space, and want to learn about Medicaid and the broader enterprise as they look for ways to adapt their systems.  
  • There continues to be mergers and re-shuffling of the more established vendors as they look to adapt to and serve the needs in the Medicaid space.
    • This was BerryDunn's 17th conference. We have broadened our services and maintained our values. I'm grateful that BerryDunn continues to have a stable presence at the conference.  
  • Our Medicaid Practice Group mission statement (see below) aligns with the CMS Data and Systems Group Director's reason for being in his role. 

Additional thoughts: Asking "why," change, and education

I also appreciated conversations within our Medicaid community based on the “why": Why are we doing what we do? Why focus on modernization? Health equity? Social determinants of health? 
The "why" drives what we do by providing us with our North Star, helping us with strategy, and giving us our roadmaps for proceeding. By starting with the purpose and outcome we strive for, we can align the changes we need to make.  

Change can be a source of fear, and there is a risk of venturing into the unknown. Medicaid leaders understand that the work they are responsible for is critical to their members, providers, and taxpayers. Lives depend upon our work, and the potential of "change" can have positive or negative consequences. Effective planning can mitigate the risks and help alleviate staff, member, and provider fears about change. 

Education also plays a big part in the mitigation equation. After tying the purpose to the vision, roadmap, and phased plans to modernize our programs, there needs to be an education plan to bring everyone up to speed and build confidence in those who will be impacted.

Conclusion

I am grateful that the BerryDunn Medicaid Practice Group's mission complements the goals of CMS and the direction in which states and territories are moving. We are honored to participate in this vital work and join all in the Medicaid community as we work on the initiatives before us. I leave you with our mission statement and invite you to share your organization's mission with us.

BerryDunn's Medicaid Practice Group helps Medicaid agencies improve the health and lives of individuals by empowering, inspiring, and partnering with our clients—we innovate, share deep expertise, and provide an independent perspective to resolve challenges. We are the success partner for Medicaid agencies, building healthier communities and stronger futures.

I look forward to seeing you all again next time in Denver! Let's make it a great year!

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MESC 2022: Reflections from 30,000 feet

Read this if you are at a state Medicaid agency.

The COVID-19 PHE has raised many questions for Medicaid programs across the country. The Centers for Medicare & Medicaid Services (CMS) and other healthcare organizations have been providing guidance on how to best manage the PHE since it began. In particular, CMS has provided recommendations on how Medicaid programs can implement new processes and rules into their Medicaid Enterprise Systems (MES) for individuals to remain under continuous enrollment until the end of the PHE. 

Strategies for MES

BerryDunn has been working with many states and territories to develop strategic plans to comply with specific rules and requirements throughout the PHE. Some of these strategies involve changes to the original designs of the MES. Examples include:

  • Updating system rules to maintain individuals enrolled in continuous coverage throughout the PHE
  • Retesting system rules to confirm systems are working properly once PHE rules are removed
  • Revamping system notifications so reminders keep individuals informed about ongoing changes
  • Training staff on the new system updates so they can manage calls and orient individuals on changes regarding their eligibility

CMS continues to release updated guidance on how Medicaid programs can best prepare for the end of the PHE in order to resume normal operations. These recommendations indicate that Medicaid programs adopt strategies to maintain coverage of eligible individuals as the continuous enrollment requirements come to an end, following the conclusion of the PHE, while allowing coverage for ineligible individuals to terminate. Medicaid programs must ensure their systems are prepared for the transition, but some of these updates and changes to the systems may pose greater challenges: 

  • Since there are no precedents to compare with the current PHE unwinding event, Medicaid programs will need to execute changes within a limited timeline and work with the issues that may arise as they execute unwinding
  • For some Medicaid programs, system rules, both current and updated ones, are not able to run simultaneously
  • Medicaid programs may need to hire additional staff, train new employees, and retrain or cross train current employees within a small window of time
  • Medicaid programs will need to perform additional MES testing to confirm those systems are working as required
  • Medicaid programs will incur additional costs to cover additional operational efforts
  • System vendors will incur extra work that may affect project timelines and other priorities

If you have any questions or would like to learn more about how BerryDunn can assist you with the PHE unwinding efforts, please contact the Medicaid consulting team.

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Design, Development, and Implementation (DDI) and project impacts resulting from the Public Health Emergency (PHE)