Practical Strategies for Medicaid, Schools, Hospitals, and Communities

During Children’s Mental Health Awareness Week, May 3–9, and Mental Health Awareness Month, we are spotlighting actionable solutions across the US children’s behavioral health system. This post is intended for children’s behavioral health providers, state Medicaid agencies, school-based health centers, hospitals, local government agencies, local education agencies (LEAs), child welfare agencies, and philanthropic organizations that are working to strengthen prevention, crisis response, care coordination, and community-based continuums of care. HMA has a robust and growing team of behavioral health experts who support this work and have developed a series of case studies showcasing practical strategies implemented with clients—from crisis system design and referral pathway improvements to financing and implementation roadmaps.

Children’s Mental Health Awareness Week is a reminder that children’s behavioral health and youth mental health are not niche issues. They are systemic issues that require coordinated action across Medicaid, education, public health, hospitals and health systems, child welfare, and local government—especially where schools and community partners are on the front line.

The need remains substantial. The Centers for Disease Control and Prevention’s (CDC’s) 2023 Youth Risk Behavior Survey results, released in 2024, showed that 40% of high school students reported persistent feelings of sadness or hopelessness, even as some measures improved from 2021 levels. CDC also highlighted how bullying, safety concerns at school, racism, unfair discipline, and frequent social media use are tied to youth mental health risks.

The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) 2024 National Survey on Drug Use and Health, released in 2025, adds another important dimension. Among adolescents ages 12–17, the 2024 survey found that:

• 15.4% experienced a major depressive episode within the past year
• 10.1% had serious thoughts of suicide
• About 40% who had a major depressive episode in the past year did not receive mental health treatment

The data show that progress is possible when systems respond with real capacity, access, and support. That is why this moment calls for more than awareness. It calls for action that is operational, financeable, and grounded in what works.

At HMA, we work with child-serving systems that are trying to solve real problems, including how to strengthen crisis response, improve referral pathways, build a more coherent continuum of care, and connect strategy with implementation.

Over the coming weeks, we will feature three examples that reflect different parts of the children’s behavioral health landscape.

1. Children’s hospital mental health strategy and crisis response

This case study will highlight work to help a children’s hospital strengthen its mental health approach and support next-stage crisis system design.

In this engagement, HMA partnered with Rady Children’s Hospital Orange County to move pediatric behavioral health from strategy to implementation—aligning emergency department (ED) mental health workflows, clarifying pediatric crisis pathways, building an investment-ready fiscal pro forma, and advancing priority programs to strengthen access and care coordination. This work can inform hospitals and health systems, Medicaid agencies, and community partners seeking to reduce ED boarding and improve pediatric crisis response.

2. County-level ecosystem and referral system improvement

This case study will show how local systems can bring multiple stakeholders together to improve referral pathways and make behavioral health more accessible for children, youth, and families.

HMA supported a county-led effort to strengthen cross-system referral pathways by aligning agencies around shared intake and triage practices, clearer roles and accountability, and more navigable access points for families. This approach is relevant for local government agencies, LEAs, school-based health centers, child welfare agencies, and community providers working to reduce fragmentation and speed connection to the right level of care.

3. Building a stronger children’s behavioral health continuum in New Orleans

This case study will focus on assessing gaps, identifying opportunities, and supporting a more coherent community-based continuum for children’s behavioral health.

HMA helped deliver the first integrated view of pediatric behavioral health in New Orleans, LA, aligning schools, healthcare, philanthropy, and government around a shared understanding of unmet needs and critical system gaps, as well as charting a prioritized roadmap to strengthen and better coordinate the continuum of care.

What It Means for Key Child-Serving Audiences

• Children’s behavioral health providers: Prepare for stronger care coordination expectations (warm handoffs, follow-up after crisis, shared care plans) and increased demand for community-based alternatives to the ED
• State Medicaid agencies: Focus on financeable crisis continuums (including pediatric crisis response), payment and contracting approaches that support access and continuity, and data/reporting that demonstrates outcomes
• School-based health centers and LEAs: Strengthen referral pathways, clarify roles between schools and providers, and build protocols that support early identification while keeping students connected to safe learning environments
• Hospitals and health systems: Improve pediatric ED mental health workflows, create clearer crisis pathways, and develop investment-ready business cases for behavioral health capacity and partnerships
• Local government agencies: Convene cross-system partners, establish shared intake/triage and accountability, and use implementation roadmaps to move from planning to operational change
• Child welfare agencies: Align behavioral health access for children and youth involved with child welfare, reduce handoff failures, and integrate crisis planning into placement stability and permanency strategies
• Philanthropy: Target catalytic investments that fill continuum gaps, build capacity for implementation (not just planning), and support cross-system governance and measurement

The common thread among these examples is a simple belief: Children’s behavioral health improvement does not happen through aspiration alone. It happens when organizations and public systems translate urgency into design, partnerships, financing strategies, and implementation steps.

That is also why children’s behavioral health is so relevant. National data still point to high levels of distress and suicide risk among adolescents, despite recent improvements. CDC’s findings show how strongly youth mental health is shaped by the environments in which they live, learn, and play—especially their schools and communities.

For leaders in Medicaid, behavioral health, child welfare, education, county government, hospitals, and provider organizations, the question is not whether children’s behavioral health deserves attention, but rather is how to build systems that respond earlier, coordinate better, and support children and families more effectively.

We hope this series contributes to that conversation by sharing practical examples of work that can inform future action.

Other Resources on Children’s Behavioral Health and Youth Mental Health

• Children’s Behavioral Health Consulting: Cross‑System Solutions for Schools, Health Systems, and State & Local Agencies
• Improving Youth Behavioral Health Through School-Based Initiatives.
• Beyond the Agency: A Public Health Approach to Child Welfare
• MAHA Children’s Health Strategy Report: Driving a New Era for Child Health Policy
• Child and Teen Mental Health and the Lifting Voices initiative
• HMA Report: Los Angeles County Child Welfare-Involved Population Medi-Cal Analysis
• Webinar Replay – Youth mental health access: school-based intervention strategies

Contact us to discuss how HMA can support your children’s behavioral health strategy—whether you work for a Medicaid agency, hospital/health system, school-based health partner, LEA, local government agency, child welfare agency, provider organization, or philanthropic funder. We can help with crisis continuum planning, care coordination design, referral pathway improvement, financing and pro forma development, and implementation support.

It is hard to keep abreast of the changes being made to the healthcare system at the Federal level, and how these changes will impact behavioral health (BH) services.  The current reprioritization of funding by the Department of Health and Human Services (HHS) and the proposed changes in the budget bill pending in Congress will significantly reshape Medicaid and critical behavioral health programs.  States and local organizations will need to sharpen their understanding of this new funding landscape, so they are able to focus on addressing critical needs for prevention and treatment of mental health and substance use disorders.

Register today – HMA’s Behavioral Health Town Hall, Thursday, May 29 at 12 p.m.

With Federal funding levels in question, States and their stakeholders need to consider how they are funding BH initiatives. We’ll address participant questions and topics we know are top of mind, for example:

What steps can states take to ensure sustainable funding for critical programs? Are states strategically utilizing their Medicaid programs to preserve BH specific program dollars for other purposes? What efficiencies and enabling technologies can organizations adopt to support their mission? How should state and local entities be thinking about the opioid settlement dollars to maximize support for services and initiatives that face uncertain future financial support?

In addition, Congress is debating changes to Medicaid eligibility and funding policies that may result in shifts in key aspects of the program. States can start planning now for changes to their processes and for outreach and education campaigns that will be essential in supporting individuals with mental health and substance use disorder diagnoses. Payers should be planning for changes in enrollment and enrollee risk profiles while providers should expect changes in their payer mix and a need for enhanced collaboration with community organizations.  Are there different models that can be pursued to effectively navigate these shifts? How will all of this uncertainty affect the BH workforce?  Stakeholders need to be prepared to engage in downside risk arrangements, think about their patient/consumer engagement strategies and integrating digital BH tools that are the focus of the CMS Innovation Center agenda.

You probably have questions that we didn’t even list here. Here is your chance to ask them:  Join HMA on Thursday, May 29 at 12 p.m. at a dynamic and interactive Behavioral Health Town Hall where HMA experts Heidi Arthur, Rachel Bembas, Allie Franklin, Teresa Garate, Monica Johnson, and Sara Singleton will be available to answer your questions live on a wide range of critical topics, including:

• Federal policy, personnel, and funding changes;
• Emerging strategies for addressing social determinants of health, substance use disorder and crisis coordination (including 988);
• Leveraging cross-sector partnerships to build ecosystems of care across communities promoting coordination and collaboration;
• Behavioral health revenue cycle management and alternative payment models; and
• Innovations in addressing workforce shortages, integrated service delivery, digital mental health tools, and best practices for community mental health service delivery.

Whether you’re navigating regulations, searching for new funding, designing service delivery systems, or just trying to understand what happens next, this town hall is your chance to ask questions, share insights, and discuss real-world solutions with industry experts.

Register today

This week, our third In Focus section highlights the national 988 Suicide and Crisis Lifeline, the three-digit number for individuals in need of behavioral health crisis support. The 988 Lifeline is composed of 200-plus contact centers across the country, which connect people to trained counselors to deescalate crises, provide behavioral health resources, or connect individuals to an in-person responder. Supported by federal legislation to help create a nationwide, standardized, easy to remember 3-digit number, the program is still in its early stages, having been established three years ago this coming July.

In this article, Health Management Associates (HMA) experts provide important context about the 988 Lifeline and future policy direction and suggests actions state leaders can take to enhance use of this critical resource.

988 Lifeline: A Product of Coordinated Collaboration

The story of how the 988 Lifeline was created is an example of long-term advocacy and innovation that demonstrates how a solution needs to combine the state and local decisionmakers with federal policy and support. People experiencing a mental health crisis, thoughts of suicide, or concerns about substance misuse should receive the appropriate local response to seek support or care.

Prior to the 988 Lifeline, individuals experiencing a behavioral health crisis may have contacted 911 and, therefore, not always received the most appropriate response for their unique needs. In some situations, 911 responders—typically law enforcement, emergency medical services, or hospital emergency departments—are ill-equipped to direct people experiencing a behavioral health crisis. Trained behavioral health professionals responding to an individual experiencing a crisis is the appropriate intervention at most points of access. Increased diversion from 911 calls to 988 when an individual is experiencing a behavioral health crisis is an expected long-term outcome.

The federal government’s role is to continue to support the work to enhance the 988 Lifeline, but there’s so much more that needs to happen to increase education and awareness in states, localities, and Tribal nations. They still need support in building out their systems.

State Initiatives Strengthening the 988 Lifeline

Since the launch of the 988 Lifeline in July 2022, 50 percent of the states have approved some type of appropriation or some type of legislation to further cement 988 in their local communities. Some states have established trust funds or implemented 988 cell phone fees similar to what 911 does to provide financial support. Other states have established committees to study and support 988 implementation, building out the various components of a true coordinated crisis system of care.

HMA experts have identified strategic and operational recommendations to support this ongoing work, including:

• Be intentional about having the right people at the table where decisions are made, including voices with lived experience and people who are part of the policy-making process. Establishing this formal, standardized 988 system enables local communities to better allocate resources in crisis situations. In most cases, the contact with the 988 Lifeline is the best intervention to ensure people get the support or resources needed to resolve or deescalate the crisis.
• When designing a crisis system in a community, think about prevention and what happens when the crisis is over. Crisis systems established on a poor behavioral health foundation will fail. Stakeholders and decisionmakers should continue building out their systems by remembering that the entire continuum of care—from crisis to ongoing support—is needed.
• Identify the data that are needed to tell the story about the value of the 988 Lifeline and crisis care systems. Anecdotes are essential and should be paired with data, especially when ongoing funding is needed.

Where Is the 988 Lifeline Headed?

It is likely to take decades to generate greater awareness about the 988 Lifeline, to have interoperability between 911/988, to ensure every person in the country has access to the service no matter their zip code, and to see a fully transformed behavioral health crisis system will take decades to accomplish. The collaboration between federal, state, territories, Tribal nations, and local communities is pivotal to reaching these goals.

While we are at the beginning phases of this work, much has been done that should be celebrated. The 988 Lifeline has transformed how we as a nation talk about behavioral health and suicide prevention. Still, we as a collective have work ahead to achieve the vision of transforming the behavioral health crisis care system.

Connect with Us

Health Management Associates (HMA) is hosting a live, interactive event on Thursday, May 29, 2025. [The Ask the Experts: Behavioral Health Town Hall https://www.healthmanagement.com/insights/webinars/ask-hma-experts-behavioral-health-town-hall/ ] will explore the latest developments in behavioral health—from policy shifts and funding trends to real-world solutions for service delivery, workforce challenges, and system design. HMA and Leavitt Partners, an HMA Company, experts will be on hand to answer participant questions and share insights about 988 and other topics:

• Policy and funding updates at the federal level
• Innovative approaches to crisis response, 988 implementation, and substance use services
• Revenue cycle improvements and evolving payment models
• Strategies to strengthen the workforce, integrate care, and leverage digital mental health tools

For more information about 988 systems and effective practices emerging in crisis care, contact Monica Johnson, Managing Director for Behavioral Health. Prior to joining HMA, Ms. Johnson, Managing Director for Behavioral Health, was the director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration—the federal agency that leads public health efforts to advance the behavioral health of the nation.

During the month of May, HMA is featuring thought leadership and insights around Behavioral Health (BH) and changes within the BH delivery system in the U.S. Along with several presentations happening at NatCon25 in Philadelphia, May 5-7, we want to highlight some of the work done by HMA experts.  Starting us off, Josh Rubin, HMA Vice President, Client Solutions, has spent his career working with BH, intellectual and developmental disabilities, and child welfare service providers. In this post, he discusses the changing BH delivery system, and the issues surrounding the treatment of co-occurring mental health conditions.     

Ever since the 19^th century when Dorothea Dix crusaded up and down the east coast encouraging state legislatures to fund state psychiatric hospitals, we have had separate systems for medical and mental health care. I mean Ms. Dix no disrespect, far from it; before her work we simply had no system of care for people with mental illnesses. Her contribution was immeasurable. But in 1963 when President Kennedy signed the Community Mental Health Act, it was an acknowledgement that the “out of sight, out of mind” warehousing of people with mental illnesses in large state psychiatric hospitals was inappropriate and had to end.

Those of us who remember the heady days of the 1960s rightly celebrate the advance this represented in acknowledging the rights of people with mental illness to live in the community, and the opportunity it created for people with behavioral health conditions to build lives of dignity, productivity, and inclusion. And while we ought to celebrate that important advancement, we must nonetheless acknowledge that it maintained a separation between the underfunded mental health system, and a significantly better funded medical system. And thus, the community mental health system in America was built. It was designed to provide mental health care to the roughly 5% of the population that has a serious mental illness (SMI). In the nearly 60 years since, much has been done of which community mental health providers should be proud. We have transformed countless millions of people’s lives (and those of their families), built new program models, identified and implemented new practices, and built a service delivery system that offers a comprehensive continuum of care for people with SMI.

Unfortunately, that system was not built to address the needs of people with co-occurring mental health and substance use disorders (SUD), which is problematic because nearly half of people with a substance use disorder have a mental illness and nearly half of people with a serious mental illness have a substance use disorder. This is no surprise; the conditions are related. Some people with mental illnesses use drugs to manage their symptoms. Sometimes drug use can cause or exacerbate mental illnesses. In most cases, it is impossible to figure out where a mental illness ends, and a substance use disorder begins, or vice versa.

Yet in the U.S. we have always had separate service systems for these two conditions. Our systems grew up this way because although the stigma of mental illness is bad, the stigma of substance use is worse. While we have frequently been willing to address mental illnesses as health problems, we have long treated substance use disorders as criminal justice problems. We created community mental health centers. We launched a war on drugs.

The federal government provides two separate funding streams for states, one for mental health, the other for substance use disorder services. In many states there are separate agencies overseeing the two conditions, separate funding streams, and separate regulatory structures. Many providers respond to the funding and offer separate programs for one condition or the other.

This systemic failure leads every day to the death of Americans who have co-occurring mental health and substance use disorders but cannot access treatment for the two conditions together. Treatment works, and recovery is possible, but treatment works best when you are able to get treatment for your entire problem.

And just as the mental health and SUD systems were separated, they were both also segregated from the general healthcare delivery system. The stigma of our clients’ illnesses attached to us and our service system, so we were largely ignored by the healthcare delivery system and the people who funded and oversaw it.

While we have, as I said, much to be proud of, we cannot ignore the impact of our segregation. Our clients continue to die much younger than their peers. BH-related hospitalizations continue to increase. Overdose deaths and completed suicides, the worst possible outcomes, keep climbing, leaving incalculable suffering in their wake. And the financial costs of BH conditions continue to escalate, falling hardest on the historically underserved and marginalized communities that can least afford them. When America establishes a separate system, it isn’t equal; being ignored has consequences.

The good news? BH is not being ignored any longer. The bad news? BH is not being ignored any longer.

Healthcare policymakers have finally awakened to the reality that they will not be able to achieve their goals of better outcomes, lower costs, and improved customer service unless they address the BH needs of their populations. They are figuring out that everyone needs behavioral healthcare, and that a dichotomy that focuses BH care only on those with the most significant BH issues is ill serving. They are coming to understand that the skills, capabilities, and expertise of community BH providers have extraordinary value. It’s nice to be acknowledged and invited to help.

But it’s not all good news, because while being ignored left us underfunded and disrespected, it also protected us. Now that hospitals (which have been buying up outpatient practices at a remarkable pace) have started opening up BH services, we must compete with their deep pockets. And private equity (with even deeper pockets) has increased the pace at which they are acquiring BH providers, forcing additional competition on us. We are not even safe from our own phones. 10,000 mental health apps in the app store offer our clients a totally different paradigm for care, much of it lacking any evidence-based foundation. This makes it more dangerous for our clients, not less competitive for BH providers.

This environment requires fundamental changes in the way BH providers operate. We need new models of care that better meet the needs of the people we serve. Certified Community Behavioral Health Clinics (CCBHCs) are a step in the right direction, but they’re not a significant change in the service delivery model. If you look at the history of the BH system in America, from Dorothea Dix through today, you will see that the movement has been consistently in the same direction – inward. We have moved out of the hospitals in the countryside into clinics in the neighborhood. We have slowly chiseled away at the barriers dividing mental health from substance use disorder services. We have patiently worked to integrate with our health care colleagues. Now things are accelerating, and the pace of change is scary, but we should embrace the opportunity. We have a once in a lifetime chance to build something new, better, more effective.

HMA consultants are participating on four panel sessions at NatCon25 in Philadelphia, May 5-7. In this blog, HMA Principal Suzanne Daub offers a peek at her session topic and explains how improvisation is being used in behavioral health.

In the fast-paced, high-stakes world of behavioral health, case and care managers are often the steady bridge between crisis and stability, support and recovery. Yet the complexity of their roles—navigating systems, engaging clients with diverse needs, adapting to change in real-time—requires more than clinical knowledge. It calls for presence, empathy, adaptability, and clear communication. These are exactly the skills honed through applied improvisation.

Several years ago, I attended a national healthcare conference and found myself in a session on applied improvisation for medical professionals. I expected a few communication tips. What I experienced instead was a transformative, embodied approach to learning that blended empathy, collaboration, and spontaneity in a way that felt deeply relevant to behavioral health. I knew immediately: this belongs in our field.

That session sparked my own journey. I began formal improv training, developed a personal improv practice that I’ve now sustained for over five years, and eventually became a certified trainer in applied improvisation for healthcare professionals. Since then, I’ve been focused on bridging this work into behavioral health—especially to support case and care managers, who often work at the emotional and logistical front lines of client care.

What Is applied improv? Applied improvisation takes the tools and principles of theatrical improv—like active listening, collaboration, spontaneity, and “yes, and” thinking—and uses them in professional, non-performance contexts to strengthen human interaction. It’s grounded in neuroscience, play theory, and experiential learning.

In medical training, applied improv is used to support communication, teamwork, leadership, and emotional resilience. It helps providers stay grounded in the face of uncertainty, build trust with patients and teams, and respond rather than react. Academic medical centers, residency programs, and interprofessional training teams are increasingly turning to improv to improve quality of care and reduce burnout.

Applied improv is still emerging in behavioral health, but momentum is growing. Innovative programs are using improv to support:

• Engagement in developmental disability services where play-based, nonverbal, and responsive communication is vital.
• Reducing isolation among older adults and dementia caregivers through shared storytelling, and connection-building.
• Substance use disorder recovery by helping individuals rediscover joy, flexibility, and authentic connection in group work.
• Supervision and team development where role-play and real-time scenarios help staff practice challenging conversations and build peer support.

For case and care managers in behavioral health, applied improv can help:

• Enhance engagement, improve presence, listening, and rapport-building with clients across cultures and abilities.
• Build comfort with unpredictability and navigating uncertainty —essential when managing client crises or changing systems.
• Foster collaboration and trust in interdisciplinary teams.
• Bring joy, presence, and creative reset—tools we all need to stay grounded, prevent burnout and foster resilience.

If you’re attending NatCon25, I invite you to join our interactive workshop: “Improv in Behavioral Health: Strengthening Empathy, Collaboration and Adaptability,” where you’ll gain hands-on tools, and leave with a new lens on what it means to connect.  There are two sessions available, Monday, May 5, 4:30 PM – 5:30 PM ET or Tuesday, May 6, 11:15 AM – 12:15 PM ET, both located in room 204C.

Don’t miss these other HMA presentations at NatCon25:

Monday, May 5, 10:15 AM – 11:15 AM ET session A3 in room 103B
Harnessing Your Superpowers in Times of Disaster
Breakout Presenter: Monica Johnson, MA, LPC – Health Management Associates

Monday, May 5 10:15 AM – 11:15 AM ET session A13 in room 115BC
Building Sustainable Pathways for Behavioral Health Careers
Breakout Presenter: Allie Franklin, MSSW, LICSW – Health Management Associates

The behavioral health workforce crisis, a long-standing issue worsened by the COVID-19 pandemic, threatens the ability of provider organizations to meet growing demands for behavioral health treatment services. Despite decades of efforts, challenges such as inadequate compensation, workforce shortages, lack of diversity, and high burnout persist. In fact, a 2023 survey of state Medicaid officials on behavioral health revealed that nearly every state was engaged in at least one strategy to address the workforce shortage.^[1]

Since 2021, The Workforce Solutions Partnership, a collaboration of The National Council for Mental Wellbeing, The College for Behavioral Health Leadership, and Health Management Associates has worked to create both short and long-term solutions. Efforts have included:

• Policy papers aimed at short term solutions
  • Immediate Policy Actions for States
  • Immediate Policy Actions to Address the National Workforce Shortage and Improve Care
  • Addressing Representation in the Workforce and Emerging Opportunities for the Behavioral Health Workforce
• Review and crosswalk of over 400 recommendations from organizations across the country
• Creation of the Workforce Solutions JAM, begun in May 2024, a monthly webinar spreading innovation and discussing all elements of the behavioral health workforce
• Multiple convenings of technical experts and partners to discuss how to support action on the workforce
• And now a call to action.

The next step for the Workforce Solutions Partnership is to expand engagement with partners to address the workforce shortage. The Partnership believes that using the Collective Impact framework, will provide the structure to build a national strategy and cross-sector approach to shared implementation of workforce initiatives, resulting in effective and scalable solutions. We understand there are countless workforce initiatives underway across the country, many of which are demonstrating progress and innovations that can be scaled. Rather than duplicate or distract from existing efforts, the Partnership will build connections between these efforts, elevate their impact and empower emerging innovative ideas.

Initial areas of focus will include:

Community alignment: Enhancing recruitment and retention of a workforce that reflects the communities accessing behavioral health services.

Creation of efficiencies: Building a new operational and administrative model that improves access.

Technology integration: Exploring tech-enabled supports to enhance skill development and service delivery.

Career pathways and compensation: Improving access to career opportunities and using evolving payment models to increase salaries for behavioral health professionals.

The Call to Action outlines the Partnership common agenda, levers of change, and the process for developing a national platform for change. It outlines how partners can engage and is the launch of what we hope will be national action to build a sustainable workforce.

[1] Saunders, H., Guth, M., & Eckart, G. (2023). A look at strategies to address behavioral health workforce shortages: Findings from a survey of state Medicaid programs. Kaiser Family Foundation. https://www.kff.org/mental-health/issue-brief/a-look-at-strategies-to-address-behavioral-health-workforce-shortages-findings-from-a-survey-of-state-medicaid-programs/