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Interagency Collaboration, Care Coordination, and Rural Implementation: Pediatric Healthcare Landscape Analysis and Blueprint
THE CLIENT
Glenn County Office of Education (GCOE) is a recipient of a Providing Access and Transforming Health (PATH) grant from California’s Department of Health Care Services to implement a Capacity and Infrastructure Transition, Expansion, and Development (CITED) initiative. As part of implementation, GCOE applied for technical assistance through the CalAIM TA Marketplace to strengthen Enhanced Care Management (ECM) partnerships that connect school-based and school-linked behavioral health (BH) supports with Medi-Cal and community services. The goal was to improve pediatric behavioral health access, care coordination, and closed-loop referral pathways across school districts, county agencies, and local clinical providers.
As schools increasingly serve as the venue where many children and families first access BH supports, this case study highlights how cross-sector partners can align roles and coordination practices so students experience timely referral and smooth handoffs to community-based and clinical services—especially in rural and smaller counties. This work is relevant to behavioral health professionals working in schools (school counselors, school psychologists, educational social workers, wellness staff), county and state agencies (behavioral health, public health, child welfare, probation, social services), and clinical settings (licensed providers, FQHCs, managed care) who are strengthening prevention, early intervention, and referral pathways for children, youth, and families ages 0–25.
BACKGROUND
Like many counties, Glenn needed to align multiple agencies and initiatives happening simultaneously. As schools increasingly serve as the primary access point for student mental health, BH prevention, and early intervention, improvement depended on stronger, more reliable connections between education and healthcare—including clear referral pathways within a multi-tiered system of supports (MTSS) and timely linkage to community-based treatment.
“Health Management Associates has been an exceptional technical assistance partner throughout this project. Their team consistently exceeded expectations by accurately assessing our agency’s baseline needs alongside those of key community partners, facilitating meetings ahead of schedule to maintain momentum, and developing targeted prompts that strengthened both macro- and microsystem design efforts.
What has stood out most is HMA’s ability to create structured, collaborative planning processes that increase engagement and accountability across stakeholders. Their facilitation style helped move our organization from early exploration into actionable system design while ensuring partners had the time and support needed to provide meaningful input. We highly recommend Health Management Associates as a trusted and highly effective TA Marketplace vendor.”
Christine Taylor
Educational Administrator
Glenn County, CA
County offices of education can play an important and catalytic role in linking education and healthcare because they are well positioned to convene cross-sector partners serving children, youth, and families. In Glenn County, multiple state-driven changes affecting child and youth BH increased the need for tight interagency collaboration and seamless transitions—so each partner could act clearly within its lane or locus of control. Improving BH access also required ecosystem-level change management. Partners needed shared governance and practical coordination infrastructure (e.g., decision forums, common workflows, and information-sharing practices) to support closed-loop referrals and smoother movement between school-based supports, clinical care, and community resources. Glenn’s rural context brought both constraints and advantages: workforce capacity was limited, but long-standing relationships meant partners often knew one another and could be motivated to coordinate.
APPROACH
HMA’s technical assistance focused on building countywide infrastructure for collaboration and care coordination across schools, agencies, and clinical providers. The work centered on three components:
- An assessment of ECM readiness to identify the key factors and challenges tied to improving BH access and care coordination across multiple public agencies, schools, and community-based organizations serving county children, youth, and families.
- Provision of targeted training of direct service providers of ECM such as licensed clinicians, school counselors, educational social workers, Community Health Workers, and Certified Wellness Coaches.
- Facilitation of two in-person countywide convenings to advance interagency collaboration across ECM, Community Schools, and the Children and Youth Behavioral Health Initiative (CYBHI), with dedicated work time on referral systems and data sharing for care coordination and transitions.
Partners included county agencies (Education, Behavioral Health, Public Health, Probation, Child Welfare, and Social Services), health care organizations (managed care plans, FQHCs), and community-based organizations supporting children, youth, and families. This cross-sector collaboration supported a whole-child approach by aligning school-based services, youth mental health resources, and referral pathways across education, public systems, and clinical care.
RESULTS
Convened a countywide ecosystem of agencies and organizations to align around shared goals for children, youth, and family well-being—creating a common operating picture across school, agency, and clinical settings.
Established a collective impact model with the County Office of Education serving as backbone, leveraging its convening role to link education and healthcare partners across the county.
Translated and aligned education and health care initiatives (CYBHI, Community Schools, ECM, and the Behavioral Health Services Act/BHSA) into clear roles, workflows, and decision points—supporting lane clarity and smoother transitions across agencies and sectors.
Accelerated design of standardized referral forms, closed-loop protocols, and data/information-sharing agreements—foundational infrastructure to simplify care coordination and reduce handoff failures for children and youth moving between school, clinic, and community supports.
Strengthened ecosystem-level change management by identifying governance touchpoints and coordination infrastructure that can be maintained in rural contexts—supporting ongoing role clarity, continuous improvement, and consistent transitions for children, youth, and families.
Identified 2–3 near-term projects to “practice” new interagency coordination behaviors, paired with governance forums to sustain collaboration and continuous improvement.
Takeaway for practitioners: When schools are a primary access point for prevention and early intervention, sustainable improvement depends on ecosystem-level change management—shared governance, clarified roles, integrated behavioral health workflows, and coordination infrastructure (including closed-loop referral and interoperable data/information-sharing practices) that helps students and families move seamlessly between school-based supports, specialty BH care, and community youth mental health services.
HMA brings together nationally recognized expertise in pediatric behavioral health, hospital-based mental health integration, and public-sector policy and operations. Our clients serve rural and frontier communities, including state and local governments, health systems, federally qualified health centers, tribal organizations, providers of every specialty, and community-based groups
Contact our experts to learn more about how HMA can help your organization.
Interagency Collaboration, Care Coordination, and Rural Implementation: Pediatric Healthcare Landscape Analysis and Blueprint
THE CLIENT
Glenn County Office of Education (GCOE) is a recipient of a Providing Access and Transforming Health (PATH) grant from California’s Department of Health Care Services to implement a Capacity and Infrastructure Transition, Expansion, and Development (CITED) initiative. As part of implementation, GCOE applied for technical assistance through the CalAIM TA Marketplace to strengthen Enhanced Care Management (ECM) partnerships that connect school-based and school-linked behavioral health (BH) supports with Medi-Cal and community services. The goal was to improve pediatric behavioral health access, care coordination, and closed-loop referral pathways across school districts, county agencies, and local clinical providers.
As schools increasingly serve as the venue where many children and families first access BH supports, this case study highlights how cross-sector partners can align roles and coordination practices so students experience timely referral and smooth handoffs to community-based and clinical services—especially in rural and smaller counties. This work is relevant to behavioral health professionals working in schools (school counselors, school psychologists, educational social workers, wellness staff), county and state agencies (behavioral health, public health, child welfare, probation, social services), and clinical settings (licensed providers, FQHCs, managed care) who are strengthening prevention, early intervention, and referral pathways for children, youth, and families ages 0–25.
BACKGROUND
Like many counties, Glenn needed to align multiple agencies and initiatives happening simultaneously. As schools increasingly serve as the primary access point for student mental health, BH prevention, and early intervention, improvement depended on stronger, more reliable connections between education and healthcare—including clear referral pathways within a multi-tiered system of supports (MTSS) and timely linkage to community-based treatment.
“Health Management Associates has been an exceptional technical assistance partner throughout this project. Their team consistently exceeded expectations by accurately assessing our agency’s baseline needs alongside those of key community partners, facilitating meetings ahead of schedule to maintain momentum, and developing targeted prompts that strengthened both macro- and microsystem design efforts.
What has stood out most is HMA’s ability to create structured, collaborative planning processes that increase engagement and accountability across stakeholders. Their facilitation style helped move our organization from early exploration into actionable system design while ensuring partners had the time and support needed to provide meaningful input. We highly recommend Health Management Associates as a trusted and highly effective TA Marketplace vendor.”
Christine Taylor
Educational Administrator
Glenn County, CA
County offices of education can play an important and catalytic role in linking education and healthcare because they are well positioned to convene cross-sector partners serving children, youth, and families. In Glenn County, multiple state-driven changes affecting child and youth BH increased the need for tight interagency collaboration and seamless transitions—so each partner could act clearly within its lane or locus of control. Improving BH access also required ecosystem-level change management. Partners needed shared governance and practical coordination infrastructure (e.g., decision forums, common workflows, and information-sharing practices) to support closed-loop referrals and smoother movement between school-based supports, clinical care, and community resources. Glenn’s rural context brought both constraints and advantages: workforce capacity was limited, but long-standing relationships meant partners often knew one another and could be motivated to coordinate.
APPROACH
HMA’s technical assistance focused on building countywide infrastructure for collaboration and care coordination across schools, agencies, and clinical providers. The work centered on three components:
- An assessment of ECM readiness to identify the key factors and challenges tied to improving BH access and care coordination across multiple public agencies, schools, and community-based organizations serving county children, youth, and families.
- Provision of targeted training of direct service providers of ECM such as licensed clinicians, school counselors, educational social workers, Community Health Workers, and Certified Wellness Coaches.
- Facilitation of two in-person countywide convenings to advance interagency collaboration across ECM, Community Schools, and the Children and Youth Behavioral Health Initiative (CYBHI), with dedicated work time on referral systems and data sharing for care coordination and transitions.
Partners included county agencies (Education, Behavioral Health, Public Health, Probation, Child Welfare, and Social Services), health care organizations (managed care plans, FQHCs), and community-based organizations supporting children, youth, and families. This cross-sector collaboration supported a whole-child approach by aligning school-based services, youth mental health resources, and referral pathways across education, public systems, and clinical care.
RESULTS
Convened a countywide ecosystem of agencies and organizations to align around shared goals for children, youth, and family well-being—creating a common operating picture across school, agency, and clinical settings.
Established a collective impact model with the County Office of Education serving as backbone, leveraging its convening role to link education and healthcare partners across the county.
Translated and aligned education and health care initiatives (CYBHI, Community Schools, ECM, and the Behavioral Health Services Act/BHSA) into clear roles, workflows, and decision points—supporting lane clarity and smoother transitions across agencies and sectors.
Accelerated design of standardized referral forms, closed-loop protocols, and data/information-sharing agreements—foundational infrastructure to simplify care coordination and reduce handoff failures for children and youth moving between school, clinic, and community supports.
Strengthened ecosystem-level change management by identifying governance touchpoints and coordination infrastructure that can be maintained in rural contexts—supporting ongoing role clarity, continuous improvement, and consistent transitions for children, youth, and families.
Identified 2–3 near-term projects to “practice” new interagency coordination behaviors, paired with governance forums to sustain collaboration and continuous improvement.
Takeaway for practitioners: When schools are a primary access point for prevention and early intervention, sustainable improvement depends on ecosystem-level change management—shared governance, clarified roles, integrated behavioral health workflows, and coordination infrastructure (including closed-loop referral and interoperable data/information-sharing practices) that helps students and families move seamlessly between school-based supports, specialty BH care, and community youth mental health services.
HMA brings together nationally recognized expertise in pediatric behavioral health, hospital-based mental health integration, and public-sector policy and operations. Our clients serve rural and frontier communities, including state and local governments, health systems, federally qualified health centers, tribal organizations, providers of every specialty, and community-based groups
Contact our experts to learn more about how HMA can help your organization.
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