Table of Contents Tal d cele [Ulta (0) eee ie 2 Oa S10 eee K) 1-1] Coy \ei (0) eee eerie K Methods ......cscccccesesseeeeesseeeeeesseeeeeesseeeeeensseeeseeseeaeeeesseaaeesnssenessenseeesenssseeseeenseaaees ma J avitlaldalae) ©d'am m=] ave -Yer-] ol= r=] ale lu xe) | (en) aps {or- | 0 eee ee eee va ho} t=] ¢=v ale) (el=lam stale l-le[-\00(-)0] ee va J at] a=1e @) 0) ole) adel al id | -\- See ne 5 Ne@Xt Step .......ccccccccsesseseeeeessseeeeeesseeeeeeeasseeeeeeaseeeesceasseeeeeoeaseeeeeeuaseeesenusseeseensneeesss 5 Ne) elie) Gee 6 aXe) | (enV k= 1a Te [-\et- | 0] = eerie 6 W=Yo TI F- a \.- is =1 0-1 010g ee 6 => CaYotU a AV(= 38 =] c=] 0d 8 Bee 8 =dalit=lalaa] ge) ©)'aa mt-] ale |-{or-] 0|- eer 10 Ce) 1 =) 6, eeee 7 Authors: ¢ Daniella Gratale, MA, Director, Office of Child Health Policy and Advocacy, Nemours Children's Health e Joshua Ogburn, MPP, Manager of Policy, Nemours Children's Health ¢ Laura Hogan, MPA, Laura Hogan Consulting ¢ Allison Gertel-Rosenberg, MS, Vice President, National Prevention and Practice, Nemours Children's Health We would like to thank Kara Odom Walker, MD, MPH, MSHS, EVP, Chief Population Health Officer, Nemours Children's Health, and Cara V. James, PhD, President and CEO, Grantmakers In Health for reviewing this paper. About Us Nemours Children's Health is one of the nation's largest multistate pediatric health systems, including two free-standing children's hospitals and a network of nearly 75 primary and specialty care practices. Nemours Children's seeks to transform the health of children by adopting a holistic health model that utilizes innovative, safe and high-quality care, while also caring for the health of the whole child beyond medicine. Nemours Children's also created the world's most-visited website for information on the health of children and teens, KidsHealth.org. The Nemours Foundation, established through the legacy and philanthropy of Alfred |. duPont, provides pediatric clinical care, research, education, advocacy and prevention programs to the children, families and communities it serves. Grantmakers In Health (GIH) is a nonprofit, educational organization dedicated to helping foundations, corporate giving programs, and other philanthropic organizations improve the health of all people. Its mission is to foster communication and collaboration among grantmakers and others, and to help strengthen the grantmaking community's knowledge, skills, and effectiveness. For nearly 40 years, GIH has developed programming, provided technical assistance, and hosted convenings to help funders learn, connect, and grow. Introduction Philanthropic organizations, policymakers, communities and caregivers share a common purpose in striving for conditions that enable children and youth to thrive.' Though the COVID-19 pandemic has presented new challenges and exacerbated pre-existing stressors, it has also revealed strengths and resilience within communities. By shining a light on health disparities and the systemic underpinnings of social, racial and economic inequities, the pandemic calls upon leaders and communities to meet the moment with action. In particular, a mental, emotional and behavioral (MEB) health crisis has emerged among children and youth, presenting a significant concern along with an opportunity for improving care and support for children and young people! By aligning actions that elevate community-led voices and solutions, we can accelerate equitable MEB health and well-being for our nation's children, youth and their caregivers. This report issues a call to action for philanthropic organizations and public-sector partners that are ready to move forward in improving MEB health. It describes existing philanthropic and federal MEB initiatives, based on information gathered from policy scans, interviews, focus groups, and a convening of philanthropic organizations. Finally, it offers a potential portfolio of aligned strategies for private- and public-sector partners to consider. 'The term "caregivers" includes parents, guardians and various providers that care for children, including health care, schools and early care and education. The term "philanthropic organizations" includes nonprofit funders, public charities and individual grantmakers, along with independent, family, corporate, private and other types of foundations. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth The Issue As a result of the COVID-19 pandemic, children have experienced increased stress from changes to their routines, breaks in the continuity of learning and health care, missed life events, and an overall loss of security and safety.? Since the onset of the pandemic, more than 13.36 million children have tested positive for COVID-19.3 In addition, more than 200,000 children and youth lost an in-home caregiver to COVID-19.4 According to Dr. Vivek H. Murthy, the U.S. Surgeon General, "the challenges today's generation of young people face are unprecedented and uniquely hard to navigate. And the effect these challenges have had on their mental health is devastating." Children are requiring more immediate and intensive behavioral health care, including emergency room visits and inpatient stays in the hospital. Emergency room visits for mental health-related conditions increased by nearly 25 percent for children age 5-11 and by over 30 percent for those 12-17 years during the pandemic.® In addition, Black children, who were more than twice as likely to die from suicide than white children prior to the pandemic, are most likely to have lost a parent or caregiver to COVID-19 compared to other racial and ethnic groups.' While this crisis has been in the making for decades, many children and youth have incredible resilience® that can be leveraged with support from community leaders, policymakers, funders and other stakeholders who seek to make an impact. Call to Action We call upon national, regional and state-based philanthropic organizations and their federal partners to advance equitable MEB health and well-being for children, youth and their caregivers by aligning work on a portfolio of strategies. Youth, caregivers and communities should be the guiding voices for this effort. At a time when there are urgent MEB health needs and clear health disparities among children and youth, we invite you to join us in taking coordinated and immediate action to ensure children and youth have equitable opportunities to reach their full potential and thrive. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Methods This section describes policy scans, interviews and other stakeholder engagement Nemours Children's and Grantmakers In Health (GIH) have conducted to advance this initiative. Philanthropy Landscape and Policy Scan In late 2021, Nemours Children's performed a literature review and an initial series of structured interviews with philanthropic, nonprofit and public sector leaders to identify the current landscape of federal policy initiatives and philanthropic investments focused on improving health equity for children, youth and their caregivers. This inquiry cast a broad net by scanning published literature, white papers and other content for policy, research and programs offering promise for improving children's health. With a whole-child and life course approach in mind, the scan encompassed the health-related social needs and community conditions underlying the physical and MEB health of children, youth, and their caregivers. Additionally, Nemours Children's scanned major federal legislation and executive actions related to MEB health and underlying social determinants of health. Stakeholder Engagement Nemours Children's and GIH then performed interviews and facilitated focus groups with leaders in philanthropy. Participants provided candid insights into how they view the potential for continuing or expanding their engagement given the current policy landscape, as well as the potential for alignment between philanthropy and the public sector. Focus group participants emphasized the importance of addressing equitable MEB health, thereby clarifying the future focus of this effort. The Philanthropy Landscape and Policy Landscape sections of the Appendix describe the full findings from the scans, interviews and focus groups. In March 2022, Nemours Children's and GIH convened more than 60 stakeholders from local, state, regional and national philanthropic organizations to collectively discuss aligned approaches to equitable MEB health and well-being. The group explored barriers, opportunities and potential action steps related to workforce, data, payment and research/ evaluation. Amplifying the voice and lived experience of youth was a consistent theme across all areas. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Shared Opportunities After the convening, Nemours Children's synthesized input, refined the strategies, and folded research/evaluation into each area, as recommended by the philanthropic organizations. Table 1 below summarizes a portfolio of aligned strategies, including desired outcomes for the three remaining strategies (workforce, payment, and data), and a new cross-cutting youth engagement strategy. All strategies would support improved prevention, screening and treatment, as well as more equitable outcomes for children, youth and their caregivers. TABLE 1 Portfolio of Aligned Strategies to Improve Equitable MEB Health and Well-Being for Children, Youth and Caregivers Strategies Desired Outcomes Begin cross-sector efforts to expand and diversify the community-based MEB workforce. Improve the provision and integration of prevention, early identification, and treatment by increasing access to culturally competent community-based providers. Design and test payment models (especially in Medicaid) that realize equitable child, family and community well-being, promote prevention, and provide flexibility in the types of providers, services and settings where services can be rendered. Increase implementation of pediatric payment models through Medicaid that improve MEB health outcomes and promote prevention. Expand the use of disaggregated data analysis and participatory data gathering techniques that lead to more equitable decision-making and outcomes. Increase equity-driven decision making and reduce racial, ethnic, religious, sex, gender identity and other disparities in MEB health and well-being. Seek out and amplify diverse youth voices during the development and implementation of community-based MEB initiatives. Advance policy solutions that are informed by youth and reflect their lived experience. Next Steps Nemours Children's is organizing planning calls with philanthropic organizations interested in each strategic area, to be followed by direct engagement with federal public sector partners. By aligning actions around a portfolio of shared strategies, philanthropic organizations have the opportunity to advance equitable MEB health and well-being for children, youth and their caregivers. Nemours Children's looks forward to sharing updates on this work and encourages philanthropic organizations to adopt the above strategies. Connect with Daniella Gratale (daniella.gratale@nemours.org) at Nemours Children's if there is interest in joining the engagement. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Appendix Policy Landscape Nemours Children's conducted a scan of recent federal public laws and executive actions enacted in response to the pandemic. Congress and the Executive Branch have advanced numerous policies to address the health, economic and social impacts of the pandemic and positively impact health equity. This section describes the subset of policies focused on children, youth and their caregivers, with a focus on those intended to positively impact MEB health. LEGISLATIVE BRANCH Throughout the course of the pandemic, the federal government has sought to address the impacts of the pandemic through six legislative packages that total $4 trillion, including over $361 billion that directly benefits children and youth.? Table 2 contains a breakdown by category. In addition, Congress has held numerous hearings and developed legislative proposals in additional related areas, Mental, Emotional and Behavioral Health Recently, the U.S. Senate and U.S. House of Representatives began taking steps to develop a legislative response to the MEB health crisis among children and youth. Committees in both chambers have held multiple hearings on related topics. Numerous members of Congress have introduced individual bills. In February 2022, the Senate Finance Committee announced a bipartisan process to develop legislative proposals related to strengthening the workforce; increasing integration, coordination and access to care; ensuring parity between behavioral and physical health care; furthering the use of telehealth; and improving access to behavioral health care for children and young people'? The Finance Committee is expected to introduce a comprehensive MEB health legislative package this summer. The U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) along with the House Energy and Commerce and Ways and Means Committees are also expected to consider legislation. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth TABLE 2 Total Funding for Children and Youth Across COVID-19 Packages, by Category Category Total ($, Billion) Behavioral Health 01 Home Visiting 0.2 Child Welfare 0.9 General/Other 6.9 Nutrition 18.0 Early Care and 54.5 Education Education & Out 280.9 of School Time TOTAL 361.5 Note: Adapted from Children's Funding Project, March 2021, p. 5° Child Poverty According to the World Health Organization, poverty is the single largest driver of health." Child poverty rates in the United States significantly differ by race and ethnicity, with 7 percent of white children affected compared to 20 percent of Hispanic children; 18 percent of Black children; and 11 percent of Asian children." Eliminating the burden of poverty for children and youth will lead to improved physical health, socio-emotional development, and educational outcomes in the short- and long-term." The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2), which became law in March 2021, made several, albeit temporary, anendments to the Child Tax Credit aimed at reducing child poverty. Analyses estimated these amendments halved the child poverty rate.? Despite momentum to renew the amendments in 2021, they expired at the end of the year. Postpartum Health Insurance Coverage Ensuring mothers have health insurance coverage during the postpartum period leads to improved mental health, greater identification and treatment of risk factors for maternal morbidity and mortality," and a reduction in longstanding racial and ethnic disparities in maternal and infant health outcomes.® The ARPA included an option for states to extend postpartum Medicaid and Children's Health Insurance Program (CHIP) coverage from 60 days to 12 months. The option took effect on April 1, 2022, and lasts for five years. This is particularly significant because Medicaid is the principal payer for over 40 percent of live births each year in the United States.'6 Child Care High-quality early care and education (ECE) programs promote positive MEB health, especially for children who are from lower-income families or communities of color." Pre-pandemic child care shortages became severely worse during the pandemic as child care centers closed due to lockdowns.® While Congress allocated $50 billion to stabilize the child care sector, child care shortages continue, leading to higher prices and less access for families.2° Housing Housing quality, safety, stability and affordability significantly affect physical and MEB health, and health equity.?! As the pandemic caused major economic disruptions, millions became unable to pay their monthly mortgage or rental payments. This was especially problematic for Black and Hispanic renters who faced the most severe housing challenges.?? To address this issue, Congress created the Emergency Rental Assistance (ERA) program and appropriated $47 billion to provide emergency rent and utility assistance." In addition, state and local governments utilized funds for similar purposes from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L.116-136)."4 Food and Nutrition Research consistently shows that having regular access to nutritious food positively affects numerous health outcomes,"?> including mental and behavioral health.2® The Families First Coronavirus Response Act (P.L.116- 127), CARES Act, Continuing Appropriations Act, 20271 and Other Extensions Act (P.L.116-159), Consolidated Appropriations Act, 2021 (P.L.116-260), and the ARPA all made important contributions to promote the availability of food and nutrition for children, youth and caregivers. These laws provided funding and flexibilities for the Supplemental Nutrition Assistance Program (SNAP); Child and Adult Care Food Program (CACFP); Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and other nutrition programs.??78 In addition, they created the Pandemic Electronic Benefit Transfer (P-EBT) program to provide families with funds on EBT cards to purchase food as schools were not open as normal to provide children with meals.?9 Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth EXECUTIVE BRANCH Numerous agencies across the Executive Branch have sought to utilize their authority to address the impacts of the pandemic, advance health equity, and improve the MEB health and well-being of children and youth. Executive Office of the President Under the Biden Administration, the Executive Office of the President (EOP) has made health equity and MEB health and well-being central priorities. Equity Executive Order The executive order (EO) On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government states, "Our Nation deserves an ambitious whole-of-government equity agenda." °° It directs the Domestic Policy Council to coordinate equity efforts. It also seeks to identify methods to assess equity in federal programs, address historic inequities, and pursue other key policy goals. Office of Management and Budget Equity Request for Information The Office of Management and Budget (OMB) issued a request for information (RFI) in March 2021 to seek input, information and recommendations on methods, approaches and tools the federal government can utilize to assess whether agency policies and actions equitably serve all eligible individuals and communities." COVID-19 Health Equity Taskforce Report President Biden's EO 13995, Ensuring an Equitable Pandemic Response and Recovery, established the Presidential COVID-19 Health Equity Task Force,*2 which released a Final Report and Recommendations in October 2021. It "advocates for a health-justice-in all-policies approach that calls for commitment and collaboration across all sectors."33 The report proposes numerous outcomes, priority actions and final recommendations, including several related to children. It urges leaders to increase access to behavioral health care; research and collect data on behavioral health; improve Medicaid payment parity for behavioral health, develop standards for behavioral health equity; and to "invest in youth-led movements through grants for the integration of behavioral health into the programming of youth-led national organizations, as well as support for existing youth-focused networks in states across the country." Strategy to Address Our National Mental Health Crisis As part of his March 1, 2022, State of the Union address, President Biden announced a multipronged strategy to address our nation's mental health crisis. The strategy calls for investments in strengthening system capacity through supporting a diverse workforce, including paraprofessionals; launching a 988 crisis response line; expanding evidence-based community mental health services; investing in research; improving access to care in a variety of settings, including schools; and creating healthy environments.*4 Additionally, Health and Human Services Department Secretary Xavier Becerra announced a national listening tour to strengthen mental health and crisis care in communities. Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS) is the lead federal agency that implements the Medicaid and CHIP programs. Nearly 40 million children receive health insurance coverage through Medicaid or CHIP** This section describes actions CMS has recently taken to address pediatric health equity and MEB health and well-being for children and youth. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Social Determinants of Health Guidance On January 7, 2021, CMS issued subregulatory guidance to state health officials to encourage the adoption of strategies that address the social determinants of health (SDOH) of Medicaid and CHIP beneficiaries." The guidance promoted integrated delivery and payment models that reward providers for coordinated high- quality care. It specifically highlighted approaches that integrate behavioral health services into the broader health care system. The guidance also cited evidence of how these models lead to improved outcomes for individuals with behavioral health conditions. Focus on Equity and MEB Health CMS Administrator Chiquita Brooks-LaSure, communicated that the agency would focus on six strategic pillars, including to "Advance health equity by addressing the health disparities that underlie our health system".*® Subsequently, Brooks-LaSure and Daniel Tsai, deputy administrator and director of Center for Medicaid and CHIP Services (CMCS), detailed a strategic plan for Medicaid and CHIP, which outlined three main areas, including equity.*9 Brooks-LaSure and Tsai included the following details related to MEB health: ° Medicaid is the "largest payer for public mental health services, including for individuals with serious mental illnesses, substance use disorders, or co-occurring disorders." © Access to behavioral health care through Medicaid and CHIP is a key strategy to improve mental health coming out of the pandemic and to close the equity gap. ° CMS is working with agencies across the federal government to ensure, "evidence-based, data-driven behavioral health policy and investments are implemented across our programs." ® CMS is advancing innovative value-based whole-person care delivery and payment models that incorporate the "whole of a person's needs: physical health, behavioral health, oral health, long-term service and supports, and health-related social needs." ° CMS is committed to "partnering with states finally to bring behavioral health services (both mental health and addiction treatment) up to parity with physical health services." In April 2022, CMS released its Framework for Health Equity, which outlines five priority areas the agency will focus on in its efforts to achieve health equity and eliminate disparities. Innovation Center Strategy Refresh The Center for Medicare and Medicaid Innovation ("Innovation Center") within CMS seeks to support the development and testing of innovative health care payment and service delivery models. On October 20, 2021, CMS released an Innovation Center Strategy Refresh.*° One of the five strategic objectives of the strategy is to "Advance Health Equity," and to "Embed health equity in every aspect of CMS Innovation Center models and increase focus on underserved populations." The strategy refresh white paper outlines the importance of whole-person care models and integrated behavioral health. In addition, it mentions a next step to, "Develop and test models or care delivery innovations across models that address gaps in care, such as behavioral health, SDOH, and palliative care." Surgeon General's Advisory In December 2021, Dr. Vivek H. Murthy, the U.S. Surgeon General, issued a Surgeon General's Advisory on Protecting Youth Mental Health' The advisory described how children and youth faced mental health challenges before the pandemic, experienced innumerable stressors during the pandemic, and are relying on all aspects of society to act on their behalf. It identifies five actions philanthropic organizations can specifically take to make an impact: ' ©3132) ° Create sustained investments in equitable prevention, promotion and early intervention. * Incentivize coordination across grantees and foster cross-sector partnerships to maximize reach and bring together a diversity of expertise. * Scale up evidence-based interventions, technologies, and services. * Invest in innovative approaches and research on mental health. ° Elevate and amplify the voices of youth and families in all stages of funding and evaluation. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Philanthropy Landscape Philanthropic organizations are united by the urgent need to incorporate health equity and racial justice as primary drivers and measures of children's physical and MEB health. Systemic barriers and practices continue to result in disproportionately poor outcomes for too many of America's children, youth and caregivers. Below is a summary of key themes from research, interviews and focus groups. Philanthropic organizations are balancing the need to address today's challenges and rebuild a better system for the future. Once the public health emergency unwinds, benefits and flexibilities that can help states meet the needs of children, youth and caregivers may no longer be available. Philanthropic leaders conveyed their commitment to systems building for the future but also highlighted the concurrent need to address the acute concerns of the here and now. In addition, they indicated that prioritizing equitable MEB health for children and youth will simultaneously address the most pressing urgent needs, while presenting an opportunity to redesign the workforce, data systems and payment models necessary to support improved MEB health over time. Equity is the goal of meaningful change for this once-in-a-generation opportunity to redesign systems. Equity investments and partnerships at the federal, state and community levels are accelerating. Philanthropic leaders emphasized that this moment holds promise to move the country toward greater equity, in part due to federal policy changes and increased federal resources. Alongside, and often in partnership with the public sector, philanthropic organizations are investing in program innovations, research, policy and systems changes expected to help achieve equitable health and well-being for children, youth, caregivers and communities. Equity is a shared priority that connects and aligns across age- and sector-specific priorities. Philanthropic leaders highlighted best practices including efforts where public agencies and philanthropic organizations aligned funding to ensure a more complete count for the 2020 Census, and efforts across 20 philanthropic organizations to increase utilization of the Child Tax Credit. Strong policies and programs aimed at caregivers and communities can help children and youth flourish. Research demonstrates a clear relationship between the outcomes of children and their caregivers.*"*2 Equally prominent in the research is the role of long-standing childhood health disparities as a core driver of lifelong adult health outcomes - in policy, practice, and partnership.*?"4 In addition, research demonstrates a strong connection between child and youth well-being and the social conditions, neighborhood, environment and other factors in the lives of young people. Healthy People 2030 aptly states, "Safe, stable, and supportive relationships are critical for children's health, development, and well-being. Family-level interventions can help keep children safe and healthy. Strategies focused on children's health and safety in early childhood education programs, at school, and in their neighborhoods can also help improve health outcomes for children."45 Elevating the voice and leadership of youth and caregivers in policy and practice produces more effective solutions grounded in prevention. Philanthropic leaders conveyed that a key component of effective grantmaking practice is elevating the role of community residents and community-driven priorities through initiatives where youth and caregivers define success and inform how to get there. In an era of rapid technological, environmental and social change, youth must have substantive opportunities to provide feedback and voice their opinions on matters related to their lived experience and future. Multisector collaborations are emerging as a strategy for system change. Public financing and practice are slow to align to upstream, community-led approaches and remain primarily focused on direct service models to ameliorate poor outcomes after the fact. However, philanthropic leaders increasingly employ systems change approaches, believing that increasing resources and services for immediate needs will not improve equity without underlying structural change, and that no one sector can solve the multiple, complex issues that produce poor health and inequity. In addition, child and youth MEB health and well-being offers an overarching, inclusive and positive framing that moves beyond a deficit lens and provides opportunities to incorporate multiple sectors, address root causes, and create system change efforts. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth Philanthropic leaders and advocates are gaining new understanding about the structural underpinnings of inequity, due in part to data integration and more targeted research. Data disaggregated by race, place, language, sexual orientation and other factors is slowly becoming available from public systems and is leading to new, and sometimes alarming, findings about the disparate health and well-being of children and youth.** Health and human service providers are working to capture the experience of individuals across agencies and over time to shift the focus from the program to the consumer and from top-line findings to a more granular and synthesized view. While there is growing agreement about the need for this data, greater change requires redesign of data infrastructure and data sharing systems. Greater support and reimbursement for a diverse community-based workforce will help improve equity for children, youth and their caregivers. A diverse community-based workforce that understands the communities it serves will lead to improved equity and reductions in disparities.*7"? The current MEB workforce remains challenged by workforce shortages and payment models that do not support a diverse array of delivery models, including preventive approaches and community-based providers needed to make an impact. Aligning Efforts to Achieve Equitable Mental, Emotional and Behavioral Health and Well-Being for Children and Youth References 10. Ti. 12. 13. 14. 15. 16. Murthy VH. Protecting Youth Mental Health: The U.S. Surgeon General's Advisory. US Public Health Service, US Dept of Health and Human Services; December 7, 2021. https:/Avwww.hhs.gov/sites/default/files/surgeon-general- youth-mental-health-advisory.pdf COVID-19 parental resources kit. Centers for Disease Control and Prevention. 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