IN THIS ARTICLE
Introduction The Behavioral Health and Wellness of Children and Adolescents The Social Determinants of Mental Health Accountability for Quality Behavioral Health Services Acting on the Vision Download PDF
Introduction
Behavioral health is essential to all health. This has been made clear in the past few years, as behavioral health and wellness across the globe have been deeply tested by the COVID-19 pandemic, the opioid crisis, rising suicide rates, persistent racial inequities, and behavioral health workforce shortages. Early assessments of the impact of the pandemic have revealed increases in rates of depression and anxiety globally.1 Similarly, data exploring structural racism has found increased rates of depression in Black and other oppressed and minoritized populations.2 Indeed, the intersection of COVID-19, structural racism, and mental health inequities has led to a syndemic, or synergistic epidemic, of poor health outcomes among marginalized populations.3
Philadelphia is not immune to all of this. Like other large cities, it has been faced with an increase in adverse health outcomes stemming from worsening social determinants of health. In times of crisis, bold leadership is needed to generate innovative and lasting solutions. Across the country, political leaders are proposing solutions to address chronic homelessness and behavioral health needs. Some proposals have raised more controversy than others. Behavioral health systems are complex, with factors that relate to laws, rights for marginalized populations, housing supports and accessibility, state policies, and funding driven by state legislatures and federal policies. Thus, effective solutions require careful consideration and collaborative approaches.
The next mayor must make the behavioral health and mental well-being of all Philadelphians a central priority.
As Philadelphia selects its next mayor, there is an opportunity to make a difference. The next mayor must make the behavioral health and mental well-being of all Philadelphians a central priority, with a focus on addressing social determinants of mental health and achieving behavioral health equity. A transformative mayor can set a direction for the city to help it excel in the delivery of quality coordinated and accessible behavioral health services and contribute to the improved wellness of the entire community.
Here, we present a policy roadmap for transforming and prioritizing positive behavioral health outcomes for all Philadelphians. We begin by exploring three priority focus areas — children and adolescents, the social determinants of mental health, and accountability —concluding the discussion of each area with recommendations for the next mayor. We close with a set of additional recommendations the next mayor can use to improve behavioral health outcomes more broadly.
The Behavioral Health and Wellness of Children and Adolescents
All too often, children and adolescents are plagued by mental health or substance use challenges. And to assist them, society offers systems that are fractured or poorly coordinated, with limited access to supports.
In the landmark Adverse Childhood Experiences (ACEs) Study, researchers from the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente explored how childhood exposure to abuse or neglect, or household dysfunction, directly led to a number of poor physical and mental health outcomes in adulthood.4 Philadelphia led the nation in 2012 by expanding this study to be more inclusive of childhood experiences beyond the mostly white middle- and upper-middle-class population sampled in the initial ACEs Study. The Philadelphia ACE Project explored five additional community-level stressors – whether people surveyed had lived in foster care, had been bullied, had undergone adverse neighborhood experiences, experienced discrimination, or witnessed community violence.5 Philadelphians reported high exposure to the original ACEs, with 2 in 5 having experienced more than 4 ACEs, and almost 40% reported having experienced 4 or more of the expanded, community-level ACEs.6 Now, 10 years later, there is significant work to be done in Philadelphia for systems to meet the various health needs of the many Philadelphians who experienced childhood adversity and trauma.
Countless studies have pointed to a significant association between exposure to trauma in childhood and poor functioning as adults.7 Research has also shown that the presence of one or more caring adults can mitigate the harm, indicating that there are opportunities to support youth through a variety of programming.8 Additionally, worldwide, it is increasingly recognized that many mental health conditions emerge in childhood and adolescence, highlighting the critical need for developing behavioral health systems that can promote prevention and continuity as youth emerge into adulthood.9
Philadelphia has identified its own challenges across a variety of venues. Youth involved with child welfare and juvenile justice are particularly vulnerable. The need to examine these dual systems-involved populations and their increased educational needs was highlighted as a priority area in a 2014 study, which found that 17% of youth in Philadelphia schools had been involved in one or both of these systems.10 These youth have particular challenges with a range of behavioral health needs on top of the traumatic experiences associated with child removals from homes and placement in child welfare and juvenile justice programs.
Efforts to address access to increased youth-focused behavioral health services have been realized, such as the establishment of the Center for Advanced Behavioral Healthcare at the Children’s Hospital of Philadelphia, which expanded into newly renovated space for outpatient services in the Department of Child and Adolescent Psychiatry and Behavioral Services to help meet the needs of children and their families. Yet, reports of dire conditions for youth continue. In April 2022, the Children’s Hospital of Philadelphia PolicyLab identified the critical importance of building and sustaining programs for school-based behavioral health services in K-12 schools.11 In November 2022, experts in the youth mental health crisis and the challenges facing the Philadelphia Juvenile Justice Services Center spoke about concerns related to the city’s response to children caught up in legal system processes.12
Warnings about mental health among Philadelphia children also could be seen with the calls to the Safe2Say line from local youth increasing by 62% from 2018-2019 to 2019-2020, with feelings of loneliness and depression noted across the city.13 Compounding the problems, children — particularly children of color — seem to have lost access to important developmentally necessary supports.14 The Children First review noted the importance of closing the behavioral health service gap for children and youth to maximize access to proper quality mental health services across the city. In Pennsylvania, school-based behavioral health has been a focus of attention for the Children’s Bureau and the Department of Education,15 but the preceding white papers and policy documents support the critical need to examine the impact of these programs — and to augment services for children in Philadelphia itself.
Recommendation: Ensuring a skilled, well-trained workforce to address the needs of youth behavioral health is a leading concern.
Solutions must include augmenting pay for providers through immediate increased fee-for-service rates, along with long-term strategies for sustainable payment methodologies within the Community Behavioral Health (CBH) system, the managed care organization contracted by the City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services. Additionally, it will be critical to ensure a diverse workforce that can address the needs of all young community members, especially those from oppressed and marginalized identities. And officials must tend to the behavioral health needs of youth in schools, with an emphasis on youth involved in the juvenile justice and/or child welfare systems.
The Social Determinants of Mental Health
The social determinants of mental health are defined by the World Health Organization as the conditions in which people “are born, grow, live, work, and age” and are shaped by the distribution of money, power, and resources.16 Although the social determinants of mental health have traditionally been well understood by providers and policymakers in Philadelphia, a recommitment by leadership to invest in these determinants is essential to improving the behavioral health of Philadelphians.
Underlying the social determinants of mental health is the unfair and unjust distribution of opportunity in the city, which stems from structurally racist policies that advantage white people and disadvantage people of color. Thus, to effectively address the social determinants of mental health, the work must begin with a plan to advance racial equity within the city.
To effectively address the social determinants of mental health, the work must begin with a plan to advance racial equity within the city.
An important social determinant of mental health that Philadelphians have identified as a major concern relates to exposure to violence. In a recent Pew Charitable Trusts poll, crime, drugs, and public safety (with a specific concern of gun violence) were identified by a majority of Philadelphians as the biggest issues facing the city.17
While the causes of these issues are multifactorial and complex, high community rates of substance use disorders, including opioids, which take a major toll on Philadelphians, are often a consequence of socioeconomic deprivation.18 This means that better attention to the social determinants of health, including opportunities for gainful employment, fulfilling interpersonal relationships, and economic mobility could lead to lower rates of substance use disorders, and ultimately, community violence.
Another significant social determinant of mental health is a lack of access to healthcare. According to a 2018 report from the Department of Public Health for the City of Philadelphia, approximately 12% of adults aged 18 to 64 in Philadelphia are uninsured, and 21% of adults are enrolled in Medicaid. Primary care providers are variably available for the population across the city, with social, economic, and behavioral patient factors influencing access to care.19 For those fortunate individuals who can access care, workforce shortages often create barriers to effective, high-quality treatment.
Lack of insurance also significantly impacts the ability of Philadelphians to access substance use disorder treatment. Policies like the recent elimination of the “X-waiver” ensure that more providers can prescribe buprenorphine to treat opioid use disorders. Going forward, Philadelphia must develop a plan to expand the training and accessibility of providers to prescribe buprenorphine to those in need.
Adequate measurement and tracking of social determinants of mental health are also needed. The Place Matters reports of 2017 and 2019 used geospatial mapping to identify various social determinants of mental health (i.e, poverty, education, unemployment, crime, and ACEs) to stratify risk via ZIP code in Philadelphia.20
In a recent Community Health Needs Assessment, social determinant factors were examined, and behavioral challenges were noted for adults and youth, with a lack of providers and perceptions of high costs.21
This type of research helps to identify the problem and can lead to developing equity-centered strategies to target interventions that address and improve these social determinants, focusing on areas of the city that might be identified as behavioral health workforce shortage areas. Support to update this data regularly is needed to more precisely direct efforts.
Recommendation: Work to address the social determinants of mental health understanding that is a part of an overarching strategy to improve behavioral health outcomes.
Investing in living wages and greater employment opportunities, eliminating food deserts and food swamps, improving school quality (along with access to school behavioral health services), and strengthening the social safety net could all lead to significant improvements in behavioral health.22
City leadership should convene representatives across all departments and sectors to collaborate on developing policies that prioritize behavioral wellness, as all policies are health policies, and by extension, all policies are behavioral health policies.23 Additionally, racial equity impact assessments should be conducted on all proposed policies and programs.24
Accountability for Quality Behavioral Health Services
Accountability in behavioral health care is critical to implementing lasting and sustainable reforms in the system. Multiple barriers to accountability include a lack of a diverse, skilled workforce, challenges in measurement, misalignment of payment incentives, and misguided regulations.25
Philadelphia’s CBH system relies upon a network of funding streams that include state and federal Centers for Medicare & Medicaid Services (CMS) resources. Funding decisions must take this into account. Despite the complexity of funding and policy related to resource allocation, quality behavioral health services are imperative.
A July 2021 report by the Office of the City Controller laid out findings from an audit of the HealthChoices Behavioral Health Care Program, administered by CBH and under the oversight of the Department of Behavioral Health and Intellectual disability Services (DBHIDS).26
The audit revealed problems with documentation, reimbursement processes, procurement issues, and a lack of oversight and accountability by CBH as well as a lack of productive oversight of CBH by DBHIDS. The auditors found the payment for Community Integrated Recovery Centers was not cost-effective. Key recommendations included stronger internal controls to monitor providers and enhance adherence to policies and processes. It was also recommended that DBHIDS improve its oversight of the CBH operations. It was clear from the findings that aspects of contract oversight needed to be enhanced for the CBH activities on behalf of DBHIDS.
Recommendation: Follow the recommendations of the 2021 Audit report to increase opportunities for quality service delivery.
In addition, a sufficient and skilled workforce is required to achieve positive outcomes. Enhancing pay rates and establishing a value-based payment model with appropriate reimbursement mechanisms within the CBH system can be a critical path forward—to pay for the quality that Philadelphia needs to see in service delivery—and ensure that it is achieved. To assure Philadelphians of this accountability, leadership will need to address current barriers to compliance with standards and hold the city’s behavioral health care systems accountable.
Acting on the Vision
Beyond the recommendations already discussed, the next mayor should do the following to improve behavioral health outcomes:
1.
Meet with collaborators, people with lived experiences, providers, and communities to understand the diversity of views on the current behavioral health crisis and potential strategies for improvement.
2.
Examine the quality of practices of providers across multiple settings including schools, community outpatient sites, certified community behavioral health clinics, jails, hospitals, crisis centers, and everywhere behavioral healthcare is provided.
3.
Continue to support and expand unique programs that highlight and strengthen the potential for collective and individual recovery from behavioral health conditions like Mural Arts, First Person Arts, and similar programs.
4.
Enhance connection to peers, as seen in the Same Day Pay program, which uses low-barrier and trauma-informed work opportunities and connections to provide support for individuals experiencing economic and housing insecurity.
5.
Focus on greater accountability in measurement and data tracking, alignment of payment incentives, and cultivating a skilled, diverse behavioral health workforce.
6.
Enhance access to services for individuals with substance use disorders, including identifying places and spaces where they can be served and supporting effective programs like the Mobile Overdose Surge Response Bus.
7.
Ensure the maximum use of innovation and technology to support individual recovery through home-based services whenever possible.
8.
Pursue ongoing coordination for crisis services and linkages to support networks.
Philadelphia is currently experiencing many challenges, including gun violence, opioid misuse, suicides, homelessness, and children being exposed to adverse and traumatic experiences. The next mayor must deliver bold leadership that prioritizes the behavioral health and well-being of every Philadelphian.
This paper was developed by Ruth S. Shim, MD, MPH and Debra A. Pinals, MD with advisory support related to the Philadelphia context from Cherie Brummans. The authors would like to thank Larry Eichel and Julie Wertheimer of The Pew Charitable Trusts and Joe Pyle, Alyson Ferguson, and Caitlin O’Brien of the Scattergood Foundation for their contributions to this report.
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