OFFICIAL STATEMENT: NYSBHF's Comment on the NYS 1115 Waiver Application

NEW YORK SCHOOL-BASED FOUNDATION

COMMENT ON NYS 1115 WAIVER APPLICATION

Strategic Health Equity Reform Payment Arrangements: Making Targeted, Evidence-Based Investment to Address Health Disparities

Note: The NY School-Based Health Foundation is a 501©3 organization whose mission is to promote, strengthen and increase access to NY’s 266 school-based health centers. It operates in close partnership with the membership organization of school-based health centers, the NY School-Based Health Alliance.

The Importance of School-Based Health Centers (SBHCs) to the Waiver

Across New York State, some 266 school-based health centers (SBHCs) serve roughly 263,000 school children living in some of the State’s poorest urban and rural communities, the very communities hit hardest by the COVID pandemic. These health centers are sponsored by 49 hospitals, federally qualified health centers and other organizations and exist at the intersection of education, health care and public health. Staffed by multidisciplinary teams that include combinations of physicians, nurse practitioners, physician assistants, RNs and LPNs, dentists, social workers, psychiatrists, psychologists, and other health professionals, SBHCs provide a broad array of services, including primary, oral, reproductive and behavioral health care, chronic illness management and family outreach. SBHCs currently find themselves at the forefront in addressing a crush of children’s behavioral health needs stemming from the COVID pandemic. SBHCs serve all children regardless of the student’s financial or insurance status

and are located where the children spend their days: in their schools.

Children enrolled in SBHCs are heavily Medicaid (59%) and uninsured (12%), immigrants and of minority racial/ethnic backgrounds (79%). In many cases SBHCs offer the children’s only access to care. In addition to providing direct care, they conduct important risk screening, health education, promotion,

prevention and healthy living initiatives at the classroom and school-wide levels, thus playing an important public health role. SBHCs constitute an essential link in NYS’ health care safety net.

Research has repeatedly shown that the presence of an SBHC in a school brings many benefits: ease of access; reduced time and productivity loss for parents; reduced absenteeism, tardiness, school discipline incidents, dropout rates, and teen pregnancies; improved academic performance; reduced ER and hospital use; and increased use by students experiencing depression, suicide, and obesity. SBHCs are a powerful tool for achieving health equity and their investment in children yields a lifetime of benefits.

SBHCs and their schools are essential to achieving three of the proposed Waiver’s four goals:

Waiver Goal 1:“Building a More Resilient, Flexible and Integrated Delivery System that Reduces Health Disparities, Promotes Health Equity and Supports the Delivery of Social Care.”

SBHCs are community-based providers not only serving children but, with their school partners, having a strong outreach to families in those communities. They treat the whole child, seeking to address their physical, behavioral, and social needs. They enjoy a network of relationships with other medical and social service providers serving their communities, which enables them to address, by referral, social and medical needs they cannot meet on premises. Health conditions that children present to SBHCs should be seen as early sentinels of health problems that will affect the entire community.

Given their roles and position in the community, SBHCs seek inclusion in the 1115 Waiver process, specifically in:

• HEROs: HEROs, the “coalitions that will focus on collaboration and coordination, and facilitation of activities that best address the needs of the communities they serve” (P. 10), should be required to collaborate with SBHCs, which are uniquely positioned to identify risks—including those related to the social determinants of health--and close care gaps for children.

• Data Infrastructure: In addition to planning and coordination, the HEROs will play an important role in building the data infrastructure necessary to support the success of the Waiver (P. 13). The Waiver application notes that “CBOs, behavioral health providers and other small practitioners [a description that characterizes SBHCs] did not have ready access to data resources” under DSRIP, the last 1115 Waiver (P. 13), nor have they benefited from massive historic NYS investment that has created the RHIOs, the SHINY and the NY eHealth Collaborative, existing interoperable resources serving NYS. The new Waiver application offers the opportunity to address this disparity and to incorporate and support the efforts of the NY School-Based Health Foundation and Alliance in assuring that SBHCs have the data necessary to function in an interoperable, evidence-based health care world.

• SDHNs: The Social Determinants of Health Networks are the local networks of CBOs that “will collectively use evidence-based interventions to coordinate and deliver services to address a range of social care needs that will improve health outcomes.” (P. 19). Again, SDHNs should be required to collaborate with SBHC which are uniquely positioned to close care gaps for children and to identify risks, including social drivers of care which can impact the family

• Telehealth: As community-based organizations already operating with their own referral networks of health care and social needs providers, SBHCs must also be vital participants in the telehealth initiatives cited in the 1115 Waiver. Given years of chronic underfunding, SBHCs should be candidates in “providing support to CBOs around building capacity, adopting and utilizing technology, service delivery integration, creating and adapting workflows and other business practices, including billing and payment.” (P. 19)

• Workforce Training to support HEROs and SDHNs: As community organizations, SBHCs must be included in “the investment SDHNs will make in Capacity Building and Training to Achieve Health Equity Goals” (P. 27), which includes “training to do social need assessments, strengthening their capacity to address behavioral health and social care needs, facilitating telehealth care delivery and incorporating principles of implicit bias and cultural sensitivity.”

Inclusion of schools: Schools, with connections to virtually every family in the community, often serve as anchors in their communities. They are on the forefront of every social and economic development affecting the community. Like SBHCs,they should be considered pivotal players in the Waiver-built

networks that will knit together community resources to address disparities and prepare for future public health emergencies. Particularly relevant are community schools, a subset of schools in underserved communities,whose vision is the school as a central community resource, offering holistic child and family services including health and social care, in addition to education.

Goal 3.2:“Develop a Strong, Representative and Well-Trained Workforce”

SHBCs experience similar workforce needs for a“strong and well-trained workforce that is both representative of the populations being served”as do other safety net providers. Moreover, they can bring an important asset to the solution, namely their presence, particularly in high schools, where health care workforce training programs and internships can be the first step in a young person’s health care career ladder.

In addition,community health workers, if available to SBHCs, could play a pivotal role in community outreach, student engagement, and coordination/navigation to assure that students receive the services needed to assure their medical and social needs are met.

Goal 4: “Creating Statewide Digital Health and Telehealth Infrastructure” (P. 42)

While some SBHCs used telehealth prior to the pandemic, when the COVID lock-down hit, all rapidly pivoted to telehealth to continue serving their children. The NY School-Based Health Foundation has been active in helping SBHCs regularize, optimize and integrate telehealth into SBHC operations. Telehealth holds enormous promise for SBHCs, enhancing their ability to offer access whenever schools are closed, whether it be holidays, school breaks, summer vacation, or shutdowns. It is also key to expanding access to specialties that cannot feasibly be offered on site; sharing scarce SBHC staff--such as supervising physicians, psychiatrists, dietitians, and social workers--to service multiple sites; and

allowing SBHCs to serve siblings and children from other schools. Telehealth has been found key to facilitating parent engagement in the care of their children. Finally, it has been key to helping SBHCs address the continuing tsunami of COVID-related behavioral health needs among low-income children.

Inclusion of SBHCs in Goal 4 of the Waiver is therefore essential. In their efforts, SBHCs experience precisely the problems the Waiver application enumerates—"lack of internet connectivity, hardware and devices, provider training and adequate staffing.” (P. 43). So too do they need the technical assistance offered through the proposed “Equitable Care Access Fund” for safety net providers, i.e.,

predictive analytics, data system interoperability, patient-facing tools and devices, participation in e-consult programs that expand access to specialty consult services, and the ability to hire community health workers to bridge the digital divide. (P. 44).

Important Waiver opportunities for supporting the work of SBHCs:

Adequate and reliable SBHC reimbursement: Adequate and reliable payment is essential to building the capacity and realizing the potential of these key community health players. Historic underfunding has limited SBHC capacity, creativity,and ability to engage in non-reimbursed activities and to compete

for personnel in a fierce health care job market.Often, they rely on charitable giving and the in-kind support of their sponsoring organizations to survive and flourish. NYC has supported its SBHCs through a small grant program of its own.

SBHCs experience three categories of financial loss:

1. Underpayment for many Medicaid-covered services

2. The cost of caring for uninsured children and

3. Lack of reimbursement for health promotion, prevention and public health activities which offer scale and are often the most broadly impactful.

NYS covers some of the latter two losses through an annual statewide grant of $17M, divvied up among the 49 SBHC sponsors and their 266 sites. Even this support has been reduced since its peak in 2006 when the grant totaled $24M. Meanwhile the cost of care has risen sharply. If the grant had simply been adjusted for inflation,it would total $34M today.

The Foundation offers the following recommendations designed to address the objectives of the Waiver and increase access to care for school children while building the capacity of SBHCs to serve them.

1. Expand Medicaid coverage for children and adolescents in NYS that are attending public school with a SBHC on campus: This will result in a double benefit—increasing health care access and improving the health of low-income school children while undergirding the financial health of SBHCs. Investing in children’s health care is relatively inexpensive while the pay-off is large and lasting.

2. Utilize federal Waiver monies to expand the number of SBHCs in NY as a relatively inexpensive investment in expanding the access of underserved children to care.

3. Allow Medicaid billing for group therapy offered by SBHC mental health providers as it already does for FQHCs and Article 31 providers. Group therapy has been found more effective in many situations than individual therapy and it additionally holds the potential to scale care and reach more children.

4. Allow flexibility in billing for Medicaid services provided to students outside of designated clinic space in a school. Because of this barrier, SBHCs could not bill for services delivered to children with COVID symptoms in specially designated isolation rooms. It also inhibits the use gymnasiums and cafeterias for vaccinations or boosters.

5. Assure that telehealth services continue to be reimbursed at a rate equivalent to in-person services, thus allowing SBHCs to:

   1. Maximize access to care during school closures

   2. Maximize access to specialty care

   3. Extend care to students in schools lacking an SBHC.

   4. Share scarce personnel across SBHC sites.

   5. Continue telehealth effectiveness in meeting burgeoning behavioral health needs.

6. Tap Waiver resources to strengthen SBHC telehealth capacity, including making available stable/expanded broadband, Wi-Fi and bandwidth, peripheral devices that will expand telehealth capability, and the purchase of devices that may be lent or given to students, helping to address the digital divide that characterizes NYS’ underserved communities.

7. Allow SBHCs to use telehealth to link to and serve schools lacking an SBHC, thus overcoming the barriers of transportation and lost class time entailed in the current requirement that such students travel to the SBHC site. With little additional expense, this would allow SBHC sponsors to construct a “hub-and-spokes” model for expanding student access to SBHC services, linking schools without SBHCs to those hosting SBHCs.

8. Further promote expansion of SBHC services by expanding the Small Clinic License designation to include schools staffed by an RN and connected via telehealth to an SBHC network and its sponsoring institution, thus allowing billing for some RN services. This would also allow billing for in-person services delivered by visiting SBHC providers and thus eliminate need for students to travel to an SBHC.

9. Initiate high school-based training programs to recruit and train a future, community-based health care workforce. Examples include training programs and student internships for medical, nursing and dental assistants and community health workers, beginning in the tenth grade. Such training would assure jobs upon graduation. Moreover, early opportunities to take the first step in a health/social needs career ladder are vital to creating a health care workforce likely to reflect their communities and to remain or return to serving those communities.

The current language of 1115 Waiver application barely mentions SBHCs, schools or children. No issue is more critical to a community than the health, well-being, education, and future of its children. In this respect, the schools and the SBHCs that serve them offer invaluable assets to the Waiver’s success in its goal of addressing health disparities and achieving health equity. Schools and SBHCs must be a vital part of the Waiver and its processes.

For more information, contact the NY School-Based Health Foundation, nysbhfoundation@gmail.com or call: (518) 217-5588