How does New Hampshire’s system of care approach support families involved with child welfare?

Background

For nearly 15 years, New Hampshire has sought to create a comprehensive, coordinated network of behavioral health services and supports for children and families, focusing on improving access and ensuring that care is coordinated across child-serving systems. In 2010, New Hampshire established a Children’s Behavioral Health Collaborative of more than 50 organizations, including child welfare-focused entities, that were committed to developing a comprehensive, integrated approach to supporting children with behavioral health needs. Early on, members of the collaborative focused on the system of care values that they wanted reflected in their approach, which would inform future work in critical ways. Those values included: child- and family-driven; community-based; culturally and linguistically competent; and trauma-informed.

In 2012, the New Hampshire Department of Health and Human Services (DHHS) received a grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to operationalize the previously articulated values and develop a child- and family-driven system of care throughout the state. That funding supported Families and Systems Together (FAST) Forward, an intensive care coordination program for children and older youth ages 5 to 21 with behavioral health needs and their families that are served by multiple systems (juvenile justice, child welfare, behavioral health). FAST Forward operationalized system of care guiding principles and values, led to the adoption of the high fidelity wraparound practice model, and provided the structure for delivering and coordinating services.

In 2016, a state law built on these efforts and established the purpose, roles, and responsibilities for the System of Care for Children’s Mental Health in New Hampshire. This statute codified a comprehensive SOC to serve all children and older youth receiving publicly funded behavioral health services in the state including, but not limited to, those involved with the child welfare system. This coincided with the establishment of New Hampshire DHHS’s Bureau for Children’s Behavioral Health.

New Hampshire passed a law in June 2019 in response to an assessment of New Hampshire’s child welfare system and the federal Family First Prevention Services Act of 2018 (Family First), among other events. This legislation helped advance the system of care by requiring DHHS to expand support and oversight for the care management entities (CMEs), develop a single statewide behavioral health assessment tool, redesign residential treatment services for children and older youth, expand eligibility for FAST Forward, establish children’s mobile crisis services, and more.

System of care governance

DHHS and the state Department of Education are the two entities primarily responsible for the implementation and oversight of New Hampshire’s system of care. The New Hampshire Division for Behavioral Health sits under DHHS and includes the Bureau for Children’s Behavioral Health (BCBH), which seeks to expand the state’s system of care to serve all children and families in need of publicly funded behavioral health services. BCBH also oversees all child- and family-focused behavioral health services delivered by certified community behavioral health centers and community mental health centers, CMEs, statewide mobile crisis response, and residential treatment facilities.

Within the state’s Department of Education is the Bureau of Student Wellness and Nutrition, which houses the Office of Social and Emotional Wellness, which leads the implementation of a statewide multi-tiered system of supports for behavioral health and wellness model, among other key initiatives.

Strategies to support families involved with child welfare

Although the state laws setting up New Hampshire’s system of care addressed behavioral health services for all children and families in need, they specifically identified children involved in the child welfare system. This led to the development of critical services including mobile crisis response and stabilization, and care coordination for children with complex behavioral health needs. The laws also aligned New Hampshire’s system of care with Family First and Medicaid’s Early Periodic Screening Diagnostic and Treatment benefit.

The state’s CMEs play a particularly critical role in service access and care coordination for children and families involved in the child welfare system who have behavioral health needs. CMEs use an evidence-based, high fidelity wraparound model to assess and connect children and their families to a range of customizable services, including peer support.

Community mental health centers, juvenile justice partners, and the CMEs all use the Child and Adolescent Needs Assessment (CANS) to facilitate and support seamless coordination of care and collaboration among all system partners. CANS “is a key element to ensure that we’re speaking the same language to really help families and tell one story across the continuum of care,” said Daryll Tenney, bureau chief of BCBH.

System of care impact and sustainability

In addition to high rates of child and family satisfaction, evaluation findings demonstrate that the financial impact of the system of care approach in New Hampshire parallels national outcomes. This includes increased spending on community-based services, fewer psychiatric hospitalizations, and a decrease in emergency room use for enrolled children and older youth. Evaluators found that FAST Forward contributed to a significant reduction in state costs in New Hampshire from 2012 to 2016, with expenditures per enrollee decreased by 28%, or savings of over $115 million in total expenditures.²

Financing is a critical part of sustainability. New Hampshire has braided funding from several sources to support the implementation of the system of care, including state funds from the Department of Education and DHHS, as well as state general funds and federal sources like Title IV-A, Title IV-B, Title IV-E, SAMHSA, and Medicaid. Katja Fox, director of the division for behavioral health at DHHS, described that while complicated, the agencies do their best to be “payer agnostic” in their approach, and tease apart payment mechanisms on the back end to make the provision of services seamless for children and families on the front end. Recently, BCBH and Medicaid have been working with the state’s Department of Insurance to develop a system of parity between Medicaid and commercial insurance plans.

1 The content of this brief was informed by interviews with Morissa Henn, Deputy Commissioner; Marie Noonan, Interim Director of the Division for Children, Youth and Families,; Daryll Tenney, Bureau Chief, Bureau for Children’s Behavioral Health; and Katja Fox, Director, Division for Behavioral Health, New Hampshire Department of Health and Human Services, August 26. 2024.

2 Fauth, J., Wilson-White, J., & Erdmann, J. (2016). FAST Forward System of Care 2016 Final Interpretive Evaluation. Center for Behavioral Health Innovation, Antioch University New England.