As mental health problems in schools soar, provider pulls out of southwestern districts

Several southwestern school districts in Virginia have less than a month before losing a key mental health services provider, which is citing changes in how the state handles the provision of such services as a reason for pulling out.

Family Preservation Services announced in a Oct. 27 letter that it would cease providing therapeutic day treatment services — school-based services for children enrolled in Medicaid to address behavioral, emotional and mental health issues  — for children and adolescents on Dec. 12 due to “procedural and fiscal challenges.” 

“For years, FPS and other providers of (therapeutic day treatment), including our local Community Service Boards / Behavioral Health Authorities, have been advocating for TDT to be reviewed and updated by (the Virginia Department of Medical Assistance Services) to reflect a service that is more in line with our inclusive education system of today,” wrote Andy Kitzmiller, state director for Family Preservation Services in the October letter. “However, these changes have not been made, nor does it appear that they will be in the near future.”

The Roanoke-based provider has been in operation for more than 20 years and serves 11 localities including Wise, Dickenson and Buchanan counties and the city of Norton.

State researchers reported less than a month ago that student behavior and mental health problems in schools have skyrocketed since the pandemic.

Norton City Schools Superintendent Gina Wohlford said that after losses of service workers who dealt with students with behavioral issues last year, she’s concerned about her ability to get enough health workers for the next semester.

“A lot of the workers have been the same workers who have really developed some strong relationships with our students, so I really do worry,” said Wohlford.

Managed care

In the last several years the Virginia Department of Medical Assistance Services, which administers the federal Medicaid program in Virginia, began to move mental health services into a managed care system. 

Previously, mental health providers would submit a record of their services to Medicaid for reimbursement. Now, they must request authorization to provide the service from the managed care organization first.

Christina Nuckols, a spokesperson for DMAS, said the move helped avoid confusion and gaps in coordination where individuals received some services through a managed care health plan and others through fee-for-service. 

But since the agency’s decision, the number of people receiving therapeutic day treatment has dropped, falling by 81% from 2019 to 2021, according to data from DMAS. A total of 19,303 members received such services in 2019 compared to 3,633 in 2021.

Mindy Carlin, executive director for the Virginia Association of Community-Based Providers, said that since Virginia’s 2019 change, managed care organizations have become much more “stringent” about authorizing therapeutic day treatment.

However, Carlin said at the same time, the way schools handle children with serious mental illness has also changed since the regulations and reimbursement rates were first established.

Therapeutic day treatment and the reimbursement rates were designed to serve groups, Carlin said — but schools no longer separate out students with behavioral issues, meaning that providers often are left working with individuals.

“The rates aren’t even close to being sufficient to cover the cost of delivering the service that may be direct to one child, and so it’s not financially feasible,” Carlin said. 

Family Preservation Services is working with the school divisions impacted by its decision on other ways to meet the needs of the students, according to spokesperson Kyle McMahon.

The provider isn’t alone. Carlin said Intercept Health, one of the largest private providers of student mental health services in Virginia, is no longer offering therapeutic day treatment. An employee who answered the phone at Intercept confirmed Friday evening that the provider was no longer offering the service, but the director did not respond to a request for comment.

Agency asks for review

In the early fall, DMAS requested $850,000 to secure a contractor to evaluate the costs related to ongoing and necessary changes to Medicaid behavioral services. 

As part of its request, the agency is asking for a review of the state’s therapeutic day treatment services, stating that it has a “problematic rate and unit structure that has made it impossible for providers to deliver the service.” 

“The service was designed before youth with serious emotional problems were mainstreamed out of self-contained classrooms,” the agency wrote. Additionally, “the service is written as a group-based service but the structure of the school day makes that delivery method nearly impossible and thus providers are having to deliver it as an individual service. This service needs to be redesigned into an evidence-based school services with an appropriate rate and rate structure.” 

The agency is asking for a redesign of the services to a more evidence-based program “with an appropriate rate and rate structure.” 

“Our system is experiencing unprecedented strain due to the impacts of the pandemic on the behavioral health workforce which have led to attrition and burnout and the cascading effects of our ongoing psychiatric bed crisis and addiction epidemic,” the agency wrote.

Carlin said she’s pleased to see that DMAS is making the requests but is concerned that the process will take too long, especially for children with extensive needs.

“That’s concerning to me because you’re going to see the trends continue of more and more suicide attempts and more kids in ERs for mental health reasons,” Carlin said.

‘The sheer volume of mental health needs’

Keith Perrigan, superintendent of Bristol Virginia Public Schools, said schools in Southwest Virginia are facing a crisis in mental health services and have been using federal COVID-19 response funds to fill the gaps. 

However, those one-time funds will run out soon.

The Joint Legislative Audit and Review Commission, in a study of the impacts of the COVID-19 pandemic on education, recently found that school staff rated student behavior as the most serious issue facing divisions as they return to in-person learning. Most students “feel nervous, anxious or on edge,” JLARC noted. 

Perrigan said Bristol staff have noticed an increase in students’ behavioral and mental health. 

“But to see the sheer volume of mental health needs across the commonwealth, I think was eye opening,” he said.

JLARC recommended that lawmakers provide divisions with funding for training on behavioral issues and classroom management. They also suggested the General Assembly consider amending state law to clearly define “direct school counseling” to help reduce the amount of time counselors spend on non-counseling activities, and to allow qualified and licensed psychologists in other fields to be provisionally licensed.

School psychologist positions have some of the highest vacancy rates among all staff vacancies in Virginia.

“Unfortunately, this is not just a school issue, it’s a community issue,” Perrigan said. “And whether you’re talking to law enforcement or school teachers or health providers, mental health may be the greatest challenge that we’re experiencing right now. And we’ve got to find a way to start filling these holes and bridging the gap.”