In my 27 years working in the behavioral health field, one thing has become abundantly clear: “good health” is dependent on so much more than one’s physical condition. Biological, behavioral, social, cultural, economic and environmental factors all impact the well-being of individuals and communities. This concept, known as “population health,” focuses on a systematic effort to improve health outcomes in subpopulations that share multiple clinical and social attributes—such as women, veterans, or people who live in poverty.
Population health provides our field with a unique opportunity to encourage and influence the design and adaptation of systems of care that focus on the whole health of individuals, ultimately keeping our clients as healthy, happy, and productive as possible.
A prime example of the importance of a population health approach to local systems of care is childhood poverty. A staggering 16 million children in the U.S. are living below the federal poverty level. Almost half of children in this country are living in or near poverty. For providers— particularly those familiar with Adverse Childhood Experiences (ACEs)—the responsibility to address children’s stress related to poverty is critically important.
Kids who grow up in poverty are at greater risk of poor outcomes in physical and behavioral health, well-being, and educational achievement, and these risks can last a lifetime. In fact, ACEs such as family violence, substance abuse and mental illness are directly connected to health risk behaviors and disease in adulthood. Experts have recently begun to consider economic hardship as an ACE, as it is incredibly traumatic and causes “toxic stress” with similar outcomes to other ACEs.
However, despite the fact that as many as 67% of people experience at least one ACE, too few behavioral health providers are prepared to screen, assess, and develop treatment plans for kids based on ACE scores and approaches to treatment and service planning. Children living in poverty are more likely than other children to have mental health problems, and these are more likely to be severe, especially during times of economic hardship. Yet at the same time, often these children are inappropriately or overmedicated to treat behaviors related to trauma. A 2014 analysis of antipsychotic prescribing in children revealed quality of care concerns, such as wrong treatment and poor monitoring, in a whopping 67% of Medicaid claims analyzed.
Funding for the care of children living in poverty is fragmented across federal and state systems, such as schools, state children and family services, Medicaid, the Children’s Health Insurance Program, and supplemental security income. A lack of coordination among providers and payers further puts these already vulnerable children at risk. Behavioral health providers that serve children and families must make extra efforts to coordinate care and coverage. As much as that burden is onerous, it will allow for better outcomes and—importantly—inform your advocacy efforts.
Implement a population health approach
To truly address the health effects of childhood poverty, changes need to be made at the national and state levels in education, research and policy. But what can you do today to help improve the mental and physical health of the children you serve?
1. Adjust your program and practice
Treatment providers, particularly behavioral health providers, need to develop highly specialized assessments and treatment plans that address ACEs, childhood trauma and early intervention. An example is the Restorative Integral Support (RIS) approach that was developed as part of the New York-based HEARTS (Healthy Environments And Relationships That Support) program. RIS is a flexible model that allows providers to raise awareness of ACEs within their agencies, unite services to address them and integrate knowledge of trauma, resilience and recovery into their programs.
While you may not be able to completely redesign your program quite yet, you can make simple changes, such as screening all of your pediatric clients for poverty and using a trauma-informed approach to services for all children who screen positive. ACE screening tools are also available.
2. Advocate for change