Partnering with Children’s Hospitals to Disrupt the School-to-Prison Pipeline

For 18 years, Health Law Advocates (HLA), a nonprofit, public interest law firm headquartered in Boston, has used legal advocacy to help children with mental health needs overcome barriers to treatment and avoid the justice system. HLA’s Mental Health Advocacy Program for Kids (MHAP for Kids), which began in 2017, has now assisted almost 2,000 children who were in or close to entering the justice system because they were not receiving the mental health services they needed. MHAP for Kids’ work is multifaceted and includes special education and school discipline advocacy, advocacy to various state agencies responsible for providing services to young people, and ensuring access to health insurance coverage.

An independent, two-year evaluation found that MHAP for Kids’ work

• improves school attendance,
• decreases the use of emergency mental health services,
• lowers overnight hospital stays, and
• reduces the use of emergency shelters.

Over the past two years, MHAP for Kids has partnered with a new ally in our efforts to disrupt the school-to-prison pipeline: the Medicaid health plan made up of mental health-care providers from Boston Children’s Hospital (BCH). This health plan, created in 2018 as part of Massachusetts’s statewide Medicaid transition to accountable care organizations (ACOs), includes BCH, its primary care doctors, and its affiliated specialists, and is the only exclusively pediatric ACO in Massachusetts. BCH’s ACO covers 130,000 children across Massachusetts.

The MHAP for Kids and BCH ACO pilot supports and educates BCH’s primary care providers, behavioral health teams, and medical care coordinators through trainings and consultations by an experienced MHAP for Kids attorney, which in turn drive case referrals from BCH’s providers to MHAP for Kids. Below are some lessons learned and reasons why we believe children’s hospitals are great partners for children’s advocates.

The Benefits of Partnering with a Children’s Hospital

1. Providers were eager for trainings on issues affecting the school-to-prison pipeline and ways they could intervene to interrupt the pipeline. The partnership was designed to increase provider capacity in complex legal areas, many of which relate to the school-to-prison pipeline. One of the ways the pilot shared information with providers was through targeted trainings developed and led by one of MHAP for Kids’ senior attorneys. Children’s hospitals like BCH employ numerous kinds of healthcare professionals, and the pilot offered trainings targeted toward different groups of employees, including primary care providers, behavioral health providers, social workers, and medical care coordinators. Practices and care coordination teams worked directly with MHAP for Kids to identify the most relevant and helpful topics. Training topics included special education services for students with acute behavioral health needs; understanding state agencies like the Department of Mental Health, the Department of Youth Services, and the Department of Children and Families; and the role of the juvenile court staff and juvenile court attorneys when there is an open child welfare, status offense, or delinquency matter. Each of the trainings included legal information, relevant case examples, and practice advocacy tips for providers. Many times, the providers were already very familiar with the systems at play, but they were (unsurprisingly) less familiar with the legal nuances of them. Over and over again, providers demonstrated high levels of interest in better understanding the juvenile court system and how to help their patients and families avoid unnecessary contact with it.
2. Providers sought out one-on-one consultations about complicated legal issues affecting their patients. In addition to the trainings, the pilot also provided funding for individual consultations to BCH providers. Doctors, behavioral health providers, and care coordinators were all able to schedule consults with the senior MHAP for Kids attorney via videoconference, telephone, or email about de-identified and anonymized patients or on questions regarding special education, state agencies, and the juvenile court system. Over the course of the pilot, MHAP for Kids provided information to BCH providers on a number of topics, including the special education process, the intersection of special education law and public charter schools, advocating for more therapeutic school placements, the Massachusetts anti-bullying law, how providers could assist parents with navigating a child welfare case, behavioral health waitlists, and the adequacy of the behavioral healthcare that patients were receiving. Some of the time, the consultation was sufficient to address the underlying issue. Other times, at the conclusion of the consultation, the provider decided the family needed legal representation from MHAP for Kids and provided referral information directly to the patient’s family.
3. Providers appreciated the warm handoff for patients’ families. Although not explicitly part of the pilot, one of the benefits of the trainings and consults being conducted by a single, senior MHAP for Kids attorney was that BCH staff had a streamlined process for referring families for MHAP for Kids’ services. The identified senior attorney was available to speak to BCH-referred families and explain MHAP for Kids’ work and how the program might be able to assist them if they completed the MHAP for Kids’ intake process. Ideally, providers felt not only that they had an increased understanding of how to help their patients navigate legal barriers to behavioral healthcare but also that they knew exactly where to send families whose needs exceeded the providers’ ability to assist.
4. Children’s hospital providers are a great source of referrals. Since HLA created MHAP for Kids in 2017, the program has received hundreds of referrals from healthcare professionals. According to the most recent program evaluation data, healthcare providers are the largest referral source for MHAP for Kids, constituting 27 percent of total MHAP for Kids case referrals. The BCH ACO has sent us almost 100 referrals in the last 18 months.
5. The cases healthcare providers refer are appropriate. MHAP for Kids frequently works with children and families with significant behavioral health needs. According to the most recent program evaluation data, 40 percent of the children accessed crisis or emergency mental healthcare services, 34 percent required inpatient psychiatric hospitalization in the past year, and 19 percent of students had been suspended at least once in the past year. According to preliminary data analyzed by Patricia Elliott, DrPH, from the Boston University School of Public Health, the referrals from ACOs, including BCH’s, are very similar to other MHAP for Kids’ cases. There are no statistically significant differences in any measures of childhood behavioral health acuity, including youths’ overall difficulties, emotional symptoms, conduct problems, hyperactivities and inattention, and prosocial behaviors, which means that the families referred to MHAP from BCH are a good fit for our program.
6. In the future, provider referrals may help MHAP for Kids reach families we wouldn’t otherwise reach. The ACO referrals were more likely to be on behalf of younger children than average for MHAP for Kids’ clients overall, and they were more likely to be female. That tells us that healthcare providers may be an important means of identifying families who require the assistance of MHAP for Kids but who have been underrepresented among MHAP for Kids’ clients. If we can address the barriers to mental healthcare earlier in children’s lives and ensure they receive the services that they require and to which they are entitled, we can reduce the chances that they become court-involved because of unmet mental health needs later in childhood or adolescence.
7. Partnerships with children’s hospitals and Medicaid health plans may be an avenue for new funding sources for legal services like MHAP for Kids. Organizations interested in starting a program like MHAP for Kids in other parts of the country should consider partnering with children’s hospitals because they may have access to additional means of funding. These funding resources could come in the form of private grants, legislative allocations, or even internal hospital funding. In some cases, states with Medicaid waivers could pursue special federal, time-limited funding through the federal Medicaid system.
8. Partnerships between lawyers and children’s hospitals create a team of experts for cases. Every lawyer who practices in special education knows he or she will likely need a good expert to prevail at hearing, and experts can be hard to come by for legal services attorneys. Children’s hospitals have a whole team of experts at the ready—primary care doctors, medical specialists, psychiatrists, psychologists, and education experts. By developing trusting relationships with these providers outside a contested case, lawyers can increase the likelihood that such providers will be willing to share their time and expertise when needed on a case.
9. Training and consultation partnerships with lawyers empower providers to advocate on behalf of their patients. Trainings and consultations with a lawyer make it more likely that providers understand how to write a persuasive letter or evaluation for students with mental health needs, even before a lawyer gets involved, and even if a lawyer never gets involved.
10. The casework may create avenues for systemic policy reform. BCH and HLA have worked together on children’s health policy reform campaigns for decades. This casework partnership is an opportunity to deepen that connection, while at the same time providing “real-life” patients and case examples.

Conclusion

Children’s hospitals are great partners to smash the school-to-prison pipeline. Lawyers and healthcare providers can work together to ensure a future where no child is unfairly disciplined for an unmet health need and parents do not feel forced to seek involvement from juvenile courts or child welfare agencies to secure the behavioral health services that their children need. Partnerships between us can

• increase provider understanding of the juvenile court system and the risk of juvenile court involvement;
• offer providers legal avenues to pursue needed services for patients other than just referring them to child welfare agencies and juvenile courts; and
• create a team of experts we can use to secure services for children from schools, from state agencies, and through health insurance without involving the court system.

In these ways, lawyers and children’s hospitals can work together to divert kids from the juvenile court system and into the behavioral health services they need.