Assessment of the Type, Frequency, and Duration of Mental Health Services for Youth In out-of-Home Care

Background

Youth in out-of-home care (OOHC) experience disproportionately high levels of trauma exposure and behavioral health need with 40–88% of youth in OOHC meeting diagnostic criteria for at least one mental health disorder. Yet the extent to which these needs are met through public systems remains unclear. Statewide implementation of universal trauma screening and standardized functional assessment using the Child and Adolescent Needs and Strengths (CANS) instrument in one Southeastern State provides an opportunity to examine behavioral health service utilization through Medicaid and to evaluate whether service type, frequency, and duration are aligned with assessed need and functional change over time. This study examined service utilization patterns and longitudinal associations between service dosage and youth wellbeing.

Methods

This study analyzed linked administrative data from child welfare screening, BH assessment records, and Medicaid claims for youth in OOHC between 2016 and 2022. The final dataset included 14,547 youth with Medicaid claims associated with behavioral health services. Six service categories were examined: individual behavioral health services, individual substance use services, family behavioral health services, group behavioral health services, behavioral health screening or assessment, and substance use screening or assessment. Youth placed in Private Child Placing or Child Caring agencies were excluded due to bundled billing structures. Chi-square and one‑way ANOVA models examined differences in service utilization by timing of first claim relative to OOHC entry. Latent growth curve modeling assessed predictors of initial levels and rates of change in CANS risk behavior and behavioral/emotional needs scores, adjusting for gender, age, race/ethnicity, and adverse childhood experiences.

Results

The majority of youth receiving services had claims for individual behavioral health services (84%) and behavioral health screening or assessment (66%), while fewer received substance use services (5–27%). Most youth initiated behavioral health services after entry into OOHC (70%), with significant differences in service type by timing of first claim. Youth receiving services prior to OOHC entry had significantly higher mean service frequency for individual and family behavioral health services and longer overall service duration. We modeled CANS risk behavior and behavioral/emotional needs using piece-wise trajectories, with significant improvement from entry into OOHC to approximately 7 months after entering OOHC and then stabilization between 7 and 13 months. Greater total service frequency (β=0.11, p<.001) and longer service duration (β =0.18, p < .001) were associated with higher initial levels of risk behaviors. Similarly, higher levels of service frequency and duration were associated with higher initial behavioral/emotional needs; only longer total duration predicted faster improvement during the first 7 months in OOHC (β=0.23, p<.001).

Implications

Standardized screening and assessment processes are effective in identifying youth with higher BH needs and generating service utilization patterns broadly aligned with assessed risk. However, inconsistent associations between service type and functional change, along with data limitations related to bundled billing and nonspecific claims coding, constrain the ability to determine service effectiveness. System reforms focused on improving data specificity, aligning assessment results with treatment planning, and enhancing analytic capacity are critical to strengthening BH outcomes for youth in OOHC.