ZERO TO THREE’s HealthySteps Lays Critical Foundation for Children’s Mental Health

For millions of children, Medicaid provides access to health care that is essential to their growth and development. California’s Medicaid program, Medi-Cal, has created pathways to cover many of the preventive behavioral health services that Modern Medicaid Alliance partner ZERO TO THREE’s HealthySteps program offers. HealthySteps provides early childhood development support to families at pediatric and family medicine primary care practices to help ensure a strong foundation for life.

The Modern Medicaid Alliance interviewed HealthySteps-affiliated provider Dr. Kate Margolis, Associate Clinical Professor, UCSF Departments of Psychiatry and Pediatrics, to discuss the HealthySteps program as well as Medi-Cal’s role in helping to support the vision of HealthySteps. 

How does the HealthySteps program help to improve the mental health of babies, infants*, and children in California, including dyadic care?

HealthySteps creates a foundation for standardizing preventative behavioral and social-emotional health care for children served in the primary care setting. Through a population-health cased universal screening process, HealthySteps structures an automatic response to an identified concern by creating pathways for tailored intervention and referral. This system helps mitigate missed opportunities, gaps in care and even implicit bias that often leads children – especially children from under-resourced and minoritized communities – to fall through the cracks and deepen health inequities. What’s unique about HealthySteps is that the program provides dyadic care services, which addresses the needs of both the mother and the baby as a whole unit during this critical period of growth and development.

*Infant mental health refers to how well a child develops socially and emotionally from birth to three years of age. It reflects the developing capacity of the child to form close relationships, manage and express emotions, and explore the environment and learn.

Does HealthySteps have a lasting impact?

By providing care through a culturally-attuned, family-centered lens during well-child visits, HealthySteps helps babies and their caregivers build their mental health muscles both individually and as a family. This, in turn, will make them more resilient in the face of adversity and will reduce the likelihood of developing mental health challenges later in their lives.

What role does Medi-Cal play in HealthySteps?

Over half of California’s children are served by Medi-Cal. Creating a pathway for Medi-Cal to pay for HealthySteps services means that we are making preventive child health and development and behavioral health services more accessible to families who face economic disadvantages.

Medi-Cal has made big strides in reimbursement for HealthySteps services by creating a mechanism to bill for a mental health service for an emerging or subclinical behavioral health concern. This enables organizations to adequately staff their clinics with providers who deliver preventative behavioral health services. Looking ahead, California is also launching a Medi-Cal dyadic services benefit, which includes a behavioral health well-child visit.

Allowing for payment of HealthySteps and HealthySteps-aligned services is one way in which Medi-Cal is making preventative behavioral health and child health equity a real priority.

What is the connection between the mental and behavioral health of parents and of their children?

The mental and behavioral health of children and of their caregivers are completely intertwined physiologically, socially and via basic needs.

Co-regulation provided by a caregiver during pregnancy and to a child during infancy establish the foundation for how a child experiences and navigates the world. Caregivers receive support with self-regulation via supportive relationships, strong communities, cultural resilience and behavioral interventions, as well as physical supports like food, housing, childcare, employment, and transportation.

Children also learn about social and intimate relationships from what they experience of their caregivers. They experience physiological and other emotional reactions in direct response to how their caregiver is experiencing the world and expressing themselves. This in turn is how children learn to express themselves to others.

What are some experiences as a HealthySteps provider that stand out to you?

There are so many, but the one experience I consistently see is a family that has recently immigrated and birthed a child within our hospital. The mother has experienced unimaginable traumas both in the country of origin and in the immigration journey, only to arrive with very little social and concrete support.

Sometimes, HealthySteps is unavailable to meet these families during their first newborn visit, so the provider generates an e-referral. We try to reach out to these families to engage them between appointments; however, that can be very difficult to do for wide variety of reasons.

The magic of HealthySteps is that we’re always looking out for these families during their next clinic visits. We’re almost always able to successfully engage them by leveraging our relationship with their provider, which allows us to create more trust in the initial engagement.

What barriers do you see that Medi-Cal could address to provide more access to families and children?

Medi-Cal has set up amazing billing options to cover the full range of HealthySteps services. However, for the many children who are served by Medi-Cal and receive care at Federally Qualified Health Centers (FQHCs), the same-day exclusion represents a significant threat to children accessing these benefits.

FQHCs are prohibited from drawing down much potential new revenue from these benefits, as they are intended to be offered on the same day as a well-child visit. Ideally, Medi-Cal would change the policy to allow for same-day prospective payment system (PPS) rate reimbursement for, at minimum, behavioral health interventions provided during pediatric well visits.