Youth Opioid Response: Marin Final Report and Action Plan August 14, 2020

Table of Contents Executive Summary ...... 3 Introduction ...... 4 Methodology ...... 4 Marin County Profile ...... 5 Marin County Demographics ...... 5 Marin County Health Indicators ...... 7 State of Adolescent Behavioral Health Screenings in Marin County ...... 9 School Health and Wellness Profiles ...... 10 Key Findings ...... 13 Adolescent Needs ...... 13 Parent Needs ...... 15 School Needs ...... 16 Policy Needs ...... 17 Spotlights on Promising Practices ...... 19 Path to Impact: A Framework for Charting a Path Forward ...... 22 Capturing the Current State...... 22 Illustrating the Ideal State ...... 23 Action Plan ...... 23 Vision Statement ...... 23 Actions for 2020 and Beyond ...... 23 Conclusion ...... 24 Appendix I...... 25 Community Groups Supporting Adolescent Behavioral Health ...... 25 Education and Assessment Resources ...... 25 Appendix II.: Community Meeting 1 Summary ...... 26 Brief Summary ...... 26 Takeaways ...... 26

1 Appendix III. Community Meeting 2 Summary ...... 27 Brief Summary ...... 27 Framing the Meeting ...... 27 Key Takeaways from the Meeting...... 27

2 Executive Summary

The YOR Marin Project set out to examine Marin County’s needs surrounding opioid use disorder and co-occurring condition prevention and treatment for high school-age adolescents (13 to 17 years old). Key areas of interest included the prevention and treatment of co-occurring mental health conditions, and how high schools can be leveraged as part of any solution or strategy pursued to tackle youth OUD or co-occurring conditions.

Over the course of 2019 to 2020, the YOR Marin Project team conducted an environmental scan, interviews, focus groups and community meetings with community members to understand where gaps exist in meeting adolescent and family needs. The team identified key findings, best practices from other jurisdictions, and developed a logic model to explain the current state of behavioral health prevention and treatment, and the ideal state community members wish to see develop. Within that spectrum, community members and the YOR Marin Project team determined that identification of needs and navigation to services and supports are top needs along that spectrum.

As part of the grant project, the YOR Marin Project team developed and action plan for next steps that county agencies and community members can take to tackle existing needs. Action plan items identified by the Project include • House YOR project within RxSafe Marin as an ongoing RxSafe Marin action team • Assess wellness capabilities across high schools and identify where gaps exist • Explore public-private partnership to sustain public high school wellness in Marin County • Analyze what policies need to be changed at the state and/or local level for high school wellness to succeed • Develop and adapt existing trainings for teachers, families and adolescents to better prevent and identify opioid use disorder (OUD) • Create a partnership with Crisis Text Line • Develop navigation for case management services to track access to treatment and address follow up needs • Create a data dashboard to track key youth behavioral health indicators in Marin County • Consider a pilot study of universal screenings

3 Introduction

The opioid crisis and its effects on the public’s health have been well-documented, and adolescents have not been immune to this crisis. Fatal overdoses for adolescents and young adults age 15 to 24 years more than tripled from 1999 to 2014,i and in 2016, 3.6% of adolescents age 12 to 17 reported misusing opioids over the past year.ii In , 3.5% of youth age 12 to 17 reported misusing pain medications in the past year, and 0.6% of reported having SUD for pain medication from 2015 to 2016.iii Even more concerning, 21.8% of students in grade 11 report having used prescription pain medications at least once to get high.iv In Marin County, student-reported survey data suggests that use of any drugs is up for both 9th and 11th graders, with particular specific increases in heavy drug use and marijuana.v

Opioid use and substance use more generally involve complex biological, social, cultural and economic factors, and often present with co-occurring mental health conditions. As community members dedicated to improving adolescent health, individuals from several organizations including Marin County Behavioral Health and Recovery Services, RxSafe Marin, Marin County Office of Education, Tamalpais Union High Wellness and BluePath Health secured funding through the California Department of Health Care Services’ Youth Opioid Response (YOR) California grant opportunity to conduct a needs assessment for community planning purposes. The goal of YOR California is “to improve and expand access to a continuum of opioid use disorder (OUD) prevention, intervention, Medication-Assisted Treatment (MAT), and other treatment and recovery services for youth (ages 12-24) and their families, thereby preventing opioid overdose-related deaths.”

This community planning project—the YOR Marin Project—specifically aimed to examine community needs surrounding opioid use disorder and co-occurring condition prevention and treatment for high school-age adolescents (13 to 17 years old). We particularly sought to examine how high schools might be leveraged as access points for prevention and treatment, given that high-school age adolescents spend nearly six hours per weekday at school. Our team approached this examination with the understanding that while high schools can be effective access points, the burden should not be solely placed upon the education system to tackle adolescent health needs, and that multi-sector organizations serving youth should and can be engaged in this work.

Methodology The YOR Marin Project team pursued a multi-phased approach to gathering data for this project. First, the team conducted a literature and secondary data review to understand the current state of opioid use, other substance use, and mental health prevention and treatment for adolescents in Marin County. The team analyzed county data on utilization, claims and resources currently available for Marin County residents, to the extent these data were publicly available.

4 This also included an accounting of best practices for prevention and treatment, including for use in educational settings.

Second, the team conducted stakeholder interviews and two focus groups with 51 individuals from 38 organizations. Stakeholder representatives were identified directly by project team participants, or through snowballing techniques, in order to ensure that broad representation was included in this project. Interviews were conducted with parents, students, school administrators, health care providers, health care payers, substance use and mental health advocates, local researchers, school-based health experts in California, and community benefit entities within health systems. Team members conducted semi-structured interviews and discussions using an interview guide. (See Appendix for a full list of organizations interviewed and focus groups.)

Third, we solicited feedback from stakeholders at three community planning meetings. Community planning meeting discussions were ordered sequentially to ensure that participants were able to vet findings and engage in action planning. The focus of each meeting was as follows:

• Community Planning Meeting 1: Report-out of draft findings and vetting with participants • Community Planning Meeting 2: Development of action items for the final action plan • Community Planning Meeting 3: Discussion of county agency and community stakeholder ownerships and involvement in action plan items Marin County Profile Marin County Demographics

Marin County adolescents age 14 to 17 comprise 5.16% (13,467) of the total population of Marin County (260,955).vi Most Marin children are white (60.2%) or Hispanic/Latino (25.5%), and most (72.8%) of households have two parents present, higher than the California average (63.5%).

Fig. 1. Marin County child population breakdown by race compared to California, 2018.

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The majority of Marin County high-school age adolescents attend public high schools. These students are assigned to high schools in the Novato Unified School District (2,500), San Rafael City Schools (2,475), Shoreline Unified School District (160), and Tamalpais Union High School District (3,921).

Fig. 2. Marin County public high school districts and enrollment, 2020.

6 Marin County Health Indicators

Marin County is often ranked healthiest county in California, but health indicators present a more mixed picture of health in Marin County, including for its adolescent population. With regard to opioid overdoses, Marin experienced eight deaths due to all opioid-related overdoses in 2018, a 28% decrease from 2016.vii No recorded opioid overdose deaths for youth age 15 to 19 occurring in Marin County were reported in 2018.viii Across the Marin County population, the buprenorphine (an opioid partial agonist) rate in 2018 was 26.9 per 1,000 residents, a 1% decrease from 2016. Prescribing rates were not reported based on age of recipient.ix

Fig. 3. Buprenorphine prescriptions, Marin County, Q3 2016 to Q2 2019.

Data from Marin County Behavioral Health and Recovery Services, which provides severe mental illness and substance use treatment to the county’s Medi-Cal population and the Access hotline for behavioral health needs, offers a brief snapshot into community member usage of the county crisis hotline and screenings and assessments (see Figure 4). In October 2019, the Access hotline received a total of 619 calls. Fifty-seven callers received mental health screenings, nine received substance use screenings, and 58 received assessments for severe mental health coverage eligibility, of which 40 were eligible for a referral to county mental health services. Thirty-nine percent of those eligible for a referral to county services received one within 14 days (the county’s standard), 36% within 15 to 30 days, and 36% more than 30 days later. Only three of those referrals were to substance use programs (R2R or BACR).

Fig. 4. Marin County BHRS Access Data, October 2019.

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Fig. 5. California Healthy Kids Survey statistics and trends across Marin County public high schools, 2009-11 to 2017-18.

More Marin County adolescents age 15 to 19 are hospitalized for mental health issues than the state average (13.4% versus 9.7%).x Local data from Partnership HealthPlan, the Medi- Cal Managed Care Plan for the county, found a 7% increase in adolescent substance use claims in 2018, with most claims listing the emergency department as the service location.xi

Adolescent responses to the California Healthy Kids Survey (Figure 5) show that use of alcohol and other drugs have declined since 2009-11, marijuana use and heavy drug use have increased since 2015-16. Parents may not perceive these problems to be as prevalent as they are. 2017 Parent Norms Survey shows a mismatch between parent perceptions and teen reporting in some areas.xii In example, 86% of high school parents didn’t think their kids were

8 drinking, but 40% of 11th graders reported in the California Healthy Kids Survey that they drank alcohol in the past 30 days.

As pertains to mental health providers and treatment for children and adolescents, California and Marin County face shortages. Marin County has 24 child and adolescent psychiatrists, a rate of 45 per 100,000, just below the “sufficient” supply of 47 per 100,000, as recommended by the American Academy of Child and Adolescent Psychiatrists.xiii Statewide, two-thirds of adolescents with major depressive episodes do not get treatment.xiv For adolescents with severe mental health needs, there are no child or adolescent inpatient beds available in Marin County.xv

State of Adolescent Behavioral Health Screenings in Marin County

Screening for behavioral health issues, including mental health, substance use, or social or emotional problems, can reduce child exposure to stress, are key to treating child behavioral health needs and reduce the risk of childhood emotional and behavioral problems.xvi The American Academy of Pediatrics (AAP) has endorsed childhood behavioral health screenings,xvii and the National Academy of Medicine and National Association of School Psychologists have endorsed their use in universal school-wide screening programs.xviii Within the Early and Periodic Screening, Diagnosis and Treatment benefit, Medicaid and the Children’s Health Insurance Program also cover behavioral health screenings for children,xix as recommended by AAP and Bright Futures.xx Screenings can take a number of forms—for example, they can screen for social and emotional needs that may indicate higher risk for developing mental health or substance use problems, or they may screen for conditions, such as depression, anxiety or substance use. Marin County currently has a patchwork approach to conducting screenings and assessments for youth across the county.

Health care settings. Pediatricians and other providers serving adolescents may screen patients for mental health or social and emotional needs. For example, Marin Community Clinics uses the Columbia Suicide Severity Rating Scale to screen for child suicide ideation. If children are identified as at-risk, they are referred to the county ACCESS hotline, which puts the child and their family in touch with Marin County Youth and Family Services, the county mental health agency. Youth and Family Services providers utilize their in-house screening tool and select questions from the CANS assessment tool to screen for mental health and substance use issues.

Juvenile justice. Adolescents may also receive screenings at different touchpoints within the justice system. Upon intake, staff administer the MAYSI screening which screens for trauma, thought disturbances, abuse, mental health and critical thinking capabilities. In probation, staff use the PACT screening tool for a full-scale risk and needs assessment to drive case planning. Additionally, staff use the CANS tool for case planning when juveniles are ordered to an out-of- home placement.

High schools. Several public high schools have screening protocols in place, depending on the situation and the student’s need, as outlined below in school profiles. For example, Sir Francis

9 Drake and Redwood High Schools conduct suicide screenings using the BSTAD tool during all suicide prevention workshops on campus.

School Health and Wellness Profiles

Shoreline Unified School District Located in , Tomales High School serves approximately 160 students in northwest and mostly rural Marin County. All students at Tomales High School have initial access to school counselors. Wellness services and staff consist of a full-time academic counselor that serves all students, a counselor from the local agency Costal Health alliance that supports students with drugs and alcohol counseling one day a week on campus, and a school psychologist that supports students with individualized education plans (IEP), ED designated students, and students requiring higher levels of support. Currently 10 students are on the SAY caseload, and seven students are on the school psychologist’s caseload.

Most referrals to wellness staff are self-referrals, referrals from school staff, or from parents. “Staff are vigilant about looking at student work and behavior for signs that a student might need more support,” reports Principal. Wellness and health services funding comes from general funding, except for the Coastal Health Alliance counselor, funded from district funds. As a result of the COVID-19 pandemic, all service providers are now using telehealth. With regard to sustainability, Tomales High School is thinking through how to sustain its current services and supports, while expanding prevention work and stress management programs, and establishing a dedicated wellness center on campus.

Tamalpais Union High School District Redwood, Sir Francis Drake and Tamalpais High Schools

Tamalpais Union High School District operates Wellness Centers at their three comprehensive high schools that seek services or information on teen health, mental health, substance use/abuse and sexual health. TUHSD Wellness is a hybrid model that combines dual emphases on health and wellness prevention and intervention services. Resources include a health specialist, nurse, counselors, social workers, wellness providers and community partners. Offerings include direct services; health education and prevention; youth development’ engagement and advocacy activities; staff training and consultations; and wellness advisory board. TUHSD Wellness services over 900 students a year offering direct services, including mental health counseling, support groups, a sexual health clinic. With regard to opioid prevention and treatment, all TUHSD high schools have at least one staff member trained on the use of naloxone for opioid use overdoses. TUHSD students received substance use prevention education in 9/10 in their Social Issues classes and mental health and substance use/abuse counselors are able to provide referrals to off-campus providers for substance use treatment. During COVID-19, TUHSD Wellness has shifted its services to a virtual platform for

10 community partners to continue providing services and supports to students using tele-health and virtual support during this time.

San Andreas High School

San Andreas High School in Larkspur, CA is the continuation high school for approximately 100 students every year in TUHSD. All students entering the school go through a school-created initial assessment with one of two staff counselors to identify risks, including depression, anxiety, suicide, cutting, drugs and alcohol. The counselors work in a health and wellness space with private meeting rooms and larger rooms for support groups. Each staff member has a caseload of students they mentor, and special education teachers and paraeducators work with a small caseload of students with IEPs that overlaps with their mentorship caseload to support student success. All staff are trained on non-violent intervention. The school also coordinates closely with outpatient health care providers to the extent possible to create flexible scheduling so that students can get the help they need, including for substance use treatment.

Novato Unified School District Novato High School, located in Novato, CA, has approximately 1400 students. It has adopted a wellness policy aligned to the district's focus on Culture of Caring and considers itself "developing as a wellness campus" such that all strategic plans at the school must account for student wellness and all staff engages in wellness professional development. This policy accounts for issues of equity, and considers how marginalization and trauma can be incorporated into wellness services and supports at the school. As a part of this initiative, 50% of all teachers have piloted or integrated wellness directly into their curriculum or instructional practices.

Additionally, the school has increased physical space dedicated to wellness. New in the 2019/2020 school year, the Emotional and Social Teams (EAST) Annex, which houses three members of staff five days a week, provides space for students to access services and supports. All students are served by wellness, and 22% utilize the supports located in the EAST Annex. Services and supports provided at the EAST Annex include a welcome center for English Language Learners and peer groups (including restorative practices, LGBTQIA+, drug education, healthy relationships, stress management, and mental health education). Agency partners that provide services and supports on campus include Bay Area Community Resources (BACR), North Marin Community Services, 10,000 Degrees, Spahr Center, Novato Community Clinic, Center for Domestic Peace, and the TURN.

San Marin High School , located in Novato, CA, is a comprehensive high school with just over 1,000 students. A focus area of San Marin is prevention, and how mental health, poverty and other social determinants affect academic achievement and attendance.

11 San Marin High School has a policy of restorative practices in place to respond to students’ behavior issues. The school has a contract with Bay Area Community Resources to provide counseling services to students five days a week, during the school day. Referrals are made to outside agencies for services, but families often lacked the capacity to access those services. San Marin is looking to open a physical wellness center in the coming years.

Marin Oaks High School

Marin Oaks High School, located in Novato, CA, is a continuation high school serving 81 students. The school’s practices have put a premium on restorative practices, having had a policy of restorative practices for over 13 years. Nicotine vaping is reported as the top substance use issue of the moment, though other substance use such as benzodiazepines is a continuing problem. To serve student health needs, Marin Oaks has three part-time mental health counselors from Bay Area Community Resources, plus an NUSD academic counselor. The school also partners with several community-based organizations and individuals to provide screenings, assessments, and interventions with students on campus. These include Petaluma People Services, 10,000 Degrees, a meditation instructor, and the mobile crisis unit.

Marin Oaks has also pursued several strategies to treat and prevent the onset of further conditions. For example, the school has a music studio where a local non-profit delivers music therapy to students, and a meditation room where students can take time to reset and regroup their thoughts. The meditation room is also used for a restorative circle and mindful meditation classes that students can take. Additionally, students participate in daily mindfulness exercises and EFT tapping sessions as mindfulness interventions to help students learn to control their emotions and behavior.

San Rafael City Schools

San Rafael High School , located in San Rafael, CA, enrolls just over 1,300 students. San Rafael has two full time mental health counselors. A third therapist is present for four days, and shared with for one day.

These services are supplemented with mental health and substance use services provided by Huckleberry Youth Services and Marin County Youth and Family Services. Huckleberry Youth Services provides a newcomers group for Spanish-speaking students, as well as substance abuse counseling. Youth and Family Services provide direct mental health services on Terra Linda’s campus to students that receive Medi-Cal. Prevention activities include sexual and reproductive health education, Spanish-language supports for newcomer students, and suicide prevention student-led outreach in the school community.

Terra Linda High School Terra Linda High School, located in San Rafael, CA, enrolls just over 1,300 students. TL has one full time mental health clinical supervisor who oversees a mental health associate program for

12 the district, as well as provides direct services to a Special Education Counseling Enriched Class program located on campus. Terra Linda also has another full time mental health associate, who provides direct mental health services to all students.

These services are supplemented with mental health and substance use services provided by Huckleberry Youth Services and Marin County Youth and Family Services. Huckleberry Youth Services provides a newcomers group for Spanish-speaking students, as well as substance abuse counseling. Youth & Family services provide direct mental health services on campus to students that receive Medi-Cal. Prevention activities include sexual and reproductive health education, Spanish-language supports for newcomer students, and suicide prevention student-led outreach in the school community.

Madrone High School Madrone High School is a continuation high school designed to deliver “rapid credit recovery” for students located in San Rafael, CA. The school enrolls 60 students, and is fed by San Rafael and Terra Linda High Schools. Madrone has one mental health therapist present two days a week, as well as a school counselor present for four days per week.

These services are also supplemented by Huckleberry Youth Services and Marin County Youth & Family Services in a similar manner at the two comprehensive high schools above.

Key Findings

Adolescent Needs

1. There is not standardized, widespread use of behavioral health screenings early enough to prevent conditions from becoming more severe.

Data collected in our project reveal that while screenings are taking place, they generally occur once an individual has identified risk for a behavioral health condition, or once a referral has taken place. (See Appendix for snapshot of screenings in Marin County.) At the same time, severe adolescent behavioral health problems continue to persist. Partnership HealthPlan claims data also shows that cannabis and alcohol use are the top two diagnoses for youth substance use disorder, with most clinical claims in the emergency department as opposed to office visits.xxi

Interviewee quotes: • “We are doing [condition-specific, mental health] screenings consistently at intake but aren’t sure what screener we use. It hasn’t been updated in 20 years.” – Mental health care coordinator in outpatient setting • “We only do the mental health and substance use screenings required by the state.” – Payer

13 • “We should screen kids when they enter high school and follow them through high school with wraparound services. The teachers should be trained what to look for [regarding substance use].” – Local advocate and program coordinator

2. When adolescents’ substance use disorder and mental health conditions are identified, they are often not able to get the care they need due to provider shortages, cost or lack of time.

Various indicators reflect that adolescents are not able to get the mental health and substance use treatment they need. As noted above, two-thirds of adolescents in California with major depressive episodes do not get treatment, and in Marin County, there are no child or adolescent inpatient beds available in Marin County. Interviews confirmed these needs in Marin County. Students generally reported that they were interested in more information on resources for themselves and their friends. One student stated that his friend travels from Marin County to Fairfield once a week to see a therapist because he is unable find an in-network provider in Marin.

Interviewee quotes: • “My friend has to drive to Fairfield once a week to see a therapist because he couldn’t find one in Marin County.” – Adolescent • “When I reached out for help at my old high school, they made me feel like I was crazy and didn’t need the help. I reached out to a local community-based organization, and they helped me.” – Adolescent • “We don’t have enough places to get help… On campus, we don’t have enough staff or funding to address any physical health or case management. There’s a need everywhere, and the need is not the same everywhere.” – Health care provider that works with high schools

3. Resources meant to benefit adolescents need to be co-designed by adolescents.

In interviews, adolescents voiced that they want more information on how to make better decisions and find help when they or their friends need it, and that they would like to see adult decision-makers include adolescent voices in the design of solutions. The adolescents also said that they would be interested in gaining access to more digital resources on mental health and substance use, both prevention and treatment. Several adults echoed these points and reiterated that students are more likely to use any education or other resource if they are involved in designing it.

Interviewee quotes: • “A piece of technology might help, but kids can’t think it’s not cool or has a bad rep[utation]. Like something that’s not in tune with kid culture. It can’t seem like an adult trying to fix problems.” – Adolescent

14 • “The messenger is just as important as the message. Teens need to be involved in developing and spreading these ideas.” - Adolescent

Parent Needs

1. Some parents and families do not recognize substance use as a top issue impacting the health and wellness of students in Marin County.

As noted, Marin County is usually ranked among the healthiest counties in the state, but these rankings often overlook areas where health indicators are worse than the state average (i.e., binge drinking, adolescent mental health hospitalizations). Several interviewees noted that many Marin County parents have a lax approach to adolescent substance use or may not see adolescent substance use as a problem. This matches Parent Norms Survey data reported above, which showed a mismatch between parent perceptions and teen reporting in some areas.

Interviewee quotes: • “Parents should be a given more information. They should be aware of what the kids go through every day when they are not at school.” – Adolescent • “We need a culture shift. There is a ‘work hard, play hard’ mentality in these communities. We need to have parents educate the students and bring forward issues that are happening.” – Health care educator • “So many parents are burying their heads in the sand, and an extra layer is the amount of pressure to perform well and to get into college.” – Parent • “They [the kids] are watching the parents come home and manage their stress and self-medicate for a long-time. They are doing what they see their parents doing.” – Parent and educator

2. When a mental health or substance use issue is identified, parents are eager to find resources for their children but may not know how to navigate the health care system to find help.

Interviewees noted that when parents look for resources, and even when they are willing to pay for them out of pocket, that they are unable to find mental health and substance use providers to treat them. Interviewees noted several reasons for why this may be the case, including difficulty navigating the health care system in Marin County; affordability for families; lack of adequate education; and allocation of resources by insurance or condition type.

Interviewee quotes: • “We have so many resources in this county, but it’s a minefield to navigate.” – Parent • “Our program has a robust parent social media group, but it is only for parents whose kids have been through our [residential treatment] program.

15 It’s an extension of the weekly parent support groups we host while the child is in treatment.” – Residential facility representative • “Parents need facts. A lot of organizations tend to be preachy and tell parents what to do. Instead, they need regular and consistent and transparently- provided education throughout the year.” – Parent • “There’s been a gutting of the middle class. People are either able to private pay, or they have Medi-Cal. Nonetheless, they all have trouble finding care.” – Health care provider that works with high schools

School Needs

1. More resources (e.g., human, financial, health services) should be put towards high school health and wellness to sustain and expand these programs.

Interviewees representing high schools generally agreed that they are eager to expand their health and wellness offerings on campuses. They noted that teachers are not opposed to participating in health and wellness but that they are already overwhelmed with their teaching loads and other commitments to incorporate health and wellness into their curricula. Interviewees recognized that current health and wellness offerings at Marin County public high schools vary widely and are variably resourced. They also reflected that, across the board, these offerings are not on a growth trajectory due to annual budget cycles that do not guarantee funding.

Interviewee quotes:

• “Part of the issue is that because funding sources are basically groundhog day every nine months, no one is planning. No one goes for a three-year or five-year contract [with a high school to provide services]… I would love to see a funded series where you meet with parents and students separately several times, then bring them together.” – Local provider • “We don’t advertise [our school health and wellness] offerings as much because when students come in, we are already slammed.” – High school psychologist • “Schools are an access point. Don’t make it the school’s responsibility entirely, but realize that making resources available at that location makes it an easier option for them [to partner with community-based organizations].” – Health plan community benefit coordinator • “In a perfect world, I would have a counselor available full-time as an intake specialist inside our meditation room. Rather than sending them to the administrative office, we would send them there, have them do an intake, get them resources, and give them time to reset themselves, with somebody there to facilitate.” – High school principal

16 2. High schools and partners are pursuing new approaches to prevention education, and there is an opportunity to incorporate other methods.

Although interviewees noted that high school health and wellness is under-resourced, they did highlight that schools and their community partners are incorporating new curricula and interventions, using the budgets they have. Several schools noted that have social and restorative justice principles and trauma-informed care drive their offerings, attempting to target upstream factors that may affect student health and wellness. These include social- emotional learning and resilience trainings for students and staff trainings on how to identify students in need. Adolescents likewise reported that schools were working to meet student needs concerning mental health and substance use.

Interviewee quotes: • “We have a lot of prevention and education at our school: EFT tapping, mindfulness and meditation are helpful. If we weren’t doing it, I assume our problems would be more severe.” – High school principal • “We are a bit of a wellness school. Everything we’re doing is wellness focused: the way we build relationships, the way we staff programs.” – High school principal • “The restorative justice team at my high school is vital [when it comes to responding to substance use and mental health]. They say, “Let’s talk about this,” and they don’t brush over the issues.” - Adolescent

Policy Needs

1. There is widespread recognition that adolescent opioid use and mental health are problems in Marin County, but they have not garnered the same level of urgency as other issues, like vaping.

Interviewees reported that there is limited yet growing acknowledgement of adolescent mental health and substance use, which aligns with Marin County BHRS survey data collected in 2019. Interviewees of all types noted that a permissive substance use culture has affected the county’s response to the opioid crisis and other substances, and that a focus has been placed on vaping. They reported that county and health care institutions are responding to the need: for example, Kaiser Permanente San Rafael has made mental health and substance use its third top priority for 2019-2020 community benefit investment, and Marin County BHRS’ Suicide Prevention Strategic Plan highlighted youth suicide and hyper-competitive academic environments as harmful to youth health.

Interviewee quotes: • “There’s been all this emphasis on vaping and not that there shouldn’t be, but it trumps the issue the rest of the country is focused on, the opioid crisis.” – Parent • “Mental health- it’s really all related to mental health. If mental health was addressed, we wouldn’t have these substance use issues.” – High school principal

17 • “There’s a weed culture in Marin that, while it also exists in other parts of the Bay Area, it’s more generational [in Marin]… people are growing weed in their gardens… It’s more common here, where if you walk into a house, there’s more likely to be a bong on the table than in many other counties.” - Principal

2. There is often a lack of data to fully describe the scope of adolescent behavioral health.

A lack of data on adolescent behavioral health, including on substance use, may inhibit community members’ and policymakers’ abilities to fully understand the extent of the opioid crisis, other substance use and mental health among Marin County adolescents. One interviewee highlighted that the California Healthy Kids Survey (CHKS) and the California Health Insurance Survey do not explicitly ask about minor opioid use. Others highlighted the need to survey students, and parents, more often, noting that the Parent Norms Survey conducted in 2017 was a helpful baseline for understanding parents’ views on substance use but that newer data may be necessary. The relatively small size of Marin County’s population was also noted as a barrier to collecting significant findings or to stratify findings by demographics such as age.

Interviewee quotes: • “We need a deeper survey than CHKS. Students need to be surveyed more often.” – Parent • “How can we better track the young people who are dying from overdoses in college outside the county but who grew up here? We’re not doing enough in high school to prevent these deaths.” – Parent • “A big limitation for Marin County data is small numbers, especially when trying to stratify data geographically or by demographic characteristics.” – Epidemiologist

3. There are many efforts around adolescent and high school health and wellness across Marin County, but there is not enough coordination.

Many interviewees agreed that Marin County has an abundance of resources for adolescents and families but that resources are not reaching those who need it. One key issue identified was a lack of coordination among and within sectors, including education, community-based organizations, public health and health care delivery. Interviewees highlighted the need for county policymakers to work with the private sector to create improved pathways to navigation for adolescents and their families.

Interviewee quotes: • “We have so many therapists and more nonprofits than anywhere else in the state. We need to coordinate and focus [our prevention and services efforts].” – Local provider • “There are so many resources around Marin like Planned Parenthood, Huckleberry Youth Programs and school wellness. It all feels really scary to think

18 about who to go to. Maybe the counselors and organizations can reach [out]more often rather than have students going to them.” – Adolescent • “A big gap is coordination: we have 17 school districts, so it’s not easy. We are constantly rolling a boulder uphill [to implement prevention programs].” – Local advocate and program coordinator

Spotlights on Promising Practices

Be Well OC Organizations in Orange County have banded together to create Be Well OC. A public-private partnership, Be Well aims to create a community-wide ecosystem of mental health and substance use services and supports. The initiative is funded by the Well Being Trust and includes over 40 partners, including Beacon Health Options, Cal Optima, Kaiser Permanente, Orange County Public Health and St. Joseph Hospital. The project has identified common principles, objectives, and key performance indicators. The linchpin of the project is the Regional Wellness Hubs, a free-standing building to provide mental health and substances use services for Orange County residents, regardless of payer. Proposed services for the Regional Hubs include triage, psychiatric intake and referral, substance use disorder intake and referral, withdrawal management, transitional residential treatment, residential treatment, and integrated support. More information is available at https://bewelloc.org/.

Boston Public Schools- Comprehensive Behavioral Health Model In collaboration with Boston Children’s Hospital and other university partners, Boston Public Schools created the Children’s Behavioral Health Model (CBHM) in 2010. CBHM is based on tiered services and supports within the school based on student social, emotional and health needs. A key feature of the CBHM is the Behavior Intervention Monitoring Assessment System (BIMAS) universal screening tool. BIMAS helps staff identify student needs for services and supports, and teachers and clinicians receive student scores so they can better serve their students and clients. As a result of sustained partnerships and capacity building, the district has increased the number of psychologists serving students from 48 to 63 and increased the number of social workers and students working with the program. Program evaluation is a core component of the program and has been integral to state advocacy work to increase funding for student mental health initiatives in the state. More information is available at: https://cbhmboston.com/.

Colorado 9to25 and Statewide Youth Development Plan Since 2014, the Colorado Department of Public Health and the Environment has been publishing annual statewide youth development plans to support healthy youth development and ensure consistency of youth policy and practices across the state of Colorado. To create these plans, the state formed Colorado 9to25, a broad-based coalition of various organizations touching youth development, to help share the initial and subsequent youth development plans. These plans are based on a positive youth development (PYD) approach to improve programs, policies and practices. The PYD approach is based on research of positive youth development programs,

19 spearheaded by the US Department of Health and Human Services, published in 2004. Colorado 9to25 also employs a gap analysis of services and programs, and stakeholder engagement, in order to shape its annual recommendations. A key product of this work is the Colorado Statewide Youth Development Plan Dashboard, which tracks youth development across several health and social indicators. More information is available at: https://www.colorado.gov/pacific/cdhs/colorado-statewide-youth-development-plan.

Crisis Text Line Crisis Text Line offers a free, anonymous texting hotline for individuals in crisis. Crisis Text Line responders are trained to navigate those seeking help to 9-1-1, or to other resources listed on the Crisis Text Line website. The organizations partners with governments and non-profits to create special keywords for communities in order to track non-identifiable data on texters. More information is available at: https://www.crisistextline.org/.

Kognito Kognito is a health simulation company. For school purposes, Kognito uses real-life simulations to train educators and staff on mental health, suicide prevention and other topics using evidence-based practices. More information is available at: https://kognito.com/products/at- risk-for-high-school-educators.

Youth Mental Health First Aid Youth Mental Health First Aid teaches adults how to help an adolescent experiencing mental health or substance use challenges, or who is otherwise in crisis. The training covers common signs of mental distress and substance use, how to interact with an adolescent in crisis, and how to connect with an adolescent in help. More information is available at: https://www.mentalhealthfirstaid.org/population-focused-modules/youth/.

Ohio: Governor’s Action Team To Address Opioid Abuse In response to community needs, the state launched new drug prevention programs, invested in best practices such as medication-assisted treatment, added capacity for recovery housing and put in place innovative models of interdiction that emphasize connecting people to addiction treatment. As a result, the state created a framework for other jurisdictions to use as a model for opioid abuse response. The model describes and outlines how to achieve seven distinct goals including: (1) Build your team to take action (2) Adopt prevention practices (3) Monitor prescribing, manage medications and halt diversion (4) Prevent overdose (5) Link people to treatment (6) Help sustain recovery (7) Support law enforcement interdiction

20 More information is available at https://mha.ohio.gov/Portals/0/assets/ResearchersAndMedia/Combating%20Opiate%20Abuse/ Ohio-2018-Action-Guide-to-Address-Opioid-Abuse.pdf?ver=2018-11-29-112926-250

Red Folder Initiative The University of California Office of the President launched the Red Folder Initiative in 2012, which requires each campus to publish a Red Folder that acts as a reference guide to mental health resources on campus for students. Staff receive a training from counselors prior to using the Red Folder. The program has been replicated at other universities and at high schools, including the high schools within the Sequoia Unified High School District. More information is available at: https://www.ucop.edu/student-mental-health-resources/training-and- programs/faculty-and-staff-outreach/red-folder-initiative.html.

Talk Vaping With Your Teen Created by HopeLab, the American Heart Association and All Mental Health, Talk Vaping provides a series of four educational emails to parents on vaping. Educational modules include an overview of what vaping is, how vaping affects mental health, how parents can talk to and support teens using vaping products, and how parents can relieve their own stress around these conversations. More information is available at https://www.allmentalhealth.org/vaping.

Vermont: Over the Dose Developed by the Vermont Department of Health and the Rescue Agency, Over the Dose is a campaign targeting young adults with social and digital media advertisements and educational content on a website to reduce the use and misuse of prescription pain medications. The educational messages focus on promoting behavioral changes and incorporates insights about opioid users’ knowledge about drug usage for its implementation strategy for social and digital media campaigns. More information is available at https://overthedosevt.com/opioids-side- effects.

West Virginia Board of Education Opioid Toolkit A toolkit outlining the principles of a program called, “Reclaim West Virginia”, that provides facts about the crisis nationally and in WV. They also provide resources for educators, students, and parents, to use in the state. An inventory of high school resources includes

• My Generation Rx: Teen Education (Educate Teens About Using Medications Safely) • Everfi: Prescription Drug Abuse and Alcohol Prevention Lessons • Operation Prevention: High School Digital Lesson Guide • Youth Mental Health First Aid More information is available at https://wvde.us/wp- content/uploads/2019/07/ReClaimWV_Toolkit.pdf

Kentucky KORE Toolkit

21 Guided by the Recovery-Oriented Systems of Care Framework, the purpose of KORE is to implement a comprehensive targeted response to Kentucky’s opioid crisis by expanding access to a full continuum of high quality, evidence-based opioid prevention, treatment, recovery support services. Informed by data on populations most in need, KORE initiatives focus on four primary populations: 1) persons who have experienced an opioid-related overdose; 2) pregnant and parenting women with opioid use disorder (OUD); 3) justice-involved individuals with OUD; and 4) children, transition-age youth, and families impacted by OUD. More information is available at https://apps.legislature.ky.gov/CommitteeDocuments/12/12041/Jul%209%202019%20Marks%2 0KORE%20information.pdf

Path to Impact: A Framework for Charting a Path Forward

To capture needs and chart a path forward for adolescent behavioral health in Marin County, the YOR Marin project partners developed a framework, the Path to Impact.

Capturing the Current State

22 Illustrating the Ideal State

Action Plan

Over the course of two community meetings to gather input, YOR project partners solicited input from community members to develop an action plan for Marin County’s response to adolescent behavioral health needs going forward. (Meeting summaries included in appendix.) As a result, Marin YOR drafted a vision statement and action plans, categorized by needs for (1) enhancing high school wellness infrastructure and sustainability and (2) improving the identification, navigation and data collection related to adolescent behavioral health.

Vision Statement

Marin County adolescents and their families have access through their high schools to a continuum of opioid use disorder (OUD) prevention, intervention, and other treatment and recovery services.

Actions for 2020 and Beyond

At community meetings, community stakeholders brainstormed and discussed the actions that need to be completed to achieve YOR Marin’s vision statement.

23 Actions to enhance high school wellness infrastructure and sustainability Action Potential county lead Anticipated completion House YOR project within RxSafe Marin RxSafe Marin YOR Q2/2020 as an ongoing RxSafe Marin action team Assess wellness capabilities across high Wellness Collaborative Q4/2020 schools and identify where gaps exist Explore public-private partnership to Wellness Collaborative Q1/2021 sustain public high school wellness in Marin County Analyze what policies need to be RxSafe Marin YOR Q2/2021 changed at the state and/or local level for high school wellness to succeed

Actions to improve identification, navigation and data collection Action Potential county lead Anticipated completion Develop and adapt existing trainings for RxSafe Marin YOR/ Q4/2020 teachers, families and adolescents to Wellness Collaborative better prevent and identify opioid use disorder (OUD) Create a partnership with Crisis Text Line RxSafe Marin YOR/ Q4/2020 Marin Prevention Network Develop navigation for case management RxSafe Marin YOR Q1/2021 services to track access to treatment and address follow up needs Create a data dashboard to track key RxSafe Marin YOR Q1/2021 youth behavioral health indicators in Marin County Consider a pilot study of universal RxSafe Marin YOR Q2/2021 screenings

Conclusion

In light of the COVID-19 pandemic and shelter-in-place orders, adolescent behavioral health needs should be a key priority for policymakers and service providers serving youth, and planning projects such as YOR Marin are more important than ever to ensuring that adolescents are able to receive the screenings, navigation, services and supports they need, even when they are not able to receive them in-person. The YOR Marin project team looks forward to continuing this work under the direction of RxSafe Marin and to completing the activities listed in the action plan.

24 Appendix I.

I. List of types/numbers of organizations/stakeholders interviewed

II. Inventory of resources in Marin County that we gathered

• MAT Providers in Marin County o Marin Treatment Center* o Marin City Health and Wellness Center* o Bright Heart Health • Non-MAT Substance use providers o Coastal Health Alliance o Marin City Health & Wellness Center* o Marin Community Clinics* o Ritter Center* o Kaiser Permanente* o Buckelew Programs Helen Vine Recovery Center o Center Point o Bay Area Community Resources Positive Changes o Marin County Behavioral Health and Recovery Services–Road to Recovery o Marin Outpatient & Recovery Services o Marin Treatment Center o Alta Mira Recovery Programs o Avery Lane, LLC o Reflections o Serenity Knolls o Bayside Marin Outpatient Program o Bay Area Community Resources* o Center for Families – Marin * o Huckleberry Youth Programs* o Muir Wood Adolescent & Family Services * *denotes serves adolescents

Community Groups Supporting Adolescent Behavioral Health • Alcohol Justice • Be The Influence • Marin Healthy Youth Partnerships • Mill Valley AWARE • Youth Court

Education and Assessment Resources

25 • A Parent’s Guide For the Prevention of Alcohol, Tobacco, and Other Drug Use • Marin County Community Resource Guide • Wellify Teen

Appendix II.: Community Meeting 1 Summary

Date: December 19, 2019 Time: 3:30-5:30 pm Location: Marin County Office of Education Campus, San Rafael, CA

Brief Summary Meeting partners held a successful first community planning meeting, with 27 attendees at the Marin County Office of Education Campus. (See below for attendee list.) The majority of attendees participated in prior stakeholder interviews, with several other community members in attendance. At the meeting, attendees: o Introduced themselves and what they hoped to get out of the meeting o Discussed our understanding of the current state of Marin county adolescents, in terms of demographics, health indicators related to OUD, SUD and mental health o Learned more about the current health and wellness offerings provided at several Marin County public high schools (Tomales High School, Novato High School, Redwood High School, Drake High School, and ) and about initiatives taking place in the Palo Alto Unified School District and Sequoia Unified High School District o Shared feedback on draft findings for the project

Project partners and meeting attendees decided to host a second community planning meeting in January 2020 to work with stakeholders on producing a vision statement and objectives for our action plan.

Takeaways • Attendees validated draft findings presented during the meeting. • Discussion was focused on understanding both the current scope of what’s offered at Marin high schools (Tomales, TUHSD, NUSD), other high schools (Sequoia Unified and Palo Alto Unified) and what the needs are. o Reaching adolescents when they want help is key. Wellness center hours and school breaks may be a barrier. o Formal training and outreach are key to screenings and interventions. Peer mentorship opportunities could be expanded. Peer to peer trainings with solutions like Kognito may be helpful. Red folder and green folder initiatives for teachers and staff may be useful at all schools.

26 o Stories and quantitative data are key to describing adolescent issues and designing solutions. Students should get their data back, have a say in programs. Outreach to students should be normalized and student-led. o Navigation for parents and students is a major issue, at many touchpoints (finding a therapist, finding a provider after the ED, getting child a diagnosis). The care and referral pathways for adolescents are not clearly identified.

Appendix III. Community Meeting 2 Summary

Date: January 23, 2020 Time: 3:30-5:30 pm Location: Marin County Office of Education Campus, San Rafael, CA

Brief Summary Twenty-two community members participated the second community meeting for the YOR Marin Project. At our meeting, we discussed an emerging model for the needs identified, and zeroed in on screening and navigation as key areas for intervention to help connect adolescents to care. We also discussed the role of high schools in this work, which highlighted considerations such as staffing and the availability of physical space for health and wellness offerings. The latter half of our meeting was used to facilitate break out groups, outlined below.

Framing the Meeting Our break groups asked participants to react to a proposed vision statement and proposed end goals, and to generate action items for stakeholders to pursue over the next three years.

The proposed vision statement read: “Through a public-private partnership financing county- based wellness centers, Marin County leaders will create policies to support the universal identification of individual student behavioral health needs and provide appropriate navigation to services and referrals to care.” Key Takeaways from the Meeting

Participants generated the following ideas from mapping action plans for (1) wellness center funding and infrastructure, and (2) screening, navigation and evaluation.

• Our project should revise its vision statement. Participants provided helpful feedback on a vision statement for the project. A new proposed vision statement to be vetted with partners should focus more on routing screening and immediate access to help when adolescents seek it. Additionally, while it should also call out support for wellness in high schools, less emphasis should be placed on developing physical wellness centers and more emphasis placed on enhancing school’s human and financial resources for health and wellness offerings.

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Wellness Center Sustainability and Infrastructure

• Assess wellness center capabilities across high schools and identify where gaps exist. The county should work with stakeholders to define and assess the “gold standard” for high school wellness. This should include an understanding of the key functions of “wellness” and an in-depth gap analysis at each school, building off this assessment and BHRS’ MHSA assessment. Findings may include variations in school needs, i.e., that SRCS may need a case manager instead of an actual physical wellness center.

• Create sustainable funding model and model for a public-private partnership for high school wellness in Marin County. As a result of the gap analysis, partners should create a business model for wellness centers by leveraging some type of public-private partnership for funding. Additionally, this funding model should work to develop county oversight for wellness work, and build a coalition for community support. This coalition could help to determine what policy levers might be leveraged or changed to better support the high school wellness initiative.

• House YOR project advisory group as an RxSafe committee to continue its work. The YOR Marin Project should live on as a steering team under RxSafe Marin and can be its youth arm. Other county agencies such as MCOE and Public Health should be involved in this steering team going forward, and their leadership should work to be better aligned on youth needs for health and wellness. Key service providers like Kaiser Permanente should be involved, and teens themselves should also be represented.

• Identify and apply for grant opportunities to implement these proposed actions. Grant opportunities can be leverage over the next few years for several purposes. These include funding for the coalition idea; a more in-depth needs assessment at each high school; implementation funding for a screening pilot or navigation tool development; and ongoing evaluation.

Identification, Navigation and Evaluation

• Develop navigation tools and case management to track access to treatment and address follow up needs. A key discussion centered around creating case management and triage teams to help adolescents when they seek help. Additionally, our project participants should work with current county efforts to fully inventory available services and supports for adolescent mental health and substance use and develop navigation tools. Ideas included using a digital app that Marin County residents can use to find resources, and more mobile in-person touchpoints using mobile clinics or by training trusted individuals in different locations as navigators, i.e., teachers, librarians, mentors.

28 • Develop trainings for teachers, families and adolescents to better identify and help those in need. As a part of screening and identification actions, participants voiced the need for trainings to equip individuals to identify teens in needs and steer them to appropriate resources. Teen training can include expansion of the peer mentor resource model across all campuses, with more touchpoints with students across all four years of high school. Teachers can also be equipped to better understand their students and identify those at risk, and the example of using the Green Folder approach was mentioned. Additionally, participants identified parents as a key stakeholder group requiring training, not just on how to identify needs but also regarding issues of stigmatization of their child’s potential behavioral health issues and unique cultural competency considerations for specific parent populations.

• Conduct a pilot study of universal screenings. Participants discussed several considerations for testing a universal screening tool in Marin County high schools. Next steps could include selection of schools and tools, education materials for parents and students on what these screening tools are and their promise, and evaluation over a time period to be specified. Another idea was to begin screenings in middle schools to catch adolescents’ behavioral health needs even earlier than high school.

• Consider creating or changing policy levers to expand and promote high school wellness. Both groups discussed meaningful actions that could involve using policy levers to promote school wellness. One group discussed the need for a singular, county-wide education policy supporting high school wellness. Another idea was to eventually use the coalition to support a ballot proposition and campaign to raise local taxes for high school wellness. Another idea was to assess the state Education Codie to determine what changes could or should be made to facilitate the expansion of wellness.

• Create an evaluation framework to ensure we set realistic expectations and can measure success. Both groups identified the need for better evaluation. Data needs include evaluation of any deployment of screening tools, utilization data on navigation tools and on any behavioral health services to be provided. Annual student satisfaction data on wellness offerings in schools and the collection of student stories would also be helpful to describe wellness’ impact and highlight needs as they emerge.

Key considerations: o Youth input is key to success o School staffing considerations, i.e. union buy-in and staffing o Physical space for a wellness center may not be necessary at every high school o Work to get teens the help they need at the moment they start looking for help, i.e., look to the States of Change model for harm reduction o Stigmatization of drugs use and mental health, especially among adults o Medi-Cal Minor Consent could be better leveraged to provide immediate behavioral health services to adolescents in need

29 i Kaiser Family Foundation. [Accessed May 30, 2019];State Health Facts: opioid overdose deaths by age group. 2016, retrieved from http://kff.org/other/state-indicator/opioid-overdose-deaths-by-age- group/?dataView=1&activeTab=graph¤tTimeframe=0&startTimeframe=15&selectedDistributions=15- 24&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. ii SAMHSA, Key Substance Use and Mental Health Indicators in the : Results from the 2016 National Survey on Drug Use and Health, retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1- 2016/NSDUH-FFR1-2016.htm#opioid. iii National Survey on Drug Use and Health, SAMHSA, 2017. iv Gregory Austin et al., School Climate, Substance Use, and Well-Being Among California Students, 2013–2015: Results of the Fifteenth Biennial Statewide Student Survey, Grades 7, 9, and 11, WestEd Health & Human Development Program, 2016, surveydata.wested.org (PDF). v CHKS data, 2009-11, 2015-16, 2017-18. vi U.S. Census Bureau, 2020. vii California Department of Public Health, Marin Opioid Overdose Snapshot: 2016-Q3 to 2019-Q2. Report downloaded January 16, 2020. It should be noted that county community groups have been independently tracking substance use-related mortalities for young adults raised in Marin County but whose deaths occurred in other counties. viii Ibid. ix Ibid. at vii. x KidsData.org, 2020. xi Partnership HealthPlan, 2020. xii Parent Norms Survey, 2017. xiii American Academy of Child & Adolescent Psychiatry, 2020. xiv California Health Care Foundation, Health Care Almanac, 2018. xv California Hospital Association, 2016. xvi Weitzman C, Wegner L. American Academy of Pediatrics, Section on Developmental and Behavioral Pediatrics, Committee on Psychosocial Aspects of Child and Family Health, Council on Early Childhood; Society for Developmental and Behavioral Pediatrics. Promoting optimal developments: screening for behavioral and emotional problems. Pediatrics. 2015;135(2):384-395. xvii American Academy of Pediatrics Council on Early Childhood, Committee on Psychological Aspects of Child and Family Health and Section on Developmental and Behavioral Pediatrics. Addressing Early Childhood Emotional and Behavioral Problems. Pediatrics. 2016;138(6):e20163023. xviii O’Connell, M.E., Boat, T., & Warner, K.E. (Eds.). (2009). Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Committee on the Prevention of Mental Disorders and Substance Abuse Among Children, Youth, and Young Adults: Research Advances and Promising Interventions. Washington, DC: The National Academies Press. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK32784/. xix Health Resources and Services Administration, Early Periodic Screening, Diagnosis, and Treatment, December 2018, available at https://mchb.hrsa.gov/maternal-child-health-initiatives/mchb-programs/early-periodic-screening- diagnosis-and-treatment. xx American Academy of Pediatrics, Bright Futures. Recommendations for Preventive Pediatric Health Care. Updated March 2020. xxi Partnership Health Plan 2018 claims data, 2020.

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