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Landscape Assessment and Gap Analysis of School-Based Primary Care and Behavioral Health for Medicaid-Eligible Youth Pediatric Healthcare Landscape Analysis and Blueprint
THE CLIENT
The client team is a coalition including a group of local and national funders seeking city-level solutions to address gaps in youth behavioral health services, a non-profit educational 鈥渜uarterback鈥� organization supporting New Orleans schools as they respond to students鈥� primary and behavioral health needs, and a children鈥檚 hospital with a robust, grant-funded school-based primary and behavioral health program exploring where it could uniquely expand impact.
Together, the partners set out to identify system-level opportunities for aligned funding, reduce the extent to which school-based staff are asked to take on additional care coordination work, and expand access for children and families to school-based primary and behavioral health services as well as community- and facility-based behavioral health services. The work focused on strengthening school-based mental health and integrated care pathways for Medicaid-eligible children and adolescents across the full pediatric behavioral health continuum.
BACKGROUND
In New Orleans, youth behavioral health and pediatric mental health needs were becoming more urgent, but the system designed to respond remained fragmented across schools, community providers, hospitals, and public agencies. School leaders and clinicians described referral pathways that were inconsistent and difficult to navigate, limited visibility into where services existed, and few shared accountability mechanisms across sectors鈥攃reating gaps in care coordination, crisis response, and follow-up. This made it difficult for stakeholders to coordinate strategy, align resources, or plan for scale.
In parallel, Manning Family Children鈥檚 Hospital and its ThriveKids student wellness initiative saw a significant opportunity to expand school based physical and behavioral health services across New Orleans Public Schools.
School teams were increasingly operating as de facto care coordinators, triaging crises, managing referrals, and filling behavioral health gaps they were not equipped or designed to address. Stakeholders saw school-based health clinics and school-based health centers as a meaningful opportunity to close gaps in behavioral health screening and response, strengthen connections to primary and behavioral health care, and provide care navigation for students and families鈥攊ncluding trauma-informed supports, universal screening, warm handoffs, and alignment with multi-tiered systems of support (MTSS).
This project brought together multiple stakeholders鈥攊ncluding philanthropy, education, hospitals, and non-profits鈥攖o fund and lay the foundation for a shared view of need and opportunity. Because 红领巾瓜报 has credibility across these sectors, we were able to support cross-sector collaboration and create a common fact base to guide investment decisions. Partners also recognized a specific local imperative: Medicaid-eligible youth and public school students needed better access to coordinated primary and behavioral health care, and the community needed a neutral, trusted convening entity to provide backbone coordination and accountability mechanisms.
APPROACH
红领巾瓜报 applied a mixed-methods, system-level approach to understand both the supply of services and the lived experience of accessing care. This behavioral health needs assessment combined service mapping, Medicaid data analytics, and stakeholder input to evaluate the continuum of care鈥攆rom prevention and early intervention to crisis stabilization, day treatment, and residential treatment. This included:
Quantitative analysis of Medicaid utilization data to assess service reach, gaps, and demand across the pediatric behavioral health continuum
Survey of school-based and community-based services, including primary care, behavioral health, and higher-acuity treatment options
Stakeholder engagement through 20+ interviews, focus groups, and surveys of school staff and providers to capture real-world barriers and system dynamics
Gap analysis using national benchmarks to estimate unmet need and quantify where the system falls short
Feasibility and opportunity assessment, evaluating not just need, but financial viability, workforce constraints, and implementation pathways
红领巾瓜报 used a unique approach for this analysis. in the absence of extensive utilization data and services, 红领巾瓜报 used the Academy of Child and Adolescent Psychiatry鈥檚 framework for the continuum of pediatric behavioral health services as a standard. We cross-referenced this with New Orleans population and Medicaid enrollment data and national utilization data to estimate how many children in New Orleans would be expected to participate in each service on the continuum and assessed the feasibility of launching or expanding each service based on an assessment of the regulatory landscape, viable revenue sources, and projected demand for each service.
We then translated these findings into a practical, phased roadmap, grounded in local context and designed to align funders, providers, and schools around a shared strategy.
RESULTS
This effort provided the first-ever integrated view of the pediatric behavioral health system in New Orleans, spanning school-based health centers/clinics, community providers, and facility-based care鈥攁nd translating findings into practical options to improve access, care navigation, and crisis stabilization for Medicaid-eligible youth.
For behavioral health professionals working in schools, state agencies, and clinical settings, the assessment produced an actionable picture of where the system breaks down鈥攁nd where investments and operational changes can measurably improve access and outcomes for Medicaid-eligible youth and public school students. Only ~2% of Medicaid-eligible youth are currently receiving school-based behavioral health services.
Clarified the role schools are being asked to play in a fragmented system鈥攐ften functioning as care coordinators and first responders to behavioral health need鈥攕trengthening the case for school-based health clinics/centers with standardized screening, warm handoffs, and care navigation supports.
Documented drivers of avoidable acute-care utilization, including gaps in community-based care: an insufficient number of providers willing to accept Medicaid, limited availability of evidence-based treatment, and the absence of respite and crisis residences鈥攆actors that can push families toward emergency departments and inpatient settings.
Balanced a community-first strategy with realistic capacity planning鈥攊dentifying opportunities to mitigate the need for some facility-based services by strengthening community-based behavioral health, while also underscoring the continued need for day and residential treatment facilities to address behavioral health and substance use needs when higher levels of care are clinically indicated.
Elevated the need for intermediary coordination to reduce silos and improve accountability across healthcare and education. The work provided a concrete rationale and initial design considerations for a neutral, trusted convening entity to coordinate primary and behavioral healthcare for Medicaid-eligible youth and public school students in New Orleans鈥攁n increasingly important model for cross-sector collaboration that has been difficult to implement effectively in practice.
Overall, the work supports a scalable model for integrated school-based behavioral health, Medicaid-aligned financing, and cross-sector care coordination鈥攈elping communities strengthen prevention, early intervention, and access to the right level of treatment.
Importantly, 红领巾瓜报鈥檚 work does not stop at identifying gaps鈥攚e help clients prioritize investments, structure partnerships, and build the infrastructure needed for long-term system transformation. 红领巾瓜报 can help organizations implement this kind of organizational change, by bringings a unique combination of:
Deep expertise in Medicaid, behavioral health systems, and school-based care, enabling rigorous analysis of both financing and service delivery
Proven ability to integrate quantitative data with stakeholder insight, ensuring recommendations reflect both system realities and lived experience
Experience designing and implementing system-level solutions, not just conducting assessments
Cross-sector credibility, allowing 红领巾瓜报 to convene and align funders, healthcare providers, educators, and public agencies
Practical, implementation-focused approach, translating complex findings into actionable strategies that are financially and operationally viable
Contact us to learn more.
Landscape Assessment and Gap Analysis of School-Based Primary Care and Behavioral Health for Medicaid-Eligible Youth Pediatric Healthcare Landscape Analysis and Blueprint
THE CLIENT
The client team is a coalition including a group of local and national funders seeking city-level solutions to address gaps in youth behavioral health services, a non-profit educational 鈥渜uarterback鈥� organization supporting New Orleans schools as they respond to students鈥� primary and behavioral health needs, and a children鈥檚 hospital with a robust, grant-funded school-based primary and behavioral health program exploring where it could uniquely expand impact.
Together, the partners set out to identify system-level opportunities for aligned funding, reduce the extent to which school-based staff are asked to take on additional care coordination work, and expand access for children and families to school-based primary and behavioral health services as well as community- and facility-based behavioral health services. The work focused on strengthening school-based mental health and integrated care pathways for Medicaid-eligible children and adolescents across the full pediatric behavioral health continuum.
BACKGROUND
In New Orleans, youth behavioral health and pediatric mental health needs were becoming more urgent, but the system designed to respond remained fragmented across schools, community providers, hospitals, and public agencies. School leaders and clinicians described referral pathways that were inconsistent and difficult to navigate, limited visibility into where services existed, and few shared accountability mechanisms across sectors鈥攃reating gaps in care coordination, crisis response, and follow-up. This made it difficult for stakeholders to coordinate strategy, align resources, or plan for scale.
In parallel, Manning Family Children鈥檚 Hospital and its ThriveKids student wellness initiative saw a significant opportunity to expand school based physical and behavioral health services across New Orleans Public Schools.
School teams were increasingly operating as de facto care coordinators, triaging crises, managing referrals, and filling behavioral health gaps they were not equipped or designed to address. Stakeholders saw school-based health clinics and school-based health centers as a meaningful opportunity to close gaps in behavioral health screening and response, strengthen connections to primary and behavioral health care, and provide care navigation for students and families鈥攊ncluding trauma-informed supports, universal screening, warm handoffs, and alignment with multi-tiered systems of support (MTSS).
This project brought together multiple stakeholders鈥攊ncluding philanthropy, education, hospitals, and non-profits鈥攖o fund and lay the foundation for a shared view of need and opportunity. Because 红领巾瓜报 has credibility across these sectors, we were able to support cross-sector collaboration and create a common fact base to guide investment decisions. Partners also recognized a specific local imperative: Medicaid-eligible youth and public school students needed better access to coordinated primary and behavioral health care, and the community needed a neutral, trusted convening entity to provide backbone coordination and accountability mechanisms.
APPROACH
红领巾瓜报 applied a mixed-methods, system-level approach to understand both the supply of services and the lived experience of accessing care. This behavioral health needs assessment combined service mapping, Medicaid data analytics, and stakeholder input to evaluate the continuum of care鈥攆rom prevention and early intervention to crisis stabilization, day treatment, and residential treatment. This included:
Quantitative analysis of Medicaid utilization data to assess service reach, gaps, and demand across the pediatric behavioral health continuum
Survey of school-based and community-based services, including primary care, behavioral health, and higher-acuity treatment options
Stakeholder engagement through 20+ interviews, focus groups, and surveys of school staff and providers to capture real-world barriers and system dynamics
Gap analysis using national benchmarks to estimate unmet need and quantify where the system falls short
Feasibility and opportunity assessment, evaluating not just need, but financial viability, workforce constraints, and implementation pathways
红领巾瓜报 used a unique approach for this analysis. in the absence of extensive utilization data and services, 红领巾瓜报 used the Academy of Child and Adolescent Psychiatry鈥檚 framework for the continuum of pediatric behavioral health services as a standard. We cross-referenced this with New Orleans population and Medicaid enrollment data and national utilization data to estimate how many children in New Orleans would be expected to participate in each service on the continuum and assessed the feasibility of launching or expanding each service based on an assessment of the regulatory landscape, viable revenue sources, and projected demand for each service.
We then translated these findings into a practical, phased roadmap, grounded in local context and designed to align funders, providers, and schools around a shared strategy.
RESULTS
This effort provided the first-ever integrated view of the pediatric behavioral health system in New Orleans, spanning school-based health centers/clinics, community providers, and facility-based care鈥攁nd translating findings into practical options to improve access, care navigation, and crisis stabilization for Medicaid-eligible youth.
For behavioral health professionals working in schools, state agencies, and clinical settings, the assessment produced an actionable picture of where the system breaks down鈥攁nd where investments and operational changes can measurably improve access and outcomes for Medicaid-eligible youth and public school students. Only ~2% of Medicaid-eligible youth are currently receiving school-based behavioral health services.
Clarified the role schools are being asked to play in a fragmented system鈥攐ften functioning as care coordinators and first responders to behavioral health need鈥攕trengthening the case for school-based health clinics/centers with standardized screening, warm handoffs, and care navigation supports.
Documented drivers of avoidable acute-care utilization, including gaps in community-based care: an insufficient number of providers willing to accept Medicaid, limited availability of evidence-based treatment, and the absence of respite and crisis residences鈥攆actors that can push families toward emergency departments and inpatient settings.
Balanced a community-first strategy with realistic capacity planning鈥攊dentifying opportunities to mitigate the need for some facility-based services by strengthening community-based behavioral health, while also underscoring the continued need for day and residential treatment facilities to address behavioral health and substance use needs when higher levels of care are clinically indicated.
Elevated the need for intermediary coordination to reduce silos and improve accountability across healthcare and education. The work provided a concrete rationale and initial design considerations for a neutral, trusted convening entity to coordinate primary and behavioral healthcare for Medicaid-eligible youth and public school students in New Orleans鈥攁n increasingly important model for cross-sector collaboration that has been difficult to implement effectively in practice.
Overall, the work supports a scalable model for integrated school-based behavioral health, Medicaid-aligned financing, and cross-sector care coordination鈥攈elping communities strengthen prevention, early intervention, and access to the right level of treatment.
Importantly, 红领巾瓜报鈥檚 work does not stop at identifying gaps鈥攚e help clients prioritize investments, structure partnerships, and build the infrastructure needed for long-term system transformation. 红领巾瓜报 can help organizations implement this kind of organizational change, by bringings a unique combination of:
Deep expertise in Medicaid, behavioral health systems, and school-based care, enabling rigorous analysis of both financing and service delivery
Proven ability to integrate quantitative data with stakeholder insight, ensuring recommendations reflect both system realities and lived experience
Experience designing and implementing system-level solutions, not just conducting assessments
Cross-sector credibility, allowing 红领巾瓜报 to convene and align funders, healthcare providers, educators, and public agencies
Practical, implementation-focused approach, translating complex findings into actionable strategies that are financially and operationally viable
Contact us to learn more.
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