Interagency Collaboration, Care Coordination, and Rural Implementation: Pediatric Healthcare Landscape Analysis and Blueprint

THE CLIENT

Glenn County Office of Education (GCOE) is a recipient of a Providing Access and Transforming Health (PATH) grant from California’s Department of Health Care Services to implement a Capacity and Infrastructure Transition, Expansion, and Development (CITED) initiative. As part of implementation, GCOE applied for technical assistance through the CalAIM TA Marketplace to strengthen Enhanced Care Management (ECM) partnerships that connect school-based and school-linked behavioral health (BH) supports with Medi-Cal and community services. The goal was to improve pediatric behavioral health access, care coordination, and closed-loop referral pathways across school districts, county agencies, and local clinical providers.

As schools increasingly serve as the venue where many children and families first access BH supports, this case study highlights how cross-sector partners can align roles and coordination practices so students experience timely referral and smooth handoffs to community-based and clinical services—especially in rural and smaller counties. This work is relevant to behavioral health professionals working in schools (school counselors, school psychologists, educational social workers, wellness staff), county and state agencies (behavioral health, public health, child welfare, probation, social services), and clinical settings (licensed providers, FQHCs, managed care) who are strengthening prevention, early intervention, and referral pathways for children, youth, and families ages 0–25.

BACKGROUND

Like many counties, Glenn needed to align multiple agencies and initiatives happening simultaneously. As schools increasingly serve as the primary access point for student mental health, BH prevention, and early intervention, improvement depended on stronger, more reliable connections between education and healthcare—including clear referral pathways within a multi-tiered system of supports (MTSS) and timely linkage to community-based treatment.

“Health Management Associates has been an exceptional technical assistance partner throughout this project. Their team consistently exceeded expectations by accurately assessing our agency’s baseline needs alongside those of key community partners, facilitating meetings ahead of schedule to maintain momentum, and developing targeted prompts that strengthened both macro- and microsystem design efforts. 

What has stood out most is HMA’s ability to create structured, collaborative planning processes that increase engagement and accountability across stakeholders. Their facilitation style helped move our organization from early exploration into actionable system design while ensuring partners had the time and support needed to provide meaningful input. We highly recommend Health Management Associates as a trusted and highly effective TA Marketplace vendor.”

Christine Taylor
Educational Administrator
Glenn County, CA

County offices of education can play an important and catalytic role in linking education and healthcare because they are well positioned to convene cross-sector partners serving children, youth, and families. In Glenn County, multiple state-driven changes affecting child and youth BH increased the need for tight interagency collaboration and seamless transitions—so each partner could act clearly within its lane or locus of control. Improving BH access also required ecosystem-level change management. Partners needed shared governance and practical coordination infrastructure (e.g., decision forums, common workflows, and information-sharing practices) to support closed-loop referrals and smoother movement between school-based supports, clinical care, and community resources. Glenn’s rural context brought both constraints and advantages: workforce capacity was limited, but long-standing relationships meant partners often knew one another and could be motivated to coordinate.

APPROACH

HMA’s technical assistance focused on building countywide infrastructure for collaboration and care coordination across schools, agencies, and clinical providers. The work centered on three components:

1. An assessment of ECM readiness to identify the key factors and challenges tied to improving BH access and care coordination across multiple public agencies, schools, and community-based organizations serving county children, youth, and families. 
2. Provision of targeted training of direct service providers of ECM such as licensed clinicians, school counselors, educational social workers, Community Health Workers, and Certified Wellness Coaches.
3. Facilitation of two in-person countywide convenings to advance interagency collaboration across ECM, Community Schools, and the Children and Youth Behavioral Health Initiative (CYBHI), with dedicated work time on referral systems and data sharing for care coordination and transitions.

Partners included county agencies (Education, Behavioral Health, Public Health, Probation, Child Welfare, and Social Services), health care organizations (managed care plans, FQHCs), and community-based organizations supporting children, youth, and families. This cross-sector collaboration supported a whole-child approach by aligning school-based services, youth mental health resources, and referral pathways across education, public systems, and clinical care.

RESULTS 

Convened a countywide ecosystem of agencies and organizations to align around shared goals for children, youth, and family well-being—creating a common operating picture across school, agency, and clinical settings. 

Established a collective impact model with the County Office of Education serving as backbone, leveraging its convening role to link education and healthcare partners across the county. 

Translated and aligned education and health care initiatives (CYBHI, Community Schools, ECM, and the Behavioral Health Services Act/BHSA) into clear roles, workflows, and decision points—supporting lane clarity and smoother transitions across agencies and sectors. 

Accelerated design of standardized referral forms, closed-loop protocols, and data/information-sharing agreements—foundational infrastructure to simplify care coordination and reduce handoff failures for children and youth moving between school, clinic, and community supports. 

Strengthened ecosystem-level change management by identifying governance touchpoints and coordination infrastructure that can be maintained in rural contexts—supporting ongoing role clarity, continuous improvement, and consistent transitions for children, youth, and families. 

Identified 2–3 near-term projects to “practice” new interagency coordination behaviors, paired with governance forums to sustain collaboration and continuous improvement.

Takeaway for practitioners: When schools are a primary access point for prevention and early intervention, sustainable improvement depends on ecosystem-level change management—shared governance, clarified roles, integrated behavioral health workflows, and coordination infrastructure (including closed-loop referral and interoperable data/information-sharing practices) that helps students and families move seamlessly between school-based supports, specialty BH care, and community youth mental health services.

HMA brings together nationally recognized expertise in pediatric behavioral health, hospital-based mental health integration, and public-sector policy and operations. Our clients serve rural and frontier communities, including state and local governments, health systems, federally qualified health centers, tribal organizations, providers of every specialty, and community-based groups

Contact our experts to learn more about how HMA can help your organization.

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 “quarterback” organization supporting New Orleans schools as they respond to students’ primary and behavioral health needs, and a children’s 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—creating 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’s 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—including trauma-informed supports, universal screening, warm handoffs, and alignment with multi-tiered systems of support (MTSS).

This project brought together multiple stakeholders—including philanthropy, education, hospitals, and non-profits—to fund and lay the foundation for a shared view of need and opportunity. Because HMA 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

HMA 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—from 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

HMA used a unique approach for this analysis. in the absence of extensive utilization data and services, HMA used the Academy of Child and Adolescent Psychiatry’s 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—and 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—and 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—often functioning as care coordinators and first responders to behavioral health need—strengthening 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—factors that can push families toward emergency departments and inpatient settings. 

Balanced a community-first strategy with realistic capacity planning—identifying 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—an 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—helping communities strengthen prevention, early intervention, and access to the right level of treatment.

Importantly, HMA’s work does not stop at identifying gaps—we help clients prioritize investments, structure partnerships, and build the infrastructure needed for long-term system transformation. HMA 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 HMA 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.