Hurricane Katrina: Barriers to Mental Health Services for Children Persist in Greater New Orleans, Although Federal Grants Are Helping to Address Them
Published: 2009-07-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--has yet to fully recover from the effects of Hurricane Katrina. As a result of the hurricane and its aftermath, many children experienced psychological trauma, which can have long-lasting effects. Experts have previously identified barriers to providing and obtaining mental health services for children. The Department of Health and Human Services (HHS) and other federal agencies have supported mental health services for children in greater New Orleans through various programs, including grant programs initiated in response to Hurricane Katrina. GAO was asked to study the federal role in addressing barriers to these services in greater New Orleans. In this report, GAO (1) identifies barriers to providing and to obtaining mental health services for children in greater New Orleans, and (2) describes how federal programs, including grant programs, address such barriers. To do this work, GAO used a structured interview and a written data collection instrument to gather views on barriers from 18 state and local stakeholder organizations selected on the basis of experts' referrals and the organizations' roles in children's mental health. To learn how federal programs address these barriers, GAO reviewed documents from and interviewed federal, state, and local officials involved in providing mental health services to children. GAO's work included a site visit to greater New Orleans.
section_title: What GAO Found
paragraphs: Stakeholder organizations most frequently identified a lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area; they most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families' obtaining services for children. Fifteen of the 18 organizations identified a lack of mental health providers--including challenges recruiting and retaining child psychiatrists and psychologists--as a barrier to providing services to children. Thirteen organizations identified sustainability of funding, including difficulty securing reliable funding sources, as a barrier to providing services. A lack of transportation was most frequently identified--by 12 organizations--as a barrier to families' ability to obtain services for their children. The two second most frequently identified barriers to obtaining services were competing family priorities, such as housing problems and financial concerns, and concern regarding the stigma associated with receiving mental health services. A range of federal programs, including grant programs, address some of the most frequently identified barriers to providing and obtaining mental health services for children, but much of the funding they have supplied is temporary. Several federal programs support state and local efforts to hire or train mental health providers. For example, HHS's Professional Workforce Supply Grant has resulted in recruitment and retention incentives to mental health providers in the greater New Orleans area. Several HHS programs allow funding to be used to transport children to mental health services, including Medicaid and the 2006 Social Services Block Grant (SSBG) supplemental funding provided to Louisiana. However, much of the funding, including that from the Professional Workforce Supply Grant and the supplemental SSBG, is hurricane-related and will no longer be available after 2010. School-based health centers (SBHC) have emerged as a key approach in the area to address barriers to obtaining mental health services for children, and although there is no federal program whose specific purpose is to support SBHCs, state programs have used various federal funding sources to support them. For example, a Louisiana official told us funds from HHS's Maternal and Child Health Services Block Grant and Community Mental Health Services Block Grant support SBHCs in greater New Orleans. SBHCs address the transportation barrier because they are located on school grounds, and they help families by reducing the need for a parent to take time off from work to take a child to appointments. In addition, because SBHCs provide both mental health and other primary care services, the type of service a child receives is not apparent to an observer, which may reduce concern about stigma. In commenting on a draft of this report, HHS provided additional information on mental health services provided in schools other than through SBHCs and emphasized the effect of a lack of stable housing on children's mental health. HHS also provided technical comments. GAO incorporated HHS's comments as appropriate.

section_title: Letter
paragraphs: The greater New Orleans area has yet to fully recover from the effects of  Hurricane Katrina, which made landfall on August 29, 2005. One issue of  concern with regard to the rebuilding effort is the availability of mental  health services for children. We estimate that in 2008 about 187,000  children were living in the greater New Orleans area—which we defined as  Jefferson, Orleans, Plaquemines, and St. Bernard parishes. Many of these  children experienced psychological trauma as a result of Hurricane  Katrina and its aftermath, and studies have shown that such trauma can  have long-lasting behavioral, psychological, and emotional effects on  children. Experts have found increases in the incidence of depression,  post-traumatic stress disorder symptoms, risk-taking behavior, and  somatic and psychosomatic conditions in children who experienced the  effects of Hurricane Katrina. In addition, children in the greater New  Orleans area may continue to experience psychological trauma because of  the slow recovery of stable housing and other factors, such as the  recurring threat of hurricanes. Data collected by Louisiana State  University (LSU) Health Sciences Center researchers have indicated that a  substantial number of these children may need referrals for mental health  services.
Hurricane Katrina devastated the health care system in the greater New  Orleans area, resulting in the closure of many area hospitals and clinics,  including Charity and University hospitals, which provided outpatient  services through clinics in addition to inpatient services. These hospitals,  which were part of the statewide LSU public hospital system, had been the  main points of entry for many low-income and uninsured children and  families to gain access to health care services. In November 2006, LSU  reopened University Hospital under its new, temporary name, Interim LSU  Public Hospital, which is operating at a lower capacity than Charity’s and  University’s pre-Katrina capacity; Charity Hospital remained closed as of  June 2009.
Experts have previously identified barriers both to providing and to  obtaining mental health services for children, such as a lack of providers  or concerns regarding the stigma often associated with mental health  services. The current state of the health care system in greater New  Orleans may have exacerbated some of these barriers. Since Hurricane  Katrina, the federal government has directed over $400 million toward  restoring health services, including mental health services for children, in  Louisiana and the greater New Orleans area. Other federal funding, not  targeted to Katrina recovery, also supports the delivery of children’s  mental health services. For example, the Department of Health and Human  Services (HHS), Department of Education (Education), and Department of  Justice (DOJ) have programs, including grant programs, that support  mental health services for children in the greater New Orleans area. These  programs provide funding through annual formula grants— noncompetitive awards based on a predetermined formula—to Louisiana  and through various discretionary grants to state and local agencies and  nongovernmental organizations.
You asked us to study the federal role in addressing barriers to mental  health services for children in the greater New Orleans area. In this report,  we (1) identify barriers to providing and barriers to obtaining mental  health services for children in the greater New Orleans area, and   (2) describe how federal programs, including grant programs, address  barriers to providing and to obtaining mental health services for children.
To describe the barriers to providing and the barriers to obtaining mental  health services for children in the greater New Orleans area, we developed  structured interview questions and a written data collection instrument  (DCI) to use in obtaining views of state and local stakeholder  organizations. To develop these tools, we reviewed relevant data and  literature and conducted interviews with subject-matter experts  knowledgeable about mental health services for children in the greater  New Orleans area to identify known barriers to mental health services for  children. We selected 18 state and local stakeholder organizations to  participate in our structured interviews and DCI based on referrals from  subject-matter experts and knowledge of the organizations’ roles related  to children’s mental health services in greater New Orleans. Each  represented at least one of the following types of organizations: state  government agency; local government agency; school district; mental  health provider organization; nonprofit organization, including faith-based  organizations; and social service or juvenile justice organization.
In our structured interviews, we asked open-ended questions to gather the  18 stakeholder organizations’ views concerning barriers, using a  combination of in-person and telephone contacts with representatives  from each organization. Specifically, we asked the representatives of each  organization, as a group, to identify the three greatest barriers to providing  and the three greatest barriers to obtaining mental health services for  children. At the conclusion of each structured interview, we administered  the DCI to collect the views of each representative about the current  barriers to mental health services for children in a standardized way, using  a scale to assess whether the barriers had increased or decreased since  Hurricane Katrina. In our analysis of the DCI, we aggregated the  representatives’ responses to develop an overall response for each  organization. Because the 18 organizations were not selected by random  sample, their views cannot be generalized to all organizations or  individuals working in the field of children’s mental health services in the  greater New Orleans area.
We obtained data from HHS’s Health Resources and Services  Administration (HRSA) and the Greater New Orleans Community Data  Center to provide context for the information we collected on barriers. We  used parish-level data and national comparison data on the pre- and post- Katrina numbers of pediatricians and psychiatrists from the Area Resource  File (ARF), which is maintained by HRSA. The ARF is a county-based  health resources database that contains data from many sources, including  the U.S. Census Bureau and the American Medical Association. To assess  the reliability of the ARF data elements that we used in our analysis, we  performed checks, such as examining the data for missing values, and  reviewed related documentation. In addition to the ARF data, we used  education and housing data maintained by the Greater New Orleans  Community Data Center, a nonprofit organization that compiles data from  sources such as the Department of Housing and Urban Development  (HUD) and the Louisiana Department of Education. We interviewed  knowledgeable Community Data Center officials about the steps they took  to ensure the quality of their data. We determined that both the ARF data  and the Community Data Center data were sufficiently reliable for our  purposes.
To describe how federal programs, including grant programs, address  barriers to providing and to obtaining mental health services for children  in the greater New Orleans area, we gathered information from various  sources, using the barriers most frequently identified by organizations in  our structured interviews as our basis. We obtained documents from and  interviewed federal, state, and local officials and grant recipients involved  in the provision of mental health services to children. We also visited New  Orleans and Baton Rouge to speak with state and local officials and grant  recipients. To identify relevant federal programs, we reviewed the Catalog  of Federal Domestic Assistance and interviewed agency officials, including  representatives from HHS’s Substance Abuse and Mental Health Services  Administration (SAMHSA), HRSA, Centers for Medicare & Medicaid  Services (CMS), and Administration for Children and Families (ACF);  Education; and DOJ. We determined through interviews and reviews of  documents such as grant applications and program reports whether the  programs we identified funded mental health services in the greater New  Orleans area. We also met with state and local officials, including officials  from the Louisiana Department of Health and Hospitals (LDHH) and the  regional human services districts in the greater New Orleans area, to learn  how federal funding was used.
The federal programs we included in the scope of our work are (1) key  programs intended to support mental health services in general and   (2) programs that address at least one identified barrier to providing or  obtaining mental health services for children. It was not possible for us to  calculate a total amount of federal funding allocated or spent to support  mental health services for children in the greater New Orleans area or the  total number of children served through federal programs because of a  lack of comparable data among federal and state agencies and individual  programs.
We conducted our work from April 2008 through June 2009 in accordance  with all sections of GAO’s Quality Assurance Framework that are relevant  to our objectives. The framework requires that we plan and perform the  engagement to obtain sufficient and appropriate evidence to meet our  stated objectives and to discuss any limitations in our work. We believe  that the information and data obtained, and the analysis conducted,  provide a reasonable basis for any findings and conclusions in this  product.
subsections: section_title: Background
paragraphs: Almost 4 years after Hurricane Katrina, the children living in the greater  New Orleans area may be at particular risk for needing mental health  services, but certain barriers may impede the delivery of such care. Since  Hurricane Katrina, there has been increasing emphasis on providing  community-based, rather than hospital-based, mental health services for  low-income and uninsured children in the greater New Orleans area.  Multiple federal agencies support the provision of mental health and  related services for these children through various programs.
subsections: section_title: Mental Health Status of Children in the Greater New Orleans Area
paragraphs: Children in the greater New Orleans area may be at particular risk for  needing mental health services. Researchers at LSU Health Sciences  Center have conducted semiannual mental health screenings in selected  schools in the greater New Orleans area since Hurricane Katrina. One of  the lead LSU Health Sciences Center researchers told us that they had  screened about 12,000 area children as of January 2008; of the children  screened in January 2008, 30 percent met the threshold for a possible  mental health referral. Although this was a decrease from the 49 percent  level during the 2005-06 school year screening, the rate of decline was  slower than experts had expected. The LSU Health Sciences Center lead  researcher we spoke with interpreted this slower-than-expected decline as  indicating that the mental health needs of children in the greater New  Orleans area continue to be significant. The effects of a traumatic event  can persist for years. For example, a 2006 study on the use of counseling  services by people affected by the 2001 World Trade Center attack found  that some people first sought counseling services more than 2 years after  the event.
Research has shown that children who grow up in poverty as well as those  who are exposed to violence during or after a catastrophic disaster are at  risk for the development of mental health disorders. In 2007 the poverty  rate for each of the four parishes in the greater New Orleans area was  higher than the national average, and in Orleans and St. Bernard parishes,  the rate was at least twice the national average. People who have  experienced or witnessed certain incidents, including serious physical  injury, during or after a catastrophic disaster can face an array of  psychological consequences. The LSU Health Sciences Center lead  researcher we spoke with told us that January 2008 data showed that 16 to  21 percent of children screened had a family member who had been  injured in Hurricane Katrina, and 13 to 18 percent of children screened had  a family member who had been killed in the hurricane.
section_title: Barriers to Mental Health Services
paragraphs: The President’s 2003 New Freedom Commission on Mental Health  determined that many barriers can impede delivery of services for people  with mental illness. The commission specifically identified stigma, cost,  not knowing where or how to obtain services, unavailable services,  workforce shortages, and a fragmented mental health delivery system as  barriers. The stigma surrounding mental illness—negative attitudes and  beliefs about mental illness that can deter people from seeking  treatment—was described as a pervasive barrier preventing Americans  from understanding the importance of mental health. The commission also  noted that there was a national shortage of mental health providers and a  lack of providers trained in evidence-based practices. The commission  recommended early intervention, education, and screening in low-stigma  settings—such as primary care and school settings—as ways to prevent  mental health problems in children from worsening.
section_title: Delivery System for Mental Health Services for Low- Income and Uninsured Children and Families in the Greater New Orleans Area
paragraphs: Before Hurricane Katrina, health care services for low-income and  uninsured children and families in the greater New Orleans area were  primarily hospital-based. These individuals had access to mental health  services through Charity and University hospitals, which were a major  source of psychiatric care for the area. About half of the patients served by  these hospitals were uninsured, and about one-third were covered by  Medicaid.
Since Hurricane Katrina and the subsequent reduction in hospital capacity,  according to state and local officials, there has been an increasing  emphasis on providing community-based mental health services, including  through school-based health centers (SBHC) and other programs that  provide mental health services in schools. In general, SBHCs are located in  schools or on school grounds and provide a comprehensive range of  primary care services to children. Louisiana’s SBHCs provide mental  health services in addition to other primary care services. The LDHH  Office of Public Health operates the Adolescent School Health Initiative,  which facilitates the establishment of SBHCs in Louisiana, establishes  standards for SBHCs, and monitors their quality of care. Each SBHC is  administered by a sponsor organization, such as a hospital or school, and  is required to have a mental health provider on staff. A parent or guardian  must sign a written consent form for a student to receive services at an  SBHC.
Some children can gain access to mental health services through the  regional human services districts, to which LDHH’s Office of Mental  Health, Office for Addictive Disorders, and Office for Citizens with  Developmental Disabilities give funding to provide services in certain  areas of the state. The regional human services districts operate and  manage community-based programs and services, including mental health  services. In the greater New Orleans area, the Jefferson Parish Human  Services Authority serves Jefferson Parish, and the Metropolitan Human  Services District serves Orleans, Plaquemines, and St. Bernard parishes.
section_title: Federal Agencies with Responsibilities Related to Mental Health Services for Children
paragraphs: Multiple federal agencies support the provision of mental health and  related services for children in the greater New Orleans area through  various programs, including grant programs. (See app. II for information  on selected federal programs that support mental health and related  services for children. See app. III for information on selected services  provided to children by these programs.)
HHS supports the provision of mental health services for children in the  greater New Orleans area through several of its agencies, including  SAMHSA, HRSA, CMS, and ACF. SAMHSA, which has the primary federal  responsibility for children’s mental health services, works to improve the  availability of effective mental health services, substance abuse prevention  and treatment services, and related services through formula grant  programs—such as the Community Mental Health Services Block Grant— and discretionary grant programs—such as the National Child Traumatic  Stress Initiative and the Child Mental Health Initiative.
HRSA works to improve health care systems and access to health care for  uninsured and medically vulnerable populations. Its Health Center  Program supports health centers in the greater New Orleans area that  provide primary care services, including mental health services, to adults  and children. In addition, HRSA supports the provision of mental health  services to children through formula and discretionary grant programs,  such as the Maternal and Child Health Services Block Grant and the  Bureau of Clinician Recruitment and Service’s National Health Service  Corps Scholarship Program and Loan Repayment Program.
CMS provides funding for health care coverage for its programs’  beneficiaries and administers certain additional grant programs related to  Hurricane Katrina. CMS administers Medicaid and the State Children’s  Health Insurance Program (CHIP), and the programs are jointly financed  by the federal government and the states. Medicaid and CHIP represent a  significant federal funding source for health services, including mental  health services, for children in Louisiana. For example, in state fiscal year  2008, the Louisiana Medicaid and LaCHIP programs reimbursed almost  $9.4 million to providers for over 66,000 claims for mental health services  for children in the greater New Orleans area. Over 110,000 children in the  greater New Orleans area were enrolled in these two programs as of  August 2008. The programs cover inpatient psychiatric services,  psychological and behavioral services provided by licensed psychologists,  physician psychiatric services, and services of licensed clinical social  workers when provided in certain settings. CMS also administers  additional grant programs related to Hurricane Katrina, including the  Primary Care Access and Stabilization Grant (PCASG), a program  intended to assist in the restoration and expansion of outpatient primary  care services, including mental health services, in the greater New Orleans  area; the Professional Workforce Supply Grant, intended to address  shortages in the professional health care workforce; and the Provider  Stabilization Grants, a program intended to assist health care facilities that  participate in Medicare to recruit and retain staff.
ACF administers programs that promote the economic and social well- being of children, families, and communities. It supports counseling and  treatment services, education, prevention initiatives, and ancillary services  such as transportation through programs such as the Child Care and  Development Fund and the Head Start program. In addition, in 2006 ACF  distributed emergency supplemental Social Services Block Grant (SSBG)  funding to Louisiana that in part supported mental health services.
In addition to the HHS agencies, other federal agencies also support the  provision of mental health and related services to children in the greater  New Orleans area. Education supports mental health services for children  through school violence prevention and substance abuse prevention  programs, such as the Safe and Drug-Free Schools and Communities State  Education Agency and Governors’ Grants. DOJ supports mental health  services for children who have been victims of crime through its Crime  Victim Assistance program.
Some programs are the shared responsibility of multiple agencies. The  Department of Homeland Security’s Federal Emergency Management  Agency (FEMA) and SAMHSA are partners in administering the Crisis  Counseling Assistance and Training Program (CCP), which provides crisis  counseling services after events for which a presidential disaster  declaration has been made. The CCP provided funding to LDHH’s Office  of Mental Health, the state CCP grantee, for crisis counseling services in  the greater New Orleans area after Hurricanes Katrina and Rita. FEMA  also supported case management services for victims of Hurricanes  Katrina and Rita through the Disaster Housing Assistance Program, which  is administered by HUD.
In addition to federal programs, state funding and donations also support  mental health and related services to children in the greater New Orleans  area. For example, a grant from the W.K. Kellogg Foundation is helping to  support SBHCs in New Orleans. Louisiana must provide matching funds as  a requirement of its receipt of some federal grants, so federal funding may  represent only a portion of the total funding. For example, both HRSA’s  Maternal and Child Health Services Block Grant and SAMHSA’s Child  Mental Health Initiative require the state to match federal grant funds.
section_title: Lack of Providers Was Most Frequently Identified Barrier to Providing Children’s Mental Health Services, and Lack of Transportation Was Most Frequently Identified Barrier to Obtaining Services
paragraphs: Stakeholder organizations that participated in our structured interviews  and responded to our DCI most frequently identified lack of mental health  providers and sustainability of funding as barriers to providing mental  health services to children in the greater New Orleans area. These  organizations most frequently identified a lack of transportation,  competing family priorities, and concern regarding stigma as barriers to  families’ obtaining mental health services for children.
subsections: section_title: Lack of Mental Health Providers and Sustainability of Funding Were Most Frequently Identified Barriers to Providing Services
paragraphs: A lack of mental health providers in the greater New Orleans area was the  most frequently identified barrier to providing services to children among  the stakeholder organizations that participated in our structured  interviews. (See table 1.) Fifteen of the 18 organizations identified a lack of  mental health providers—including challenges recruiting and retaining  child psychiatrists, psychologists, and nurses—as a barrier. Several  organizations specifically described challenges in recruiting and retaining  staff with particular training, such as in evidence-based practices or  treatment of children and adolescents. One organization said that while a  nationwide shortage of trained mental health providers contributed to  recruitment difficulties before Hurricane Katrina, the hurricane  exacerbated the situation because many providers left the greater New  Orleans area. In their responses to the DCI, 14 of the 15 organizations  reported that recruitment was more challenging now than before  Hurricane Katrina, and 12 of the 15 reported that retention was more  challenging now than before Hurricane Katrina.
Other developments underscore the lack of mental health providers as a  barrier. For example, HRSA designated the parishes in the greater New  Orleans area as health professional shortage areas (HPSA) for mental  health in late 2005 and early 2006; before Hurricane Katrina, none of the  parishes had this designation for mental health. HRSA’s ARF data also  indicate that the greater New Orleans area has experienced more of a  decrease in mental health providers than some other parts of the country.  For example, the ARF data documented a 21 percent decrease in the  number of psychiatrists in the greater New Orleans area from 2004 to 2006,  during which time there was a 1 percent decrease in Wayne County,  Michigan (which includes Detroit and which had pre-Katrina poverty and  demographic characteristics similar to those of the greater New Orleans  area) and a 3 percent increase in counties nationwide. Furthermore, LDHH  data showed a 25 percent decrease in the number of mental health  providers in the greater New Orleans area—including psychiatrists and  licensed clinical social workers—who participated in Medicaid and  LaCHIP from state fiscal year 2004 to state fiscal year 2008.
Sustainability of funding—including difficulty securing reliable funding  sources and limitations on reimbursement for services—was the second  most frequently identified barrier to providing services for children.  Thirteen of the 18 organizations identified sustainability of funding as a  barrier. One organization stated that there was a need to secure  sustainable funding from public and private sources because individuals  and organizations that had provided funding before Hurricane Katrina  were no longer donating because they were leaving the greater New  Orleans area. Two organizations said that the ability to obtain  reimbursement for mental health services provided outside of traditional  clinic settings, such as in schools, would allow some of these services to  be sustained over the long term.
Organizations that participated in the structured interviews identified  several additional barriers to providing services for children. Availability  of referral services—including the limited availability of space at inpatient  psychiatric hospitals and other types of treatment facilities—was  identified as a barrier by five organizations. One organization noted that  in order to place children in residential treatment for mental illness, it had  to compete for beds in Shreveport—located 5 hours outside the greater  New Orleans area—or potentially send children out of state. In either case,  regular family involvement in treatment, which experts say is important  for treatment success, would be limited. Three organizations identified a  lack of coordination between mental health providers or other providers  serving children as a barrier. A 2006 review of the mental health system in  Louisiana found that children with mental health problems could receive  services through multiple systems—such as primary health care, schools,  and social services—and that the lack of coordination and communication  among these systems could result in providers not providing services to  children who need them or providing duplicated services. Finally, two  organizations identified availability of physical space in which to house  programs as a barrier. One organization said that more than 3 years after  Hurricane Katrina, providers still had difficulty locating physical space.
section_title: Lack of Transportation, Competing Family Priorities, and Concern Regarding Stigma Were Most Frequently Identified Barriers to Obtaining Services for Children
paragraphs: A lack of transportation in the greater New Orleans area was the most  frequently identified barrier to obtaining mental health services for  children among the stakeholder organizations that participated in our  structured interviews. (See table 2.) Twelve of the 18 organizations  identified a lack of transportation as a barrier. For example, 1 organization  told us that it was difficult for children and families to travel to clinics to  obtain services because the bus system was not running at full capacity  and high gas prices in 2008 made travel by car more expensive. Another  organization mentioned that more families had cars before Hurricane  Katrina, but many of these vehicles were destroyed in the flooding.  Furthermore, in their DCI responses, 10 of the 12 organizations reported  that transportation was more challenging now than before Hurricane  Katrina.
Competing family priorities—including dealing with housing problems,  unemployment, and financial concerns—was tied as the second most  frequently identified barrier to obtaining services for children. Competing  family priorities was identified as a barrier by 11 of the 18 organizations,  and in their DCI responses, 10 of the 11 organizations reported that family  stress was more challenging now than before Hurricane Katrina. One  organization told us that families were focused on issues such as  rebuilding their homes and reestablishing their lives and that mental  health concerns were seen as a low priority. The organization added that  in the greater New Orleans area the cost of living, such as for rent and  food, had risen. For example, the average fair market rent in the New  Orleans Metropolitan Statistical Area for a two-bedroom unit rose about  40 percent—from $676 to $949 per month—from fiscal year 2005 to fiscal  year 2009, exceeding the estimated affordable monthly rent for a resident  earning the average income of about $37,000 a year.
Concern regarding the stigma that is associated with receiving mental  health services was the other barrier to obtaining services for children that  was identified second most frequently—by 11 organizations. One  organization said that a perception existed that a parent, by seeking out  mental health services for his or her child, was labeling that child as  “crazy.” In their DCI responses, 7 of the 11 organizations reported that  concern regarding stigma was as challenging now as it was before  Hurricane Katrina. Several organizations, however, told us that although  individuals may continue to have concern about stigma if their own child  is identified as needing mental health services, they have also observed  more acceptance of the idea of mental health services in general.
Organizations identified several additional barriers to obtaining children’s  mental health services in the greater New Orleans area. A lack of service  availability—including the availability of translation services and the  ability to easily obtain an appointment—was identified as a barrier by  eight organizations. For example, one organization told us that one  parish’s high schools had students from up to 50 different ethnic groups,  including a larger number of non-English-speaking students than before  Hurricane Katrina. Although the children were learning English, the  teachers and administrators were challenged in trying to communicate  with the parents and to preserve confidentiality when using an interpreter.  In addition, five of the eight organizations reported in their DCI responses  that the availability of translation and interpretation services was more  challenging now than before Hurricane Katrina. Three organizations  identified not knowing where to go to obtain services as a barrier. For  example, one organization said that before the hurricane many people  knew mental health services were available at Charity Hospital, but that  following its closing fewer people were aware of alternate locations  offering such services. All three organizations reported in their DCI  responses that not knowing where to go for services was a more  challenging barrier now than before Hurricane Katrina. Finally, the lack of  health insurance was identified as a barrier by two organizations. One  organization said that many parents were overwhelmed by the process of  signing up their children for LaCHIP, especially because living in multiple  states complicated the process.
section_title: Federal Programs Address Barriers by Supporting State and Local Efforts to Hire Providers; Assist Families; and Deliver Care through School- Based Health Centers
paragraphs: A range of federal programs address the most frequently identified barriers  to providing and obtaining mental health services for children, but much  of the funding for these programs is temporary. Since Hurricane Katrina,  SBHCs have emerged as a key approach to addressing barriers to  obtaining services, and state agencies have used federal funding to support  these clinics.
subsections: section_title: Federal Programs Provide Funding to Hire Providers, Supply Transportation, Assist Families, and Reduce Stigma, but Much Funding Is Temporary
paragraphs: We found that the federal programs in our review provided funding that  addresses four of the five most frequently identified barriers but that much  of it was temporary and did not fully address the remaining barrier in this  group, sustainability of funding. (See app. II and app. III, respectively, for  additional information on the federal programs in our review and selected  services supported by these programs.)
Lack of mental health providers. After Hurricane Katrina, the greater  New Orleans area received funding from CMS and HRSA programs to  address a general lack of providers, including children’s mental health  providers. For example, as of May 2008, CMS’s Professional Workforce  Supply Grant, created with the intent to recruit and retain health  professionals in the greater New Orleans area, was used to provide  financial incentives to 82 mental health providers who agreed to either  take a new position or continue in a position in the greater New Orleans  area and to serve for at least 3 years. This funding will be available through  September 2009. About two-thirds of the provider organizations receiving  PCASG funds told us they used some of the funding to hire mental health  providers; these funds will be available through September 2010. In  addition, through CMS’s Provider Stabilization Grants, awarded to  Louisiana to help health care facilities hire and retain providers, $52,001  was provided in June 2007 to community mental health centers in Orleans  Parish that serve children. As of October 2008, HRSA’s Bureau of  Clinician Recruitment and Service, which provides student loan repayment  and scholarships to providers serving in designated HPSAs, was  supporting 7 mental health professionals in the greater New Orleans  area—4 social workers, 2 psychologists, and 1 child psychiatrist.
A few federal programs support training of children’s mental health  providers, which helps address a lack of providers trained in children’s  mental health, which was identified as a barrier in our structured  interviews. SAMHSA’s National Child Traumatic Stress Initiative awarded  two grants in October 2008 to providers in the greater New Orleans area to  provide training on, implement, and evaluate trauma-focused treatment for  children. For example, providers in the greater New Orleans area were  trained on various trauma-related interventions, which included evidence- based practices that are delivered in schools. In addition, the Children’s  Health Fund Community Support and Resiliency Program, whose funding  from SAMHSA expires in September 2009, provides comprehensive  training and technical assistance on the assessment and treatment of  trauma in children for medical, mental health, education, and child care  professionals in the greater New Orleans area.
Lack of transportation. Although none of the federal programs included  in our review are designed solely to provide transportation for children  obtaining mental health services, officials we interviewed told us that  funding from several federal programs has been used in that way. For  example, Louisiana designated $150,000 in the fiscal year 2009 Community  Mental Health Services Block Grant state plan for transportation for  children in the greater New Orleans area, and funding from ACF’s 2006  SSBG supplemental grant and SAMHSA’s Child Mental Health Initiative  has also been used to supply transportation to mental health appointments  for children. Louisiana Medicaid officials told us that the Louisiana  Medicaid program provides reimbursement for nonemergency, previously  authorized transportation for enrolled children for any Medicaid-covered  service and for medical emergencies, including transportation to inpatient  mental health facilities. Louisiana Medicaid also provides reimbursement  to family or friends who provide medically necessary transportation for  Medicaid enrollees and provides reimbursement for home- or community- based treatment, which can reduce the need for transportation to provider  offices. SAMHSA’s National Child Traumatic Stress Initiative has two  grantees in the greater New Orleans area that provide trauma-focused  mental health services to children in schools, which can also reduce the  need for transportation to provider offices. For example, an official from  one grantee told us they have provided mental health services to children  who live in the more rural sections of the greater New Orleans area, for  whom travel time to services could be a significant barrier to obtaining  care.
Competing family priorities. Federal programs provide funding that is  used to alleviate conditions that create competing family priorities— including dealing with housing problems, unemployment, and financial  concerns—to help families more easily obtain children’s mental health  services. Federal programs address competing priorities, in part, by  providing case management, information, and referral services, which  can help families identify and obtain services such as health care, housing  assistance, and employment assistance. For example, the 2006 SSBG  supplemental funding supported over 25,000 case management services to  children in Louisiana from July 2006 through September 2008. In  addition, officials from a local organization that received funding from  ACF’s Head Start told us that the program had provided families with  information and referrals for mental health services. HUD’s and FEMA’s  Disaster Housing Assistance Program provided case management services,  which included social services such as job training and referrals for mental  health services, in addition to rental assistance to certain families  displaced by Hurricanes Katrina and Rita. The program ended on   March 1, 2009, but program clients in Louisiana will continue to receive  services through a transitional program through August 31, 2009.
Federal programs also address competing family priorities by providing  direct financial assistance, which may help alleviate family stress and  make it easier for families to devote resources and effort to obtaining  mental health services for their children. For example, the Metropolitan  Human Services District uses federal funding from the Community Mental  Health Services Block Grant to give financial assistance for utilities, rent,  and school uniforms to families of children who have certain mental  health disorders, or to provide family stabilization services to help keep  these children in their homes. In addition, the Louisiana state program that  uses the SAMHSA Child Mental Health Initiative grant provides time- limited funding for tutoring, school uniforms, and other expenses when  they are a part of an individualized service plan for children with  diagnosed mental health disorders.
Concern regarding stigma. An official from one of the National Child  Traumatic Stress Initiative grantees in the greater New Orleans area told  us that because school systems they have worked with have integrated the  delivery of mental health services into the schools, the stigma associated  with mental health services has decreased. In addition, some federal  programs support the provision of education services, which the  President’s New Freedom Commission on Mental health reported can  reduce stigma associated with mental health services. For example, in  2008 FEMA’s and SAMHSA’s CCP program provided information about  counseling services through a media campaign that included billboards,  television commercials, and print and radio advertisements. SAMHSA’s  State/Tribal Youth Suicide Prevention Grants provided suicide prevention  and education services through a 2007 media campaign that included  busboards, radio public service announcements, and print advertisements  throughout the greater New Orleans area.
Sustainability of funding. Although most of the federal programs we  identified were not established as a direct result of Hurricane Katrina, the  programs that are hurricane-related have been an important source of  support for mental health services for children in the greater New Orleans  area. However, much of this funding is temporary. For example, three  hurricane-related grant programs—CMS’s PCASG and Professional  Workforce Supply Grant and ACF’s 2006 SSBG supplemental funding— will no longer be available to grantees after 2010. Although the PCASG was  created with the expectation that providing short-term financial relief  would significantly increase the likelihood of the PCASG fund recipients’  sustainability, and PCASG recipients were required to prepare  sustainability strategies as part of their application, it is too early to know  whether these organizations will achieve sustainability.
section_title: Louisiana Has Used Federal Programs to Help Support School-Based Health Centers, Which Have Emerged as a Key Approach to Addressing Transportation and Other Barriers
paragraphs: Since Hurricane Katrina, the number of SBHCs in the greater New Orleans  area has increased. At the start of the 2005-06 school year, there were  seven SBHCs providing mental health and other primary care services to  children in the greater New Orleans area. Most of these SBHCs were  closed as a result of damage from Hurricanes Katrina and Rita, and the  ones that remained open had also sustained damage. During the 2007-08  school year, there were nine SBHCs in the greater New Orleans area, and  state officials told us in February 2009 that at least four more SBHCs were  in the planning stages for this area.
Louisiana’s SBHCs receive their funding from several sources. The LDHH  Office of Public Health, which oversees SBHCs in the state, provides some  state funding. There is no federal program whose specific purpose is to  support SBHCs, but LDHH and local providers have used funding from  various federal sources to support SBHCs. For example, a state official  told us that the Office of Public Health has used a small portion of LDHH’s  annual Maternal and Child Health Services Block Grant from HRSA to  support SBHCs. Some organizations that support SBHCs in the greater  New Orleans area have also received temporary funding, such as from the  PCASG and the hurricane-related SSBG supplemental funding. In addition,  the Jefferson Parish Human Services Authority, which provides mental  health services at SBHCs, has received funding allocated by LDHH’s Office  of Mental Health from SAMHSA’s Community Mental Health Services  Block Grant. Furthermore, providers at some SBHCs told us they could  receive Medicaid reimbursement for some mental health services,  including those related to psychiatric care. State officials told us that  although CMS permitted the reimbursement of social work services  provided at SBHCs, the Louisiana Medicaid program had not provided  reimbursement for social work services because of state funding  constraints. Some SBHCs may also obtain funding from nonprofit  organizations. For example, grant funding from the W.K. Kellogg  Foundation was significant in the rebuilding and expansion of SBHCs after  Hurricane Katrina.
Because Louisiana requires SBHCs to have mental health staff on-site,  SBHCs can be an access point for children who need mental health  services in the greater New Orleans area. Furthermore, some SBHCs in the  area have a psychiatrist on staff on a part-time basis. During the 2007-08  school year, the need for mental health services was the primary reason  for almost one-quarter of students’ visits to SBHCs in the greater New  Orleans area. In addition, SBHC health care providers told us that  students who visited the SBHCs for other reasons may have also received  mental health services.
SBHCs in the greater New Orleans area have emerged as a key approach  to addressing the top three barriers to obtaining services identified in our  structured interviews—a lack of transportation, competing family  priorities, and concern regarding stigma. SBHCs are generally located in  schools or on school grounds, which reduces students’ need for  transportation to obtain care. The SBHCs in Jefferson Parish serve  students on multiple school campuses, and students in schools not  colocated with an SBHC can be transported when necessary. SBHC  services may be provided at low or no cost to the patient, which lessens  the financial burden on the family. The location of SBHCs in schools or on  school grounds also reduces the need for a parent to take time off from  work to accompany a child to appointments. In addition, colocation of  mental health and other primary care services may reduce concern  regarding stigma because the type of service the child is receiving at the  SBHC is generally not apparent to an observer. One SBHC provider told us  that offering mental health services in the same location as other primary  care services “demystifies” mental health services and eliminates the  perception that they are separate from primary care services.
Officials at SBHCs told us they were working to obtain additional funding  to help achieve long-term sustainability of the clinics. Officials from the  Metropolitan Human Services District told us that it would not be possible  for every school to have an SBHC, but that they were working on an  initiative with other local organizations and school districts to develop a  “hub” system to deliver health care services, including mental health  services, to children in the greater New Orleans area. Under the planned  pilot program, individual SBHCs or other community clinics would  become hub clinics that would serve 10 feeder schools, 6 of which would  be served by 2 mental health providers funded by the Metropolitan Human  Services District, and 4 of which would be served by mental health  providers funded by other organizations. Children needing services  beyond those provided by their school mental health provider or nurse  could be referred to the hub clinic. Officials planned to begin hiring school  nurses and mental health providers for the feeder schools by July 2009.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and Education for their review.  HHS provided comments on two key issues. HHS’s comments are  reprinted in appendix IV and discussed below. In addition, both HHS and  Education provided technical comments. We incorporated HHS and  Education comments as appropriate.
In its comments, HHS stated that our draft report focused too heavily on  SBHCs, to the exclusion of other models of care. HHS noted that the  school systems in the greater New Orleans area have been very receptive  to the direct provision of mental health services in schools, because of the  psychological difficulties experienced by school children due to distress  related to Hurricane Katrina. HHS supplied additional information on  SAMHSA’s National Child Traumatic Stress Initiative’s two grantees in the  greater New Orleans area, which provide mental health services in  schools. We highlighted SBHCs in our draft report because they have  emerged as a key approach to serving children in the greater New Orleans  area, due in part to the state’s use of federal funds to support this model of  care. Our discussion of SBHCs in the greater New Orleans area is not  intended to imply that they are the only model for providing school-based  mental health services to children, and we have added additional  information to our report on the National Child Traumatic Stress Initiative  grantees. HHS also commented that many SBHCs do not provide mental  health services, and that those that do provide them may not have staff  who can provide more intensive services. However, as our draft indicated,  all SBHCs in Louisiana are required to have a mental health provider on  staff and therefore can be a valuable resource for children seeking mental  health services. We have also added information to the report indicating  that some SBHCs in the greater New Orleans area have a psychiatrist on  staff on a part-time basis.
HHS commented that our draft report minimized housing problems faced  by children and families in the greater New Orleans area in our discussion  of barriers to obtaining mental health services; HHS also stated that the  lack of stable housing in the area is one of the greatest barriers to  children’s mental health recovery. We disagree that the draft report  minimized the role of housing problems. Our findings were based on  barriers identified by stakeholders, who described what they believed to  be the greatest barriers to families obtaining mental health services for  children. The draft report included information related to housing  problems in greater New Orleans in our discussion of competing family  priorities, which tied as the second most frequently identified barrier to  obtaining mental health services for children. However, we added  information to the report to emphasize that housing problems may affect  children’s mental health.
In its comments, HHS also provided additional information on SAMHSA’s  Child Mental Health Initiative, which we have incorporated as appropriate.  We also expanded our description of FEMA’s and SAMHSA’s CCP in our  appendix on federal programs in response to HHS’s comments.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the Secretary  of Health and Human Services, the Secretary of Education, and  appropriate congressional committees. The report also will be available at  no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7114 or bascettac@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff members who made major contributions to  this report are listed in appendix V.
section_title: Appendix I: Child Population Estimate for the Greater New Orleans Area
paragraphs: We have estimated that about 187,000 children through age 17 were living  in the greater New Orleans area during 2008. To arrive at this estimate, we  calculated the total enrollment for all public and private schools in the  greater New Orleans area by adding the number of public school students  as of fall 2008 (89,178) to the number of private school students reported  for the 2008-09 school year (41,188). About 130,366 children were enrolled  in public and private schools in the greater New Orleans area for the 2008- 09 school year, which was 70 percent of pre-Katrina enrollment (186,530  in the 2004-05 school year). However, school enrollment data  underestimate the total child population, as they do not include all  children younger than school age. Therefore, we generated our estimate  by adding the total enrollment data to birth data for 2004 through 2008.  (See fig. 1.)
section_title: Appendix II: Selected Federal Programs That Have Supported the Provision of Mental Health Services in Greater New Orleans
paragraphs: Table 3 is a list of the federal programs in our review that have been used  to support the provision of mental health or related services to children in  the greater New Orleans area. The list includes 9 formula grant programs  that support the provision of mental health services through  noncompetitive awards to the state based on a predetermined formula,  and 13 discretionary grant programs that support services that address at  least one of the identified barriers to providing and obtaining mental  health services for children. It was not possible for us to calculate a total  amount of federal funding allocated or spent to support mental health  services to children in the greater New Orleans area or the total number of  children served through federal programs because of a lack of comparable  data among federal and state agencies and individual programs.
section_title: Appendix III: Mental Health Services Provided to Children in Greater New Orleans Supported by Selected Federal Programs
paragraphs: Figure 2 is a list of selected services supported by the federal programs in  our review for children in the greater New Orleans area.
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Helene F. Toiv, Assistant Director;  Elan Martin; Roseanne Price; Julie L. Thomas; Laurie F. Thurber; Jennifer  Whitworth; Malissa G. Winograd; and Suzanne Worth made key  contributions to this report.
section_title: Related GAO Products
paragraphs: Hurricane Katrina: Federal Grants Have Helped Health Care  Organizations Provide Primary Care, but Challenges Remain.   GAO-09-588. Washington, D.C.: July 13, 2009.
Disaster Assistance: Greater Coordination and an Evaluation of  Programs’ Outcomes Could Improve Disaster Case Management.   GAO-09-561. Washington, D.C.: July 8, 2009.
Disaster Assistance: Federal Efforts to Assist Group Site Residents with  Employment, Services for Families with Children, and Transportation.  GAO-09-81. Washington, D.C.: December 11, 2008.
Catastrophic Disasters: Federal Efforts Help States Prepare for and  Respond to Psychological Consequences, but FEMA’s Crisis Counseling  Program Needs Improvements. GAO-08-22. Washington, D.C.:   February 29, 2008.
School Mental Health: Role of the Substance Abuse and Mental Health  Services Administration and Factors Affecting Service Provision.   GAO-08-19R. Washington, D.C.: October 5, 2007.
Hurricane Katrina: Status of Hospital Inpatient and Emergency  Departments in the Greater New Orleans Area. GAO-06-1003.  Washington, D.C.: September 29, 2006.
Hurricane Katrina: Status of the Health Care System in New Orleans  and Difficult Decisions Related to Efforts to Rebuild It Approximately   6 Months after Hurricane Katrina. GAO-06-576R. Washington, D.C.:   March 28, 2006.
Hurricane Katrina: GAO’s Preliminary Observations Regarding  Preparedness, Response, and Recovery. GAO-06-442T. Washington, D.C.:  March 8, 2006.
Mental Health Services: Effectiveness of Insurance Coverage and Federal  Programs for Children Who Have Experienced Trauma Largely  Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.