Ensuring Every Child Benefits from Behavioral Health Quality Improvement (QI) Initiatives

The need for children’s behavioral health services has never been more urgent. In 2023, 40% of high school students in the U.S. reported persistent feelings of sadness and hopelessness, a 33% increase compared to 2013. One in five students said they had seriously considered suicide.

Despite these trends, less than half of children with behavioral health needs receive treatment, with even lower rates among Black and Hispanic youth.  A clear quality improvement (QI) framework can increase access and enhance service delivery, but if it is not intentionally designed to identify and address racial, ethnic, gender, and other disparities, it can inadvertently worsen them. An explicit and intentional focus on health equity from the beginning of any QI effort is needed to ensure that all children receive the effective care they deserve.

This issue brief outlines common challenges and strategies for using QI to promote equity in children’s behavioral health services. Illustrated with examples from efforts to address racial and ethnic disparities, the recommendations included here are broadly applicable to reducing inequities across a wide range of populations and circumstances.

Longstanding unaddressed disparities in social determinants of health combined with racism, discrimination, lack of trust in the children’s behavioral health system, and limited reliable data impede efforts to achieve equity. Despite higher prevalence of certain common conditions, Black and Hispanic youth are less likely to see a behavioral health specialist and the disparity between Black and White youth has increased over time.

Black and Hispanic youth are the recipients of lower overall mental health care expenditures than White youth, with Black youth especially experiencing lower outpatient expenditures.  Lower levels of access to outpatient services can lead to the use of more intensive and costly interventions such as use of the Emergency Department (ED) for behavioral health reasons; indeed, while such visits have increased for all youth, they have done so at a faster rate among Hispanic children and Black children, who are the most likely to utilize EDs. There continue to be significant disparities in access and utilization, making these crucial considerations in behavioral health care.

Quality improvement (QI) is the systematic approach to using data to guide actions that result in better outcomes. QI is a powerful tool for improving services and addressing disparities, even when all groups experience improvement.

Connecticut’s Mobile Crisis Intervention Service (MCIS) provides a rapid, in-person response to any child experiencing a behavioral health crisis. Funded by DCF and available free of charge to all families in the state, MCIS diverts children from more intensive and restrictive levels of care and instead provides de-escalation and stabilization supports in the home, school, and community.

Access to the service is available through both 988 and United Way’s 211, the centralized call center that connects callers to one of 14 local community providers. CHDI has served as Connecticut’s MCIS Performance Improvement Center (PIC) since 2009, helping the state gain national recognition as a model for crisis services for children. Our continuous QI work has facilitated dramatic improvements in mobility rates and response times that have been sustained for nearly 15 years. Connecticut and CHDI were central in developing the national MRSS Best Practices and the Data Best Practices Guide provides a data and QI model for other states to adopt.

Understanding the various ways families connect with MCIS allows for more specific targets for improvement.

Recommendations

To achieve the best outcomes for all youth, behavioral health services must prioritize equity throughout the entire quality improvement process. Historically, the tools and frameworks used to improve these services have not focused explicitly on identifying and addressing disparities. Actively measuring disparities and the effectiveness of strategies to address them is essential for improving outcomes.  Recommendations include:

1. Invest in quality improvement work. Many services have no data at all. Some services that collect data never have those data analyzed, reported, and used for QI. QI must be supported with sufficient resources to establish data infrastructure and support staff with the expertise to analyze, report, and use those data for QI. Providers need time to collect data and conduct internal QI processes. Often an independent and objective QI entity can improve efficiencies and provide support to providers by analyzing data, offering consultation, sharing strategies across providers, and ensuring the entire system is making progress on performance and equity goals.

2. Increase accountability to the public: Transparency fuels trust and accountability. Publishing QI data— stratified by race, ethnicity, language, and other demographics—not only highlights disparities but also motivates stakeholders to act. Public reports and dashboards ensure communities, policymakers, and other partners can track progress and advocate for improvements.

3. Involve families and those with lived experience. Embedding individuals and families with lived experience into the QI process ensures interventions address real-world needs, build trust, and avoid unintended harm

4. Train providers in QI approaches. All partners in a system or initiative must have a common understanding of the goals and process for improvement. Shared trainings focused on QI tools and equity principles can increase staff buy-in, improve data integrity, and help ensure there is a consistent language and approach across a system.

Accurate data deployed within an equity-focused QI framework provides a roadmap for evaluating effectiveness and ensuring services work better and more equitably.

This is an excerpt of an issue brief published in December 2025 prepared by Kellie Randall, PhD, Associate Vice President of Quality Improvement at the Child Health and Development Institute (CHDI).  The complete issue brief can be seen here.