Taking Action to Transform Childrens Mental Health

1
Taking Action to Transform Childrens Mental
Health

• Larke Nahme Huang, Ph.D.
• American Institutes for Research
• Presentation for
• Childrens Mental Health Voice of Florida
• Statewide Summit
• January 10-11, 2006

2
Overview

• Where we are selected findings in childrens
  mental health
• How can we transform mental health care for
  children, youth and their families?
• Whats happening around the country?
• Creating and sustaining momentum for
  transformation

3
Where we are
4
Selected National Findings A Public Health
Crisis in Mental Health

• 20 adults/children have a mental health problem
• ½ have a serious emotional disorder
• 13 of preschoolers have emotional/behavioral
  disorder
• 20 million suffer from serious disabling mental
  illness
• Suicide 30,000 a year 80/day
• 40 had contact with primary care provider
  within the last month
• Adolescents 15-19y/o 3rd leading cause of
  death 17-19 think about killing themselves
  5-8 make attempt only 1/3 get treatment
• YET,
• Only half of individuals with serious mental
  illness get treatment, services or supports

5
Childrens Use of Mental Health Services
Number of Youth Admitted for Mental Health
Service in the US.
Cases of Mental Health Service Use per 100,000 US
Youth Population
1,318,722
86.3
1,897
69.7
707,854
1,118
1986
1997
1997
1986
Inpatient Outpatient MH Clinic Services
Only Dept. HHS, Rutgers Univ., Annie Casey
Foundation, 2002
6
Selected Findings for Youth

• Of children with serious emotional/behavioral
  disorders 50 drop-out of high school (compared
  to 30 of students with other disabilities) (U.S.
  Dept of Education, 2001)
• Youth entering Juvenile Justice 66-75 have
  serious emotional problems (Coalition on Juvenile
  Justice Teplin, 2002)
• 1/3 children in mental health system have a
  co-occurring disorder (age 11 age 17-18 SA)
  (Kessler)
• (SAMHSA, 2005)

7
Selected Findings for Youth

• 500,000 children in foster care estimates up to
  40-80 have emotional/behavioral and/or substance
  abuse problem
• 44
• highest of
• of Latino youth in foster care, 57 (The AFCARS Report  Preliminary FY 2001
  Estimates as of March 2003.  Washington, D.C.,
  DHHS, 2003.  ( latest federal statistics  on
  foster care supplied by the states for the
  Adoption and Foster Care Analysis and Reporting
  System Zero to Three)

8
Disparities for Children of Diverse Racial and
Ethnic Groups

• Black and Latino kids identified/referred at same
  rates as general population, but less likely to
  receive specialty mental health or meds
  (Kelleher, 2000)
• African American and Latino children have highest
  rates of unmet need (Sturm, 2000)
• Asian American and Latino female teens have
  highest rates of depression (Commonwealth Fund,
  1997)
• 1 of 5 Latina teens makes a suicide attempt
  (CDCP, 2005)
• Minority children tend to receive mental health
  services through juvenile justice and child
  welfare systems more often than through schools
  or mental health setting (Alegria, 2000)
• In child welfare, minority youth have poorer
  outcomes, fewer services, less likely to have
  plans for family contact and more likely to be in
  out-of-home placements (Courtney et al, 1996).

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How can we transform mental health care?
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Transformative Concepts

• New Freedom Commission
• Resiliency and Recovery
• Family-Driven Care
• Using What Works
• Harnessing Technology

• Public health framework
• promotion,
• prevention,
• early identification,
• intervention,
• aftercare

• Builds on Systems of Care Values/Principles
  Customized to Local/State Community
• strengths-based, individualized,
• family-driven, youth-guided, culturally
  competent,
• community-based, coordinated services and
  supports across agencies

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1. Resiliency and Recovery

• Work toward goal of resiliency/recovery
• Identify and build on strengths of youth and
  family
• Outcomes are different, including optimism,
  quality of life as legitimate outcomes
• Strengthening protective factors, e.g., family
  community assets

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2. Family-Driven Care

• Families have a voice
• choosing supports, services, and providers
• setting goals
• designing and implementing programs
• monitoring outcomes
• determining the effectiveness of all efforts to
  promote the mental health and well being of
  children and youth

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How Do We Operationalize Family-Driven?

• Families and Youth
• Have accurate, understandable, and complete
  information necessary to make choices
• Share decision-making and responsibility for
  outcomes with providers.
• Are organized to collectively use their knowledge
  and skills as a force for systems transformation.
  
• Engage in peer support activities to reduce
  isolation, gather and disseminate accurate
  information, and strengthen the family voice.
• Attitude shift professionals as partners

SAMHSA Focus Groups Blau, Osher 2005
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How Can We Make It Work?

• Providers
• Embrace the concept of sharing decision-making
  authority and responsibility.
• Providers take the initiative to change practice
  from provider-driven to family-driven.
• Administrators and Staff
• Share power, resources, authority,
  responsibility, and control with families and
  youth.
• Administrators allocate staff, training, support
  and resources to make family-driven practice work

15
How Can We Make It Work?

• Communities
• Change efforts focus on removing barriers and
  discrimination created by stigma.
• Values shift from blaming to strengthening
  families
• Everyone who connects with children, youth, and
  families continually advance their cultural and
  linguistic responsiveness as the population
  served changes.

16
How Can We Make It Work?

• Policies
• Family-run organizations receive resources and
  funds to support and sustain the infrastructure
  that is essential to insure an independent family
  voice in their communities, states, tribes,
  territories, and the nation.
• Meetings and service provision happen in
  culturally and linguistically competent
  environments where family and youth voices are
  heard and valued, everyone is respected and
  trusted, and it is safe for everyone to speak
  honestly.
• Whole family approach to care
• Response to changing demographics
  family-driven care for all families?

17

How Can We Make It Work?
DSS
DJS
PS
MH
CH F
I A
L MI
D LY
R. Crowel, 2005
18
How Can We Make It Work?
H/MH
Legal
CHILD FAMILY
ED/ VOC
Case Mgmt
CW
Rec
19
How Can We Make It Work?

• MEDICAID
• Medicaid Inpatient
• Medicaid Outpatient
• Medicaid Rehab. Svcs.
• Medicaid EPSDT

• MENTAL HEALTH
• MH General Revenue
• MH Medicaid Match
• MH Block Grant

• EDUCATION
• ED General Revenue
• ED Medicaid Match
• Student Services

• SUBSTANCE ABUSE
• SA General Revenue
• SA Medicaid Match
• SA Block Grant

• CHILD WELFARE
• CW General Revenue
• CW Medicaid Match
• IV-E
• IV-B
• Adoption and Safe Families Act

• OTHER
• TANF
• Childrens Medical Services
• Mental Retardation/Developmental Disabilities
• Title XXI
• Local Funds

• JUVENILE JUSTICE
• JJ General Revenue
• JJ Medicaid Match
• JJ Federal Grants

S. Pires, 2002
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How Can We Make It Work?
CHILD WELFARE
JUVENILE JUSTICE
EDUCATION
MENTAL HEALTH
Blended, Braided, Flexible Child Focused vs.
System Focused
Care Coordination
Provider Network
Child and Family
Plan of Care
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3. Using What Works

• Identifying and implementing practices that work
  (evidence-based, best practices)
• Examine array of existing programs/services,
  discard practices that are not effective
• Build in accountability and CQI data feedback
  loops beyond monitoring
• Families want what works and family choice

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Using What Works

• The effectiveness of services, no matter what
  they are, may hinge less on the particular type
  of service than on how, when, and why families or
  caregivers are engaged in the delivery of
  care...it is becoming increasingly clear that
  family engagement is a key component not only of
  participation in care but also in the effective
  implementation of it. (Burns, Hoagwood,
  Mrazek)
• Evidence based practices are part of the answer
• Promising and best practices need to be in the
  mix
• Balanced by strong engagement between families
  providers
• And a goal of resiliency and recovery- reaching
  potential

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Useful Websites for Evidence-Based and Promising
Practices

• National Registry of Evidence Based Programs and
  Practices (NREPP)
• http//www.delprograms.samhsa.gov/template_cf.cfm
  ?pagemodel_list
• Office of Juvenile Justice Delinquency Prevention
  Model Programs Guide
• http//www.dsgonline.com/mpg2.5/mpg_index.htm
• Georgetown University National Technical
  Assistance Center
• http//www.gucchd.georgetown.edu/programs/ta_cent
  er/topics/evaluationevidencebasedpractice.htm
• National Wraparound Initiative
  http//www.rtc.pdx.edu/nwi
• National Implementation Research Network
• http//www.nirn.fmhi.usf.edu
• Center for Evidence Based Practice  Young
  Children With Challenging Behavior
  http//challengingbehavior.fmhi.usf.edu/fixsen-eta
  l-may03.html
• State of Hawaii ttp//www.hawaii.gov/health/menta
  l-health/camhd/library/pdf/ebs/ebs016.pdf

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4. Harnessing Technology

• Delivery of care e.g., telehealth,
  tele-trainings, etc.
• Decision-support
• Providers Interagency Decision-Support
  Coordinated information technology infrastructure
  to enable sharing of data
• Family Decision-Support Information collection,
  organization and dissemination to support
  family-driven care
• www.networkofcare.org

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Is there evidence that transformation will
improve youth, program and system outcomes?
26
Comparative Cost Data

• Community-based Services vs
• Institutional Costs
• (approx. average annual per child cost)
• Kansas 12,900 vs. 25,600
• Vermont 23,344 vs. 52,988
• New York 40,000 vs. 77,429
• (2001 data)

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Wraparound Milwaukee

• Outcomes
• Reduced juvenile delinquency
• Higher school attendance
• Better clinical outcomes
• Lower use of hospitalization
• Reduced costs of care
• Program costs 4,350/month vs. 7,000 per month
  per child for residential treatment or juvenile
  detention
• Replications Madison, WI Indianapolis, State
  of New Jersey, etc.

B. Kamradt 2002
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Boston Childrens Hospital Community Health
Partnerships

• Partnership with Schools
• Low income African American/Hispanic, poor
  performing schools
• School Guidance Counselor- school-wide
  prevention/early intervention programs starting
  in 6th grade
• Outcomes 3 years, all 7th graders pass English
  MCAS exam
• In top 52 schools for closing achievement gap
  between white and minority students
• 
  Beardslee, 2006

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Whats happening around the country?Key
mental health an issue beyond the specialty
mental health system
30
Leverage NFC Report for State-Level Reform

• Different strategies
• focus on specific goal areas or general concept
  of transformation and recovery
• www.nasmhpd.org for state implementation
  activities
• Major State reform efforts
• Childrens Substance Abuse and Mental Health
  State Infrastructure Grants (7)
• State Infrastructure Grants (7)

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State Reform Efforts New Mexico

• Interagency Behavioral Health Purchasing
  Collaborative- formed by Governor
• Legislation statewide system of behavioral
  health care emphasize prevention, early
  intervention, resiliency, recovery,
  rehabilitation
• 17 agencies- comprehensive BH plan
• Inventory all expenditures
• Commitment to system of care values
• Single delivery system with shared vision and
  goal Straight from NFC
• Uniform billing codes and definitions
• Emphasis on evidence-based practices

32
State Reform Efforts New Mexico

• Contracting with 1 Statewide Entity (carries full
  risk)
• Contract with providers
• Braided flexible funding single billing process
• UR/UM
• Assuring Care Coordination
• Consumer/Family relations
• Behavioral Health Planning Council
• 51 families and consumers
• Local Systems of Care

33
State Reform Efforts Kansas

• Kansas Transformation Work Groups
• Governor-supported Driven by advocates and
  Consumer and Family Organizations
• State-wide work groups focusing on 6 goals of NFC

34
State Reform Efforts Illinois

• Illinois Childrens Mental Health Act
• Legislation created Childrens Mental Health
  Partnership
• 25 member cross agency, advocates and legislators
• Re-organize childrens mh services
• Mandate To develop Childrens MH Plan June
  2005 cross agencies, budgets, prevention and
  education component
• Make childrens mental health a priority

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Creating and Sustaining Momentum for
Transformation
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Components of TransformationFormer Surgeon
General, Dr. Julius Richmond
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Creating An Action Plan for Transformation

• Transformation requires three essential elements
• a new and continuously expanding knowledge base
• a social strategy to accomplish change,
• sustained public and political will

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Sustaining Momentum

• Process (who signs up when the meetings
  over?)
• Ongoing commitment to collaboration
• To principles and a shared vision
• Ongoing funding and resources
• Political will
• Driven by
• Knowledge of what works
• Demonstrable benefits
• Strategic alliances and support
• Focused by
• Systematic planning and action

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Whats really required for transformation?

• Proof its the right thing to do
• Data
• Political outcomes
• Clinical and Quality of Life outcomes
• Economic outcomes
• Progressively deeper collaboration
• Economic buy-in (match issues, reprioritizing
  funding)
• Policy, procedure, relationship values changes
• Experiences the benefits of collaboration

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Whats really required for transformation?

• Progressively stronger engagement of
  families/advocacy organizations
• Design implementation
• Evaluation
• Training/Social Marketing
• Advocacy

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Transformation is Messy

"The truth is that change is inherently messy. It
is always complicated. It invariably involves a
massive array of sharply conflicting demands.
Despite the best-laid plans, things never happen
in exactly the right orderand in fact, few
things rarely turn out exactly right the first
time around real change is intensely personal
and enormously political.
- David Nadler, from Champions of Change
42
Achieving the PromiseUse the New Freedom
Commission report to.

• Help the community (local, state, nationally)
  understand what they should want
• Why a child with behavioral health needs who
  graduates, is employable, and has a future is a
  good outcome for the child, the community and the
  country.

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Frame Understandable Messages.

• Communities, legislatures, governors will not
  always understand why systems of care, or
  evidence-based practices, or recovery and
  resiliency or childrens self-esteem are good
  things.
• They will understand why children who are not
  incarcerated, who do not drive drunk, who
  graduate, and who have higher incomes as adults
  is a good thing.

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Use transformation to focus on childrens lives
in their communities, not their lives in our
systems
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WE SHALL HAVE ALL OF ETERNITY IN WHICH TO REST.
NOW, LET US WORK FOR THEIR SAKE AND OURS