The Presidents New Freedom Commission on Mental Health

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FL--CMHV
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Transforming Mental Health for Children,
Adolescents and Families

• Mike Hogan
  Ohio DMH, Commission Chair

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Transforming Mental Health for Children,
Adolescents and Families

• Headlines from the Commission
• Ideas as You Design YOUR Change Process

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President George W. Bush Announcing
the New Freedom Commission Albuquerque,
New Mexico April 29 2002Child/Adolescent
Concerns in the Presidents Speech

• Consider this example -- a 14-year-old boy who
  started experimenting with drugs to ease his
  severe depression. This former honor student
  became a drug addict. He dropped out of school,
  was incarcerated six times in 16 years. Only two
  years ago, when he was 30 years old, did the
  doctors finally diagnose his condition as bipolar
  disorder, and he began a successful program...

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• The Commissions goal shall be to recommend
  improvements to enable adults with serious mental
  illness and children with severe emotional
  disturbance to live, work, learn, and participate
  fully in their communities.
  Presidents Executive Order, April 2002

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The Presidents Commission Scope and Urgency of
the Problem
Prevalence of SED
5-9 Youth with SED very serious problems in
home or at school 9-13 Youth with SED some
problems at home, school 20 Youth with any
diagnosable disorder
Mental health problems among children and
adolescents constitute a public health crisis for
our nation. Report of the Children and Families
Subcommittee
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9-13
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5-9
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The Presidents Commission Scope and Urgency of
the Problem
Prevalence of SED
5-9 Youth with SED very serious problems in
home or at school 9-13 Youth with SED some
problems at home, school 20 Youth with any
diagnosable disorder
At least 25 of adolescents are at serious risk
of not reaching productive adulthood National
Research Council, 2002
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9-13
20
5-9
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Severe Emotional Disturbance Consequences In
Many Sectors Outside the Mental Health System

• Schools
• Behavioral, social-emotional development problems
  are the leading cause of school failure
• While kids with SED have worst outcomes in
  special ed.
• TANF and foster care
• 30-50 of population has mental illness major
  contributor to adult un/underemployment,
  parenting problems (e.g. effects of maternal
  depression on infant development) and poor child
  outcomes
• Health care
• Consensus in pediatrics/adolescent medicine
  Behavioral disorders are the most serious health
  challenges for adolescents
• With specialty mental health care at capacity,
  ERs become an (inefficient, problematic) locus
  of care, and crisis-driven residential
  placements are over-used
• Criminal justice
• Two thirds of juvenile offenders have a mental
  illness (Higher for girls)

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A Challenge Fragmentation is the RESULT OF
REFORM Our old mental model of community
mental health
SAMHSA-CMHS
Federal level
DMH
State level
Funding?
County
Local level
Case Mgt.
M.H. Care
Social Services
Coordinated Care
School
Child
Court
Clinic
Income Support
Meds
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Fragmentation of Services after Reform
Justice
Medicaid
CMHS
HRSA
ACF
Education
SSA
DMH
Ed/SpEd..
State Medicaid Agency
DSS
Health
DYS
BDD
County
Case Mgt.
M.H. Care
Social Svce
LEA/School
Family Child
Court
Meds
?
Income Support
Clinic
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25 Years Since the Carter CommissionWe Also
Have New Opportunities
The biggest change in mental health from 1978 to
today is that
we now know that recovery is possible for any
individual with a mental illness Rosalyn
Carter
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Vision For A Transformed Mental Health
System

• We envision a future where recovery and
  resilience are the expected outcomes and when
  mental illnesses can be prevented or cured.

We envision a nation where everyone will have
access to early detection and the effective
treatment and supports essential to live, work,
learn and participate fully in their communities.
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National Goals To Transform Mental Health Care

• Establish Mental Health as Essential to Health
• Provide Consumer and Family Centered Care
• Eliminate Disparities in Mental Healthcare
• Early Mental Health Screening and Treatment
  Across the Lifespan
• Provide The Best Care Science can Discover and
  Offer
• Capitalize on Technology

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So that is the national picture What should our
strategy be?
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Lessons From Corporate Transformation Kotter,
HBR, 1995 Leading Change Why Transformation
Efforts Fail

• Not establishing a great enough sense of urgency
• Not creating a potent enough Guiding Coalition
• Lacking a Vision
• Undercommunicating the visionby a factor of 10!

• Not removing obstacles to the vision
• Failure to plan/create immediate wins
• Declaring Victory too soon
• Not anchoring the change in the culture

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Ohios Access to Better Care (ABC) Initiative

• GOAL
• To better address the needs of children and
  families with behavioral health needs across the
  developmental spectrum and across the many
  settings/systems where children receive care.
• OBJECTIVES
• Improve access to better prevention, early
  intervention, and treatment services. Reduce
  trading custody for care
• Emphasize community-based, family-centered
  solutions Strengthen and support parent
  involvement
• Emphasize outcome-based and evidence based
  programs
• Increase collaboration and accountability between
  child serving agencies Align and redirect
  resources in addition to increasing capacity
• ABC is
• - A 35M Governors budget initiative now being
  implemented, with a dozen components in 8-9
  Cabinet agencies

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Conceptual Model (Just to prove we have one)
Developmental/Environmental Risks (Start Early in
Childhood)
Risks of Genetically Linked Disorders (Increase
as Children enter teen years)
More ER Use for Child Behavior Issues
Neediest kids sent to residential treatment
parents give up custody to get care
Depresses childs ability to develop
relationships and function independently
Bipolar Disorder
ADHD
Depression
Anxiety, depression
20 of HS Students Consider Suicide
Maternal Depression 30-50 of low income moms
Poor parenting
PTSD
Conduct Disorder
Many Youth in JJ /CW systems mentally ill
Behavioral/Learning Problems Escalate Including
AOD Use
Learning Problems
Child Abuse
50 of Urban Students Fail to Graduate
Age
Birth
3
5 ELEMENTARY SCHOOL 12
MIDDLE-HIGH SCHOOL 18
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ABC Begins to Address Behavioral Health Needs
More ER Use for Child BH Issues, Neediest kids
sent to residential treatment parents give up
custody to get care
Developmental/Environmental Risks
Risks of Genetically Linked Disorders
Depresses childs ability to develop
relationships and function independently
Bipolar Disorder
Problems
Anxiety, depression
ADHD
Depression
20 of HS Students Consider Suicide
Maternal Depression 30-50 of low income moms
Conduct Disorder
Most Youth in JJ system have mental illness
PTSD
Poor parenting
Behavioral/Learning Problems Escalate Including
AOD Use
Learning Problems
50 of Urban Students Fail to Graduate
Child Abuse
Age
Birth
3
5 ELEMENTARY SCHOOL 12
MIDDLE-HIGH SCHOOL 18
Expand School Screening sites (MH)
Strengthen OFCF Accountability Support/
Intercept kids/families prior to residential
placement --Interagency
shared individual/ family plan family
driven/friendly
--Emphasize collaborative Home/ Community
Based Care --Expand
Intensive Home Based Services, pooled funding,
local collaboration (MH, Medicaid)
Expand Early Childhood Mental Health, Incredible
Years, Positive Parenting (MH, Health)
Expand Behavioral Health Professionals Working In
and With Schools, Childrens/Juvenile Systems.
(MH, AOD, DYS, ODE)
Enhance Home Visiting through Increased
Screening and Training (Health)
Promulgate/Support ODE Guidelines for School
Climate/SafetyStrengthen Student Assistance
Programs (ODE, AOD, MH)
Develop, Implement Evidence-Based Prevention
Framework replacing uncoordinated approaches.
(AOD lead)
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Examples from Ohios Experience ABC Initiative

• Establishing a sense of urgency
• Leader consensus built over timeChild welfare
  review, Cincinnati Enquirer series
• Creating a potent Guiding Coalition
• Inside/outside leadership Childrens Cabinet
  WITH kids advocates
• Co-creating a Vision
• Framed As-Is (custody for care, costly
  institutional care, etc.) vs. Desired State of
  accessible, parent-driven, early community care
• Undercommunicating the visionby a factor of 10!
• Personal visits to legislators, legislative
  dinners, Editorial Board visits, budget testimony
  etc. etc.

• Removing obstacles to the vision
• The jury is not inIs this not MUCH harder to do
  in the public sector? (Hello, CMS)
• Creating immediate wins
• Launching FAST 05 early
• Strategic evaluation
• Promoting related successes e.g. Care teams
• Declaring Victory too soon!
• Houston, we have a problem
• Didnt we do kids mental health last year?
• Not anchoring the change in the culture
• The democracy problem

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Thank You
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Goals To Transform Mental Health Examples
Moving an Action Agenda Forward

• Provide Consumer and Family Centered Care
• Develop an individualized plan of care for every
  child with a serious emotional disturbance
• Two Dimensions One Plan/One TableFamily Driven
• Involve consumers and families fully in orienting
  the system to recovery and resilience
• Many many examplesthe Strategic Question How
  dDo We Build the Capacity?
• Realign (federal) programs to meet needs
• Federal Action Agenda Broad, but how deep?
• Broaden the State Mental Health Plan
• With Federal support T-SIG grants
• Without waiting for the feds
• Protect Rights Support Olmstead, Eliminate
  custody relinquishment, Reduce S/R
• New state waiversFederal/State legislative
  proposals, Trauma informed and violence-free
  environments

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Goals To Transform Mental Health Examples
Moving an Action Agenda Forward

• Early Mental Health Screening and Treatment
• Promote the mental health of young children
• Improve and Expand School-Based Mental Health
• Screen and link with treatment
• Screening and collaborative care in primary care