Creating a System of Care: A Partnership Between Title V and SAMHSA

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Creating a System of CareA Partnership Between
Title V and SAMHSA

• Susan Stromberg
• Child, Adolescent, and Family Branch, SAMHSA
• Jeffrey Lobas, MD
• Child Health Specialty Clinics
• Gary Lippe
• Dept. of Human Services, NE Iowa

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Comprehensive Community Mental Health Services
for Children and Their Families(Systems of Care)

• Susan Stromberg
• October 16, 2007

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The Comprehensive Community Mental Health
Services for Children and Their Families Program
(Childrens Program)

• Encourages the development of home and
  community-based systems of care
• SOCs meet the needs of children and adolescents
  with serious emotional disturbances and their
  families
• SOC communities are administered in States,
  political subdivisions of States, Native American
  tribes or tribal organizations, and U.S.
  territories

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Systems of Care

• Systems of care are developed on the premise that
  the mental health needs of children, adolescents,
  and their families can be met within their home,
  school, and community environments.
• These systems are developed around the following
  principles
• child-centered
• family-driven
• strength-based
• culturally competent
• Additionally, interagency collaboration is
  embedded within these systems.

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Systems of Care Program Framework

• Accountability through outcome evaluation
• Comprehensive array of services
• Cross-agency coordination
• Cultural competence
• Early identification and intervention

• Family partnerships
• Home and community-based services
• Least restrictive service environments
• Strength-based individualized service planning

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System of Care Model
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Do the Math.

• Childrens Mental Health suffering from a lack
  of
• services for children adolescents
• non-restrictive settings
• full community-based service array
• interagency coordination
• family involvement
• cultural competence
• Need for SYSTEMS OF CARE!!

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System of Care Core Values

• Community based
• Child and family focused (family driven and
  youth guided)
• Culturally and linguistically competent

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System of Care Guiding Principles

• Comprehensive array of services
• Individualized care
• Least restrictive setting
• Family and youth involvement
• Service integration

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System of Care Guiding Principles

• Care coordination
• Early identification and early childhood
  intervention
• Smooth transitions
• Rights protection and advocacy
• Nondiscrimination

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System of Care Concept is

• A framework and guide, not a prescription
• Flexible and creative
• Adaptive to family and community needs
• Consistent in philosophy

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Systems of Care Resilience, Leadership
Transformation

• What is involved?
• Rethinking traditional approaches
• Strengths-based
• Family driven youth guided
• Embracing culture

• Who is involved?
• Youth
• Adults
• Families
• Providers
• Communities

Transformation
Systems of Care
Leadership
Resilience
Fulfilling Potential
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Systems of Care Resilience, Leadership
Transformation

• What is involved?
• Rethinking traditional approaches
• Strengths-based
• Family driven youth guided
• Embracing culture

• Who is involved?
• Youth
• Adults
• Families
• Providers
• Communities

Transformation
Systems of Care
Leadership
Resilience
Fulfilling Potential
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System-of-Care Communities of the Comprehensive
Community Mental Health Services for Children and
Their Families Program
Lyons, Riverside, Proviso, IL
Milwaukee, WI
Illinois (Chicago area)
Northwoods Alliance, WI
Lake County, IN
Sault Ste. Marie Tribe, MI
Willmar, MN
Albany County, NY
Lancaster County, NE
Marion County, IN
Detroit, MI
Nebraska (22 counties)
Bismarck, Fargo, Minot, ND
Cuyahoga County, OH
Sacred Child Project, ND
Southern Consortium Stark County, OH
Oglalla Sioux Tribe, SD
Northern Arapaho Tribe, WY
Allegheny County, PA
Passamaquoddy Tribe, ME
Montana Crow Nation
Maine (4 counties)
u
Erie County, NY
Vermont 1 (statewide)
King County, WA
u
Vermont 2 (statewide)
New Hampshire (3 regions)
Clark County, WA
u
u
Worcester, MA
u
Four Counties, OR
u
Rhode Island 1 (statewide)
u
Clackamas County, OR
Rhode Island 2 (statewide)
u
u
Lane County, OR
Connecticut (statewide)
Idaho
Mott Haven, NY
u
New York, NY
United Indian Health Service, CA
Westchester County, NY
u
Burlington County, NJ
u
South Philadelphia, PA
Glenn County, CA
Delaware (statewide)
Sacramento County, CA
u
u
Baltimore, MD
Napa Sonoma Counties, CA
Montgomery County, MD
Contra Costa County, CA
u
Washington, DC
u
u
Oakland, CA
Alexandria, VA
San Francisco, CA
Charleston, WV
u
Monterey County, CA
Edgecombe, Nash, Pitt Counties, NC
u
California 5 (Santa Cruz, San Mateo, Riverside
Ventura, Solano Counties)
North Carolina (11 counties)
North Carolina (10 counties)
Santa Barbara County, CA
u
3 counties Catawba Nation, SC
Clark County, NV
Charleston, SC
u
San Diego County, CA
Greenwood, SC
Gwinnett Rockdale Counties, GA
Rural Frontier, UT
Pima County, AZ
Navajo Nation
Eastern Kentucky
u
Las Cruces, NM
u
Hillsborough County, FL
El Paso County, TX
Kentucky (8 counties)
West Palm Beach, FL
Colorado (4 counties)
Birmingham, AL
Denver, CO
Broward County, FL
Yukon Kuskokwim Delta Region, AK
Wichita, KS
Nashville, TN
Louisiana (5 parishes)
Oklahoma
Funded Communities
Fairbanks, AK
Jackson, MS
Travis County, TX
St. Louis, MO
Ft. Worth, TX
Date Number
Date Number
St. Charles County, MO
Parsons, KS
Wai'anae Leeward, HI
9-1-93 4 2-1-94 7 9-1-94 9 11-1-94
2 9-1-97 9 10-1-98 13 11-1-98 1
9-30-99 20 5-1-00 1 7-1-00 1 10-1-02
18 9-30-03 7 9-30-04 4
Guam
Missouri
Choctaw Nation, OK
Puerto Rico
u
u
u
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Systems of Care as a Transformation Strategy
Vision Beliefs Actions x (CQI)2
Moving from family involvement to family driven
FamilyInvolvement

• Customer focused
• Family driven
• Bridging Systems

Fully embracing youth involvement
YouthInvolvement
Integrating technical assistance activities
TechnicalAssistance
Opening the data set Establishing key benchmarks
Research
Sustainability - defining how systems of care
contribute
Moving from concept to reality. Tools strategies
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National Wraparound Initiative

• Setting standards
• Developing materials that are user-friendly

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Continuous Quality Improvement

• Embracing CQI and the Benchmarking Initiative

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CQI Feedback
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Indicator 32 - Caregiver and Other Family
Involvement in Service Plan

• Increase family involvement in developing the
  service plan, either through attending planning
  meetings or approving treatment plans.
• Benchmark 100

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Systems of Care Work!

• Reductions in use of restrictive levels of care
  and residential placements across systems
• Cost reductions and cost avoidance
• Improved clinical and functional status
• Decreased juvenile recidivism and incarceration
• Improved school attendance and achievement

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Family driven means

• Family-driven means families have a primary
  decision making role in the care of their own
  children as well as the policies and procedures
  governing care for all children in their
  community, state, tribe, territory and nation.

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Beginnings
Youth MOVE
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Youth Involvement in Systems of Care

• A starting point for understanding youth
  involvement and engagement in order to develop
  and fully integrate a youth-directed movement
  within local systems of care. http//www.tapartne
  rship.org/

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Transformation Resources
Got a question about a family-driven,
youth-guided system of care? Start
here www.systemsofcare.samhsa.gov
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Work togetherThere is strength in numbers

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System of Care Partnership between SAMHSA,
DHS, and CHSC

• Jeffrey Lobas, MD, EdD.

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Child Health Specialty Clinics

• Iowas Title V Agency for Children with Special
  Health Care Needs
• Funded through IDPH, categorical grants,
  contracts, reimbursement for services
• Administratively housed in the Dept. of
  Pediatrics at the University of Iowa

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Title V Children with Special Health Care
Needs Child Health Specialty Clinics (CHSC)
Direct Services
Enabling Services
Population Based Services
Infrastructure Building
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CHSC Mission

• The Child Health Specialty Clinics (CHSC) mission
  is to improve the health, development, and
  well-being of children and youth with special
  health care needs in partnership with families,
  service providers, communities and policy makers.

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Child Health Specialty Clinics
Mason City
Spencer
Sioux Center
Oelwein
Elkader
Dubuque
Ft. Dodge
Waterloo
Sioux City
Carroll
Iowa City
Des Moines
Davenport
Council Bluffs
Chariton
Creston
Burlington
Ottumwa
Shenandoah
Regional Centers
Satellite Centers Central Office
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Some of the Programs and Services CHSC Offers

• ABCD II Project
• Birth to Five Services
• Health and Disease Management
• Continuity of Care Program
• Family to Family Support
• Integrated Evaluation and Planning Clinics
• Regional Autism Services Program
• Telehealth
• Iowa Medical Home Initiative
• Early ACCESS

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History of CHSC and Childrens Mental Health

• 1997-Needs Assessment
• 1999-Future Search
• 2001-Governors White Paper
• 2002-Creston Project
• 2003-Magellan and CHSC
• 2004-CHSC Statewide Implementation
• 2005-Oversight Committee
• 2007-SAMHSA System of Care

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Creston Project

• Evaluation of Statewide Services
• Research on a Delivery Model
• Statewide Implementation
• Spread Strategy
• Collaborative approach

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Evaluation of Service Delivery for CHSC

• Focus Groups
• Structured Interviews with Families and Community
  Leaders
• Outcome Research
• Flow and Time Studies
• Satisfaction Surveys

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Patient Data

• Patients seen July 2004 June 2005
• Burlington 85 Carroll 84
• Council Bluffs 119 Creston 196
• Davenport 20 Dubuque 71
• Fort Dodge 219 Mason City 555
• Ottumwa 175 Sioux City 150
• Spencer 631 Waterloo 16
• Total 2321

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Most Common Primary Diagnosis at CHSC

• ADHD (all types) 63
• Conduct / Oppositional Defiant Disorders 7
• Reaction Attachment Disorders 5
• Developmental Disorders 4
• PDD Spectrum and other Child Psychosis 3
• Total with behavioral or mental health diagnosis
  93

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Outcomes Research

• Key Components of Intervention Model
• Multidisciplinary Team
• Enhanced care coordination.
• Initial on-site psychiatric assessments, if
  indicated by intake procedures
• Telehealth/telepsych patient follow-ups
• Telehealth consultations to primary care and
  other service providers
• Educational events targeting service providers
• Best practice/care guidelines
• Systemic data collection regarding patient/family
  outcomes and service delivery processes and
• A community advisory board and consumer
  participation

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Enhanced Care Coordination

• Care Plan development
• Arrangement of Service Delivery
• Alignment of advocacy across systems
• Collaboration with family and physicians
• Crisis intervention plan
• Follow-up with family and team

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CANS DATA

• Degree of Clinical Change (percent) at Discharge
  for Children who Received CBHP vs. Usual Care
• Enhanced Program
• Dimensions Key Components (1-8) Usual Care   
• (N25)   (N34) 
• Problems 4 -30 
• Mental health 3 -23 
• Substance use 22 -56 
• Risk Behaviors 10 -4 
• Functioning 24 -18 
• Caregiver capacity 11 -7 
• Strengths 9 -9  
• significant difference between groups (plt.05) 

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CANS DATA

• Children who received CBHP services were more
  severe from children who received usual care
  across several factors including
• Being more often abused (68 v. 8)
• Had used psychiatric inpatient care (24 v. 0)
• This increasing identification of children with
  complex behavioral health needs significantly
  affected the potential degree of clinical change
  at discharge.
• As a result, the CBHP was the most effective
  model in improving both the functional and
  strengths/supports dimensions in CANS-MH scores.

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CANS DATA

• CANS-MH score results from the CBHP data is
  comparable to a recent comprehensive review of
  level of care needs across the New York state
  system of mental health utilizing the CANS
  instrument.
• Data suggests that IEPC is similar to the
  intensity of services provided by the Intensive
  Case Management levels of care in New York.

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Findings

• A multidisciplinary team approach was very
  effective
• Care coordination and follow-up of services was
  important to patient outcomes
• Appropriate triage at intake yielded greater
  efficiency and more effective results to patients
• Tele-health is an extremely valuable tool in
  providing services to underserved areas of the
  state
• Clinical guidelines enhance care

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Findings

• There is great variability among regional centers
  in many areas which makes quality assurance
  difficult to achieve
• The role and methods of triage has to be
  standardized and more training needs to be
  provided
• Increased cost efficiency can be gained through
  standardized methods of triage, appropriate use
  of team, standardization of forms and dictation
  methods and gaining reimbursement for services by
  non-physician providers
• Highest level of unmet need was identified as
  availability of child psychiatry

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Conclusions

• A standardized approach is needed at all centers
  which would include
• Comprehensive triage and follow-up plan
• Availability of a multidisciplinary team at each
  regional center
• Utilization of standardized history forms and
  clinical tools - Vanderbilt CHSC Med Hx Beh Hx
  Social Hx and School Hx forms
• Standardized dictation methods into the PEDS
  centralized transcription and issuance of reports

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CHSC Challenges and Barriers

• Inadequate Resources (Long-waiting lists)
• Minimal services available
• Emergency and Crisis Intervention
• Wrap-around Services
• Social Marketing and Outreach

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Evolution of Service Model

• Oversight Committee
• Discussions between CHSC, DHS, SAMHSA
• Development of Proposal
• SAMHSA System of Care

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Childrens Mental Health System of Care
Early Identification
Primary Care
Schools
Juvenile Justice
Child Welfare/ DHS
Community
Mental Health Agencies
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care


Schools
Multidisciplinary Team
Juvenile Justice
Child Welfare/ DHS
Community
Mental Health Agencies
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigator Team
Navigator Team
Outreach/ Lighthouse
Juvenile Justice
Child Welfare/ DHS
Community
Mental Health Agencies
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigator Team
Navigator Team
Outreach/ Lighthouse
Juvenile Justice
Rx and and Care Plan
Family Team Meeting
Care Coordination (Process)
Monitor and Feedback
Evaluation and Dx
Intake/ Triage
Child Welfare/ DHS
Community
Mental Health Agencies
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigator Team
Navigator Team
Outreach/ Lighthouse
Juvenile Justice
Care Coordination (Process)
Family Team Meeting
Monitor and Feedback
Intake/ Triage
Evaluation and Dx
Rx Care Plan
Child Welfare/ DHS
Community
Subspecialty and Primary Care
Mental Health Agencies
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigator Team
Navigator Team
Outreach/ Lighthouse
Juvenile Justice
Care Coordination (Process)
Evaluation and Dx
Rx and Care Plan
Family Team Meeting
Intake/ Triage
Monitor and Feedback
Child Welfare/ DHS
Community
Subspecialty and Primary Care
Mental Health Agencies
Community Based Wraparound Services
Families
Family/Youth Advocacy Orgs
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigators Team
Navigators Team
Outreach/ Lighthouse
Juvenile Justice
Care Coordination (Process)
Family Team Meeting
Monitor and Feedback
Evaluation and Dx
Rx and Care Plan
Intake/ Triage
Child Welfare/ DHS
Community
Subspecialty and Primary Care
Mental Health Agencies
Community Based Wraparound Services
Families
Family/Youth Advocacy Orgs
Emergency and Crisis Management
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Childrens Mental Health System of Care
Implementation and Coordination
Monitor and Follow-Up
Evaluation, Assessment and Diagnosis
Treatment and Care Plan
Early Identification
Community Circle of Care Child Health Specialty
Clinics
Primary Care

Schools
Multidisciplinary Team
Navigator Team
Navigator Team
Outreach/ Lighthouse
Family Team Meeting (Local)
Juvenile Justice
Treatment and Care Plan
Care Coordination (Process)
Monitor and Feedback
Evaluation and Dx
Intake/ Triage
Child Welfare/ DHS
Community
Subspecialty and Primary Care
Mental Health Agencies
Community Based Wraparound Services
Families
Family/Youth Advocacy Orgs
Emergency and Crisis Management
Quality Assurance and Evaluation
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Community Circle of Care

• Partnership, Collaboration, Integration

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Systems of Care Work
Community Circle of Care
DHS Iowa Department of Human Services
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ACCESS
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Navigation
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COORDINATION
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INDIVIDUALIZED SUPPORTS
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Systems of Care Professionals and Families Share
Common Goals
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• We want children and youth to be in safe and
  stable homes
• We want to assist families to meet their
  childrens needs
• We seek family preservation or reunification if
  the child has been removed

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Meeting the mental health needs of children,
youth, and families is critical to achieving
these goals
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What Works?

• When children and youth with serious mental
  health needs receive coordinated services, their
  functioning substantially improves at school, at
  home, and in their community.

Data Trends 104, September 2004, University of
South Florida
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A System of Care IsA community partnership
among families, youth, schools, and public and
private organizations which provide coordinated
mental health services. Our partners include

• Families
• Education
• Provider Agencies
• Mental health and substance abuse professionals

• Juvenile justice
• Primary health care
• Faith community
• Other community organizations
• Child welfare

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A System of Care IsGuided by Core Values

• Family-driven and youth-guided
• Researched and evidenced based
• Supports Individualized for each family
• Wrap around services provided
• Culturally and linguistically competent
• Community-based

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Benefit Homes Are Stable

• The percentage of children and youth who lived in
  multiple settings decreased by 11 percent over 12
  months.

Source CMHS National Evaluation Aggregate Data
Profile Report, 2005
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Benefit Families Are Stronger

• Caregiver strain is reduced in many families.
• More than a quarter of families had higher
  functioning after 30 months more than half
  remained stable.

Source CMHS National Evaluation Aggregate Data
Profile Report, 2005
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Benefit Families Have More Resources

• Caregiver job, vocational, and educational skills
  improve.
• Incomes increase.
• Families have more time and support.

Sources CMHS National Evaluation Updates from
the National Evaluation, Services Evaluation
Committee Meeting, 2004 CMHS National Evaluation
Aggregate Data Profile Report, 2004
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Community Circle of CareA care
coordination, wrap around system of care
Community Circle of Care
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Outcome Improved Access to Needed Services

• Decisions about services are made based on what
  the family needs funding is secured through the
  care coordinator which eliminates time and effort
  for the family.
• Services are identified and service gaps are
  filled whenever possible.

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Outcome Empowered Caregivers

• Decisions about services are family driven.
• Parent voice is integral to the developing system
  and to system change at the local and state level
  
• Families have access to other caregivers who have
  experience parenting a child with mental health
  and behavioral challenges.

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Outcome Coordinated Services

• Child welfare, health care, education, and mental
  health professionals work closely together.
• Mental health services are introduced in homes by
  system of care representatives including parents
  who have caregiver experience with a child who
  has mental health and behavioral challenges.
• Professionals who work in the system of care are
  offered technical assistance to better understand
  and serve their clients in a family centered
  approach.
• Needed child and family services are more
  accessible.

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Outcome Decreased Out-of-Home Placements

• Early mental health intervention helps children,
  youth, and families stay together.
• Early mental health intervention reduces the
  length of time for out-of-home placement.

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Outcome Individualized services and supports
for each family

• Supports based on family needs
• Wrap around services
• Services developed in response to needs

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What Our Partnership Could Accomplish

• Coordinated, community-based services that
  support families in need
• Collaborative, individualized plans of action for
  families in their local community
• A community support structure that is accessible
  and family-focused

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Mental Health Perspective of State Title V
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Title V Performance Measures
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AMCHPs Role

• AMCHPs 2005-2009 strategic plan identified
  emotional behavioral health as a priority focus
  area
• Develop Key Partnerships- Public Health, Mental
  Health Systems, Private Sector
• AMCHP in partnership working for policy and
  legislative reforms
• 2006 - AMCHP convened a series of meetings with
  NASHP, SAMHSA, MCHB to produce roadmap
• Developing common set of principles

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Key Partners

• Maternal and Child Health Bureau
• Substance Abuse and Mental Health Services
  Administration
• National Academy of State Health Policy
• Georgetown Child Development Center
• Family Voices
• Federation of Families

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A Common Set of Principles

• A continuum of services relating to mental
  health
• Strengthening the interface between public health
  and mental health, including prevention
• Increasing protective factors and risk reduction.
  
• Mental Health and Primary Care (Medical Home)

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Current Activities

• Developing A Public Health Approach to Mental
  Health
• Collecting and Disseminating Best Practice Models
• Development of Monograph
• Conceptual Framework for PH approach
• Continuum of Services
• Common language

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Next Step Engagement

• Strategies to Engage Stakeholders formally and
  informally
• Stakeholder Meeting
• Focus Groups
• Interviews
• Document Review
• Surveys
• Presentations

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Challenges for Leadership

• Dialogue between cultures
• Trust and understanding
• Value