Transforming Children

1
Transforming Childrens Mental Health Services

• Presentation to OMHSAS Childrens Advisory
  Council
• May 1, 2006

2
Historical Overview

• Prior to the 1960s, childrens mental health
  services were very limited in Pennsylvania, as
  they were throughout the country.
• There were childrens units in State Mental
  Hospitals, with limited publicly funded services
  in communities.
• In 1965, Eastern State School and Hospital, a
  state facility exclusively for children under 18
  years of age, opened.
• There were some child guidance centers and
  regional diagnostic and evaluation centers
  beginning to appear.

3
Community Mental Health Movement

• Following the passage of federal community mental
  health legislation in 1963, Pennsylvania embarked
  on a process for developing community mental
  health and mental retardation service
  legislation.
• In 1966, the Mental Health and Mental Retardation
  Act was passed, which provided the foundation for
  the development of services throughout
  Pennsylvania, in a partnership where the State
  provides most of the funding, and County
  government serves as the local authority,
  responsible for managing the program.

4
Still, little for children

• community mental health movement was largely
  focused on adults.
• There continued to be limited community services
  for children and adolescents.
• This was true throughout the country, not just
  Pennsylvania.

5
Unclaimed Children

• In 1982, Unclaimed Children The Failure of
  Public Policy by Jane Knitzer was published,
  describing the appalling lack of appropriate
  services for children with emotional and behavior
  disorders.
• The publication of this book galvanized the
  field, spurring efforts at reform.
• In 1984, Congress created the Federal National
  Institute of Mental Health Child and Adolescent
  Service System Program (CASSP) Initiative.

6
Pennsylvania Reaction

• Connie Dellmuth took over what functioned as the
  Childrens Bureau.
• 1985, Pennsylvania was awarded a federal grant
  for CASSP systems development.
• A state structure was established, and the
  process was begun to provide funding for CASSP
  coordinators to be established in each county
  MH/MR Program.

7
Student Assistance Program

• 1985 saw the beginning of the Student Assistance
  Program, a collaborative effort involving mental
  health, drug and alcohol, and education, to
  provide screening and assessment in all 501
  school districts in the Commonwealth.

8
Service Development

• Intensive Case Management (but development for
  children was slow).
• In the late 1980s, Pennsylvania established Host
  Home and residential treatment facilities.
• In addition, funds were provided for counties to
  establish Family Based Mental Health services.
  This was one of the earliest standardized
  programs.

9
CASSP Institute

• The CASSP Training Technical Assistance Institute
  Program was established in the early 1990s to
  provide ongoing statewide training and technical
  assistance.
• The CASSP Institute is managed through a contract
  with Penn State University.

10
Role of Parents and Family Advocates

• The role of parents in the childrens mental
  health system has been a central focus of the
  childrens service system development.
• For more than a decade, there was a CASSP
  Advisory Committee that served in an Advisory
  role to Childrens Bureau and to the Deputy
  Secretary for the Office of Mental Health and
  Substance Abuse.

11
BHRS

• In the early 1990s, Pennsylvania attempted to
  implement the highly acclaimed Wraparound
  approach to serving children with serious
  emotional disturbance.
• However, Wraparound was funded primarily by
  Medicaid as BHRS. A complex set of requirements
  were developed, many of which obfuscated the true
  essence of the wraparound philosophy.

12
Medicaid Financing

• The use of Medicaid to fund the vast majority of
  childrens mental health services has mixed
  blessings.
• There is relatively easy access because
  Pennsylvania has a very generous Medicaid benefit
  for children (children with a diagnosed
  disability are considered as a family of one
  which usually means that they are eligible for
  Medicaid).

13
However

• However, the use of Medicaid involves a medical
  necessity test, which means that the system is
  largely pathology focused.
• And there are limitations to what can be funded
  and under what conditions the services must
  operate.

14
Managed Care

• Pennsylvania introduced Medicaid Managed Care in
  the mid 1990s. Today, approximately 75 of the
  Medicaid population in Pennsylvania is covered by
  managed care.
• By July, 2007 the entire Commonwealth will have
  behavioral health managed care

15
Benefits

• Under the behavioral health component of the
  HealthChoices program, counties are required to
  ensure timely access to medically necessary
  mental health and drug and alcohol services and
  sufficient capacity to assure the consumer choice
  of their provider of service.
• Managed care has significantly increased the
  access standards to which the counties are held,
  and the depth of the monitoring of their
  compliance with those standards.

16
Reorganization

• The Childrens Bureau had been eliminated in the
  mid 1990s during a reorganization for managed
  care.
• The Childrens Bureau reestablishment in 2003 has
  returned a focus on childrens behavioral health
  services.

17
Current Environment

• Cabinet for Children and Families
• Commission for Children and Families
• System of Care Initiative
• Integrated Childrens Service Plans
• Integrated Childrens Service Initiative
• School Based Partial Initiative
• Restraint Elimination (Alternatives to Coercive
  Treatment)

18
Opportunities/resources

• Interagency Childrens (CASSP Conference)
• Office of Child Development and health Department
  Early Childhood grant
• University Childrens Policy Collaborative
• MacArthur Foundation Model System Initiative
• Childrens Behavioral Health Task Force
• Legislative Budget Finance Committee
• Youth Suicide Prevention Grant
• AND

19
Transformation Facilitation

• National Technical Assistance Center for
  Childrens Mental Health at Georgetown
• Pennsylvania one of 10 states chosen
• Purpose is to support State Childrens Directors
  in identifying and realizing their state
  transformation goals for child and family mental
  health

20
Technical Assistance

• Assessment protocol
• Monthly telephone calls
• Access to resources
• Peer support form other states
• Discipline through Action Plan

21
What will we Transform

• Childrens Bureau Retreat involving OMHSAS
  Executive staff and Parent C0-chair of Advisory
  Council identified priorities for
• Prevention and Early Intervention
• Child and Family Teams, and
• Development of the Continuum of Effective Services

22
Presidents New Freedom Commission found

• unmet need (as much as 75 do not receive special
  mental health service)
• and fragmentation
• and the lack of a comprehensive, systematic
  approach to childrens mental health

23
Subcommittee on Children and Families

• Expanded the focus of the Commission which was on
  children with serious emotional disorders
• To include intervention for children at risk for
  mental disorders
• As well as prevention of mental health problems
  and promotion of positive mental health for all
  children

24
Vision

• Based on a System of Care approach
• Calls for a broad array of services and support
  in a childs home, school and community
• In partnership with the family and consistent
  with the culture, values, and preferences pf the
  child, youth and family.

25
A Public Health Approach

• Preventing mental health problems, and
• Creating conditions that promote positive
  socio-emotional health for all children

26
10 Challenges

1. Developing Comprehensive Home and Community based
   services
2. Family Partnerships and Support
3. Culturally Competent Care
4. Individualized Care
5. Evidence Based Practice

27
Challenges, continued

1. Coordination of Services, Responsibility, and
   Funding
2. Prevention, Early Identification and Early
   Intervention
3. Early Childhood Intervention
4. Mental Health in Schools
5. Accountability

28
Workforce Development

• Transformed system will focus on natural
  supports, and
• all staff will have expertise in how to harness
  the strengths of the child,
• partner with the family in treatment planning and
  decision-making, and
• to consult and collaborate with all other child
  serving systems.

29
What are other states doing?

• Sheila Pires has reported that many states are
  exploring ways to refinance childrens behavioral
  health services. These include
• looking for new money (primarily maximizing
  federal Medicaid),
• redirecting current spending (primarily through
  reducing residential and/or moving money from
  services that produce poor outcomes), and
• developing a locus of responsibility whereby a
  care management entity is empowered to purchase
  needed services to address the needs of the top
  5 of children who present with the most
  extensive (and potentially most expensive needs).

30
Locus of Responsibility

• Wraparound Milwaukee, the Indiana DAWN Project,
  the New Jersey single payer system, and the New
  Mexico purchasing collaborative.
• The experiences of these projects shows that
  consolidated purchasing power can effect changes
  in the provider community.
• Furthermore, the entity with centralized
  accountability must have complete family
  involvement and focus on community supports, not
  just paid services.

31
Sheila Pires

• systems change will require structural change,
  training, coaching, and support.
• Sheila recommends that Pennsylvania consider
  several counties as early adapters to begin the
  concept of centralized authority for children who
  have complex, multi-system needs. This will
  allow experimentation with integrated care
  management, case rates, risk pools, and
  regulatory/policy changes.
• It will also allow for the development of family
  and consumer involvement that is essential to the
  ultimate success of such a cross categorical
  effort.

32
Our Transformation Priorities

• Child and Family Teams
• Evidence Based Practice
• Early Identification and Early Intervention
• Interagency Integration
• Managed Care
• Youth Suicide Prevention

33
Recovery and Resilience

• People who are involved in supportive social
  relationships experience benefits in terms of
  health morale and coping
• Strengthening interpersonal and community ties is
  a resilience and development promoting strategy

34
Child and Family Teams

• In Arizona, the child and family team is
  comprised of the child, the childs family,
  foster parents, a behavioral health
  representative,
• and any individual important in the childs life
  who are identified and invited to participate by
  the child and family

35
Congruent with

• Wraparound
• Family Group Decision making
• Person centered planning
• IDEA Individual Family Service Plan

36
The Ideal

• One family
• One Team
• One Plan
• Everyone working to support the child and family

37
Family Development Credential Training Program

• Allegheny County, skills and competencies related
  to working effectively with individuals and
  families.
• to ensure that services to families are
  consistent with DHS guiding principles, i.e.,
  high quality, strengths-based, culturally
  competent, individually tailored and empowering,
  and holistic. Helping individuals and families
  reach their goals and attain a healthy self
  reliance and interdependence with their
  communities, requires workers who are skillful
  and knowledgeable. This FDC training will help
  front line workers to enhance their own
  competence, self-confidence and empowerment, so
  that they can help to engender the same in the
  families with whom they work.

38
Maryland Waiver

• a wraparound model of community-based service
  delivery for children with serious emotional
  disturbance (SED).
• The wraparound model is a family-driven,
  community-based, inter-agency cooperative model.
  Each childs plan of care is tailored to that
  child and familys individual needs.
• Under this model, a care managing entity (CME)
  will receive a set payment rate in exchange for
  delivering a specific package of specialty mental
  health services .

39
continued

• In addition to providing the specified package of
  specialty mental health services, the CME(s) may
  use the rate to provide non-Medicaid covered
  services, with the goal of preventing the need
  for more intensive services.
• The CME(s) will individualize the package of
  benefits to the needs of the child and to build
  on the strengths of the childs family and
  community.

40
Our Vision of Evidence Based and Promising
Practices

• Based on the central role of families as full
  team members and as the critical resource for our
  children
• Recognize the importance of fitting models and
  interventions with the diverse cultural
  perspectives and preferences of families and
  communities
• Place the challenges faced by kids in the context
  of their developmental issues, their family
  circumstances, and the many worlds that real kids
  function in school, peers, neighborhood, family,
  etc.
• Are individualized, holistic, and coordinated
  and
• Insist on outcomes focused treatment planning

41
Evidence Based Practice

• Cognitive Behavioral Therapy
• Functional Family Therapy
• Parent-Child Interaction therapy
• MultiSystemic therapy
• MultiDimensional Treatment Foster Care

42
Other Promising Practices

• Intensive In-Home Services
• Child respite services
• Mobile response and stabilization
• Mental health consultation
• Independent living skills and supports
• Family/Youth education and peer support

43
Whats Not listed as Evidence Based

• Traditional office based talk therapy
• Residential treatment
• Group homes
• Day Treatment

44
Alternatives to Residential

• As part of the Deficit Reduction Act for Federal
  FY October 1, 2006, CMS is considering creating a
  waiver to allow youth to stay in the community
  and receive home and community based services
  instead of being placed in a PRTF.
  The demonstration project will be granted to 10
  states as part of this consideration. CMS would
  like to publish specific information on how to
  apply by the end of the summer.

45
RTFs

• 1710 beds for In State non accredited
• 3027 beds for in state accredited
• 1963 beds for out of state accredited

46
Early Intervention

• Mental Health Consultation to Early care and
  Education
• Partnerships with education on service delivery
  to young children

47
Integration efforts

• System of Care
• Integrated Childrens Services Plan
• Integrated Childrens Services Initiative
• MacArthur MH-JJ Model System Initiative
• Education Initiatives
• Co-occurring efforts

48
Managed Care

• Broad array of evidence based and promising
  practices
• Services and Supports to family members
• Case rates or bundled rates to support evidence
  based and promising practices
• Support to the youth and family to partner in
  planning, quality monitoring, peer support, and
  service provision
• Replace deficit oriented assessments with
  strength based

49
Youth Suicide Prevention

• Promotion of wellness and healthy social,
  emotional, and behavioral development
• Reduction and elimination of stigma
• Early identification and intervention.

50
Our own Call to Action

• We spend 900 million on childrens behavioral
  health services
• We have little more than anecdotal evidence that
  our efforts result in desired outcomes
• We have a wealth of talented, committed people
  with a passion for change.