Policy and Service Development

1. Prepared by Ken Chan Chief Officer (Children and Youth) Hong Kong Council of Social Service Policy and Service Development

2. Policy issues for LA mental health system • Integration of additive problems in mental health system under the same Bureau • “Single point of responsibility” in Policy and service level • Continuum of Care and Collaboration among Departments and different sectors • Abiding law for the protection of the deprived

3. Trends of Service Development • Initiate new service for early identification of mental health problem at the Age 0-5 • Initiate children scorecard to help on monitoring the overall quality child care service including mental health • Initiate the movement of evidence-based practice in all level of service planning and policy decisions. • Prevention and treatment of co-occurring mental disorder and other problems, e.g substance abuse, suicide, unemployment, HIV etc. • Accessibility of service for ethnic minorities

4. Evidence-Based Practice • Trend in the future mental health practice and service provision

5. Goals To highlight the available social science evidence on mental health services for foster children, from which service systems models can be developed To encourage the integration of known research into the planning, development and delivery of mental health services to children in foster care To dispel some of the prevailing myths and misperceptions about the mental health needs and best treatment options for children in foster care To provide service information, implications and recommendations designed to improve the delivery of mental health services to foster children.

6. Integrating evidence-based elements in direct practice In general, research examining outcomes for community-based and institutional interventions has not used efficacy trials in which and active intervention is compared to a “passive” one such as placebo or wait-list controls. The terms strong, moderate and weak not only refer to the scientific rigor of the research design, but also to the number of studies carried out and the outcomes obtained. The clinical trials of multi-systematic therapy, a treatment supported by strong evidence, all studies have employed a random assignment design, there have been several replications and positive long-term outcomes have been consistently obtained. Interventions with moderate evidence are those where either there is less rigor in the design or there has only been one study demonstrating a positive outcome for the intervention. Finally, interventions with weak evidence either show poor outcome or do not employ rigorous research designs.

7. Case study: Evidence-Based Strategies for Working with Foster Children

11. Evidence-Based Treatments for Childhood Mental Disorder

12. Prevention and treatment of Co-occurring Mental Disorder and other problems • 二零零四年，世界心理衞生聯盟選取了「世界精神健康日」的主題為「身體與精神健康的關係-精神及生理失調的共存」(The Relationship Between Physical and Mental Health: Co-occurring Mental and Physical Disorders) • Implication for mental health service in Hong Kong • Do we have relevant data on this issue ? • How does our practice right now in handling this issue ?

13. Mueser et al. (1998) reviewed two decades of etiological theories related to co-occurring substance abuse disorders and mental disorders. Based on that analysis, they offered 4 general models that synthesize current thinking in the field regarding the etiology of co-occurring substance abuse disorders and mental disorders (Anthony, 1991; Kosten and Ziedonis, 1997; Kushner and Mueser, 1993; Lehman et al., 1989; Meyer, 1986; Weiss and Collins, 1992): • Common factor models. High rates of co-morbidity are the result of risk factors4 shared across both severe mental illness and substance abuse disorders. 4 Risk Factors are factors such as low socioeconomic status or relationship loss and bereavement that increase an individual’s, a group’s, or a community’s vulnerability to mental illness or substance abuse.

14. Models on Co-Occurring Problems • Secondary substance abuse disorder models. Severe mental illness increases a person’s chances of developing a substance abuse disorder. • Secondary mental/psychiatric disorder model. Substance abuse precipitate severe mental illness in people who would not otherwise develop a severe mental illness. • Bi-directional models. Either severe mental illness or substance abuse disorders can increase a person’s vulnerability to developing the other disorder.

15. The Healthcare for Communities Survey • Among people with co-occurring disorders, this study found that 72 percent did not receive any mental health or substance abuse treatment over the previous year (Watkins et al., 2001). • Fewer than 25 percent of individuals with co-occurring disorders received appropriate mental health services, and only 9 percent received supplemental substance abuse servies.

16. Current Situation on Co-Occurring Problems • Many Individuals Receive No Care or Inadequate Care • The National Co-morbidity Survey Replication. • Preliminary results are incompletely weighted and based on the first half of the NCS-R survey.

17. Rates of Treatment by Type (Mental Health, Substance Abuse) and by severity Level of the Disorder (NCS-R)

18. Co-Occurring Substance Abuse Disorder and Mental Disorder Conceptual Framework

19. The Science-to-Services Agenda: Closing the Gap from Research to Practice (1) • The various windows of opportunity across the life span in which co-occurring disorders may be prevented. • The effectiveness of specific interventions (e.g. group therapy, case management) for people who have co-occurring disorders. • The identification of validates, reliable, and standardized screening and assessment tools (including testing for drugs and alcohol), for co-occurring disorders that are age, gender and race/ethnicity appropriate and can be used by a range of providers in varying service settings.

20. The Science-to-Services Agenda: Closing the Gap from Research to Practice (2) • Epidemiological studies regarding cohorts of people with co-occurring substance abuse disorders and mental disorders whose levels of disease severity place them into one of the four quadrants of the conceptual framework developed for co-occurring disorders. • The cost-effectiveness of varying levels and types of interventions – whether prevention or treatment – for people with co-occurring disorders, including costs and cost-offsets in other service systems, such as criminal justice, primary health care, child welfare, homeless services, and emergency medicine. • Service system research to determine how financial incentives and accountability measures affect service system change.

21. High risk group • Children and adolescents • Women and men who have been physically and/or sexually abuse • People who are homeless • People with HIV/AIDS • People who are making the transition from the criminal justice system to the community

22. Technical Assistance • The Agency’s training and technical assistance centres6 will be encouraged to coordinate with one another to facilitate exchange of information and technologies about co-occurring disorders to reach the greatest number of providers possible, making best use of SAMHSA’s resources and knowledge dissemination capacity. • Consistent evaluations on the impact of these training and technical assistance centers will demonstrate how they have made best use of SAMHSA’s resources and knowledge dissemination capacity. • 6SAMHSA’s training and technical assistance centers include the CSAT Addiction Technology Transfer Centers (ATTCs) and Treatment Improvement Exchange (TIE), the CSAP Centers for the Application of Prevention Technology (CAPTs), and the CMHS Mental Health Services Technical Assistance Centers.

23. Technical Assistance (2) • The new Treatment Improvement Protocol for substance abuse services providers, Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT, in press). • The Integrated Co-Occurring Disorders Treatment Toolkit, being developed and evaluated for use by mental health administrators and providers, consumers, and family members as part of the SAMHSA Evidence-Based Practices Project. • The technical assistance report, strategies for Developing Treatment Programs for People with Co-occurring Substance Abuse and Mental Disorders.

24. Prevention, Early Identification, and Early Intervention • Reaching out to primary care practitioners, to educate them about the importance of screening and assessing their patients for the presence of mental and substance abuse disorders, and to provide them with information about appropriate screening and assessment methods, including alcohol and drug testing resources. • Supporting activities to help communities adopt and adapt effective, evidence-based family interventions to reduce the risks for substance abuse and mental disorders. • Further developing and broadening the Agency’s efforts to identify and disseminate evidence-based programs for the prevention and treatment of co-occurring disorders. • Financial support: creative use of the 20 percent prevention set-aside in the SAPT Block Grant to initiate activities that may forestall or prevent the development of substance abuse disorders in individuals at risk for development co-occurring mental disorders. • Working with the U.S. Department of Education to enhance partnerships at the State and local levels to respond to prevention and treatment needs of children and adolescents in schools and in mental health and substance abuse settings.

25. Service Arrangement • Persons with dual diagnosis are served within the mental health service when they are psychiatrically high – substance abuse low (substance abusing mentally ill persons); • Persons with dual diagnosis are served within the substance abuse service when they are substance abuse high – psychiatrically low (complicated chemical dependency, or psychiatrically complicate substance dependence); • Persons are served using shared resources when they are psychiatrically high – substance abuse high (the substance dependent mentally ill).

26. Lessons Learned • Strong intention of State and Federal Government to collect relevant data is important for identify and track the progress of the problem. • Single point of responsibility and professional division of labour help the development of strategies in handling co-occurring case.

27. Program Lessons • Retention is critical; consumers shouldn’t be “scared” away; • Consumer progress should be viewed in small steps; • The more options provided, the more empowered the consumer; • Staff competence to work with persons with dual diagnosis consumers should be the expectation; • Staff must be cross-trained in both fields.

28. Reference: • Larsenich, L. (2002). Evidence-Based Practices in Mental Health Service for Foster Youth. Sacramento, CA: A California Institute for Mental Health Publication. • Substance Abuse and Mental Health Services Administration. (2002). Report to congress on the prevention and treatment of co-occurring substance abuse disorders and mental disorders. Washington D. C. : U.S. Department of Health and Human Services

29. L.A. Mental Health Service Financing Prepared by Ken Chan Chief Officer (Children and Youth) Hong Kong Council of Social Service

30. Basic Structure • Fall into the US health care system: 4 routes • 1. Medicare for the elderly and disabled; • 2. Mediaid for low-income/ public assisted individuals and persons with certain disabilities • 3. Employer-subsidized coverage in the workplace; • 4. Self-purchased coverage available through private insurance companies.

31. Medicare (Federal) • Medicare is a federal health insurance program which provides benefits for eligible persons. There are 2 parts to the program: Part A is hospital insurance and Part B is medical insurance. Medicare does not cover everything.

32. Medi-Cal • Medi-Cal is Califonia’s program to pay for medical care for low-income people, especially families, children, the elderly, and people with disabilities.

33. Problems • Coverage: doctor charge over the Medicare allowable charge • Access to care: • Facilities so overloaded that access is unrealistic • Physicians’ resistance to treating such patients has been ascribed to many causes, including low and delayed payment, paperwork, cultural or language problems, noncompliance.

34. Implication • HK mental health care financing, how about the distribution of youth mental health ? Is it same as the adult ? • The availability of service, waiting period and linkage between services.