Transforming Children’s Mental Health Services

1. Transforming Children’s Mental Health Services Presentation to OMHSAS Children’s Advisory Council May 1, 2006

2. Historical Overview • Prior to the 1960s, children’s mental health services were very limited in Pennsylvania, as they were throughout the country. • There were children’s 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 Children’s 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 children’s mental health system has been a central focus of the children’s service system development. • For more than a decade, there was a CASSP Advisory Committee that served in an Advisory role to Children’s 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 children’s 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 Children’s Bureau had been eliminated in the mid 1990s during a reorganization for managed care. • The Children’s Bureau reestablishment in 2003 has returned a focus on children’s behavioral health services.

17. Current Environment • Cabinet for Children and Families • Commission for Children and Families • System of Care Initiative • Integrated Children’s Service Plans • Integrated Children’s Service Initiative • School Based Partial Initiative • Restraint Elimination (Alternatives to Coercive Treatment)

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

19. Transformation Facilitation • National Technical Assistance Center for Children’s Mental Health at Georgetown • Pennsylvania one of 10 states chosen • Purpose is to support State Children’s 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 • Children’s 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. President’s 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 children’s 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 child’s 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 • Developing Comprehensive Home and Community based services; • Family Partnerships and Support • Culturally Competent Care • Individualized Care • Evidence Based Practice

27. Challenges, continued • Coordination of Services, Responsibility, and Funding; • Prevention, Early Identification and Early Intervention; • Early Childhood Intervention • Mental Health in Schools • 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 children’s 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 child’s family, foster parents, a behavioral health representative, • and any individual important in the child’s 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 child’s plan of care is tailored to that child and family’s 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 child’s 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. What’s 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 Children’s Services Plan • Integrated Children’s 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 children’s 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.