Challenging Behaviors in Challenging Times:How We Can Best Serve Children through Multi-Agency Collaboration UNDERSTANDING OUR SYSTEMS William Arroyo, M.D. Regional Medical Director, Los Angeles County Department of Mental Health December 7, 2010
MISSION Enriching lives through partnership designed to strengthen the community’s capacity to support recovery and resiliency
New Strategic Plan (6-10-10)Goals • Enhance the quality and capacity of mental health services and supports in partnership … within available resources • Eliminate disparities … especially those due to race, ethnicity and culture • Enhance the community’s emotional and social well-being… • …with a workforce capable of meeting the needs of our diverse communities • Maximize fiscal strength… • Use of research and technological advancements…
DMH Nos. At A Glance • No. of outpatient clients: 209,386 (FY 08-09) • No. of inpatients: 15,879 (FY 08-09) • Avg. daily no. of clients in adult justice programs: 2300 • No. clients served in juvenile justice programs: 15,954 (FY 08-09) • No. of clients with Public Guardian: 2800 • No. of calls received by ACCESS: 283,098 • Crisis field evaluations: 19,000 served • 4 Urgent Care Centers (24 hr): 11,000 served
At A Glance - 2 • 47 directly-operated programs • 130 contracted agencies • 112 potential new contractor agencies • 89 pharmacies • 27 fee-for-service hospitals • 3 indigent hospitals • 338 fee-for-service individuals • 4 contracts/MOU’s with veteran’s organizations • Budget of $1.58 billion (gross appropriation) (FY 09-10)
New Treatment Strategies • Short term • Focused (especially around crisis, trauma, depression) • Evidence based • Expansion of community based approaches • Expansion of in-home strategies • Expansion of crisis resolution approaches • Integration with primary care
Main Sources of Childrens MH Funding • Realignment • Medi-Cal Managed Care • EPSDT (a Medi-Cal program) includes Therapeutic Behavioral Services, Day Treatment, Day Rehab, Outpatient • Healthy Families: basic & SED MH benefit • AB 3632 • Mental Health Services Act: FSP’s and PEI • Specialized Foster Care • Family Preservation
EPSDT (Medical Necessity Criteria) • Below age 21 • Mental disorder results in at least one of following: (1) significant deterioration in key domain (2) probability of significant deterioration in key domain or (3) a probability of not progressing developmentally
Medical Necessity Criteria - 2 • Condition is not responsive to general medical interventions • (Outpatient) Intervention would: (1) significantly diminish impairment; (2) prevent significant deterioration in key domain; or (3) allow child to progress developmentally • Meets the criteria of one of the following Dx:
ELIGIBLE DIAGNOSES • Pervasive Developmental Disorders (including Aspergers D and excluding Autistic D) • Disruptive Behavior D • Feeding/Eating D of Infancy and Early Childhood • Elimination D • Schizophrenia/Psychoses • Mood D • Anxiety D • Somatoform D • Factitious D • Dissociative D • Paraphilias • Gender Identity D • Eating D
ELIGIBLE DIAGNOSES -2 • Impulse Control D • Adjustment D • Personality D, exc. Antisocial Personality Disorder
Mental Health Services Act • Proposition 63—a California voters’ ballot initiative—passed in 2004 • Based on recovery/wellness • Stakeholder involvement • Focus on unserved and underserved • 1% tax on personal income in excess of $1 million intended to expand mental health services • 5 components • Community Services and Supports, Workforce Education and Training, Capital/Technology, Prevention/Early Intervention, Innovation
Outcomes – Increase: • Likelihood of having a safe place to live • Having meaningful use of time (e.g., school, work, training). • Having supportive relationships with family, friends, and neighbors.
Outcomes – Reduction of: • Suicide • Incarceration • School failure and dropout • Unemployment • Prolonged suffering • Homelessness • Removal of children from their homes
FULL SERVICE PARTNERSHIPS • The FSP program is for children ages 0-15 or TAY ages 16 – 24 and their families who would benefit from a program designed to address the total needs of a family whose child or youth is experiencing significant emotional, psychological or behavioral problems that are interfering with their wellbeing. • FSP programs are capable of providing a wide array of services beyond the scope of traditional clinic-based outpatient mental health services. Those participating in a FSP program will have the support of a service provider 24 hours a day, 7 days a week.
Full Service Partnership - (“high end children”) Priority populations (1) children removed or at risk of removal from their families, (2) children experiencing extreme behaviors at school (3) children involved with Probation and families affected by substance abuse Children’s Programs (0-15)
Transition Age Youth Programs (16-24) • Full Service Partnerships – (“high end” youth) • Priority Populations (1) youth with substance abuse disorders, (2) youth who are homeless or at risk of becoming homeless, (3) youth are emancipating from DCFS & Probation, (4) or youth leaving long term institutional care, experiencing first psychotic break
FULL SERVICE PARTNERSHIP SERVICES (0-15, TAY) • 24/7 clinic/field-based/in-home that include multi-discipinary teams for crisis intervention & assess • Culturally competent • Individualized • Social/recreational/faith-based • Engagement with ethnic minorities through schools/primary care clinics/shelters • Wraparound • Trauma specific services • Community re-entry services (juvenile halls & camps)
Transportation Interagency collaboration Respite Care Probation halls/camps GLBT specific MH Services & Supports for caregivers/parents, including crisis family services Temporary/permanent supportive housing Co-Occurring Disorders Services Drop-in Center Services (TAY) FSP Services (0-15, TAY) (cont’d)
FSP – TAY only • Peer partners • Support for independent living • Basic living skills • Integrated MH with law enforcement agencies
Requirement of Full Service Partnership (LACDMH) • Programs may not discriminate against individuals with a mental illness who have co-occurring disorders, including individuals with physical health problems, developmental delays, low literacy issues, substance abuse issues, or other issues. Rather, providers must demonstrate the ability to collaborate with other Departments or entities (e.g., Regional Center, DHS) in order to ensure clients access the services most appropriate for their needs and to which they are entitled.
MHSA Prevention and Early Intervention (PEI) Priority Populations • Underserved Cultural Populations • Individuals Experiencing Onset of Serious Psychiatric Illness • Children/Youth in Stressed Families • Trauma-Exposed Individuals • Children/Youth at Risk for School Failure • Children/Youth at Risk of Juvenile Justice Involvement
Priority Child/Youth Population (indigents) multi-dimensional definition • Severe emotional/behavioral crisis • In or at risk for out of home placement • Certain diagnostic categories • Severe functional impairment
OPERATIONAL AGREEMENT BETWEEN L.A. CO. and REGIONAL CENTERS (2005) Chief Administrative Officer Department of Mental Health Probation Department Department of Children and Family Services Seven Regional Centers (in L.A. County)
“AGREEMENT” State regulations indicate that “regional center funds shall not be used to supplant the budget of any agency which has a legal responsibility to serve all members of the general public and is receiving public funds for providing those services” Agreement is “…to meet the needs of persons with developmental disabilities who are also mentally ill”
GOALS OF AGREEMENT (pertaining to LACRC’s and LACDMH) Increase leadership, communication… To optimize utilization of agency resources… To decrease costs and minimize fiscal risk… To ensure continuity of services… Improve quality outcomes… Strive toward highest client functioning…in least restrict setting Timely resolution of conflicts…
AGREEMENT - OUTPATIENT LACDMH and LACRC’s will develop and implement…general plan for crisis intervention…shall include after-hours emergency response systems, interagency notification guidelines and f/u If psychiatric care is warranted, both will develop procedure for a client based on the presenting dx and medical necessity, as defined by State regulations. Once the client no longer requires MH treatment, the client is referred to LACRC for f/u
AGREEMENT - INPATIENT RC clients admitted to psychiatric inpatient facilities due to a mental disorder will be the responsibility of LACDMH. LACDMH will provide psychiatric treatment until there is no further medical necessity for acute inpatient care. Discharge shall occur when medical necessity criteria are no longer met. If placement by RC is delayed, the client is placed on administrative days for which RC’s are responsible beginning on the 5th administrative day.
CA CODE OF REGULATIONSTitle 9, Chpt 11, Section 1830.205 Los Angeles County DMH will meet the needs of Regional Center clients/consumers who meet medical necessity criteria as in CA code Persons eligible for developmental disability services referred to LACDMH for mental health services will receive an evaluation and assessment to determine the extent of their need for services. LACDMH will provide appropriate mental health services…
Critical Challenges & Issues • Funding for indigent care • Emergency response capacity given ER overcrowding & limited long-term care options • Katie A. lawsuit (children in foster care) • Implementation of MHSA components of PEI, WET and Innovations • Needs of youth in juvenile justice system, i.e. halls & camps • AB 3632 funding • Healthcare reform • Workforce issues
Resources Los Angeles County DMH website with MHSA info., list of mental health agencies, other MH links http://dmh.lacounty.gov Los Angeles County DMH Medi-Cal Network Providers (Psychiatrists and Psychologists) http://dmh.lacounty.gov/cms1_054947.pdf Los Angeles Network of Care provides an online service directory, i.e. addiction, disability insurance, housing, emergency shelter (by zip code) http://losangeles.networkofcare.org/mh/home/ Los Angeles County Guide to Medi-Cal MH Services http://dmh.lacounty.gov/cms1_046410.pdf Healthy Families http://www.healthyfamilies.ca.gov/hfhome.asp CA State DMH www.dmh.ca.gov
Resources (cont’d) CA Mental Health Planning Council’s Master Plan http://www.dmh.ca.gov/MHPC/masterplan.asp Characteristics of the uninsured: http://covertheuninsured.org/media/research/brffs.pdf Report from the President’s New Freedom Commission on Mental Health http://www.mentalhealthcommission.gov/reports/reports.htm Healthy People 2010 report – Mental Health Section http://www.healthypeople.gov/Document/pdf/Volume2/18Mental.pdf California Little Hoover Commission Report On Mental Health, Being There: Making a Commitment to Mental Health Nov. 2000 http://www.lhc.ca.gov/lhcdir/report157.html