Transcript Dec_10_presentation_DMH

A Systematic Approach to Meeting the Ongoing Needs of
Children with Complex and Enduring Behavioral and
Emotional Disorders and their Families
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A framework for a comprehensive approach
to addressing the needs of a critical care
population
Based on a review of research indicating the
practices most likely to be associated with
effectiveness
Not a single service, but a systematic
approach to integrating the arc of care across
multiple environments and multiple
interventions
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Despite important strides in service
development, we have children who are
placed repeatedly in high-level group homes
and remain in placement for long periods of
time
This subset of children have highly disrupted
family relationships that have been generated
in a variety of ways and exhibit complicated
behavior patterns
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Clinically, children and youth who experience
multiple and extended high-end group home
placement are distinguished by their complexity
and heterogeneity
“Children manifest complex psychopathology,
characterized by attachment difficulties,
relationship insecurity, sexual behavior, traumarelated anxiety, conduct problems, defiance,
inattention/hyperactivity, and less common
problems such as self-injury and food
maintenance behaviors.”
 Tarren-Sweeney (2008) The Mental Health of Children in Out
of Home Care. Current Opinion in Psychiatry, v. 21, pages
345–349.
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The subset of children and youth with repeated and
extended group home placement also put a great deal of
pressure on the demand for psychiatric hospitalization
Examined from the other perspective, the children and
youth who experience repeated psychiatric hospitalization
also are more likely to be in group care:
A recent study found that three factors are highly related
to rehospitalization:
◦ living in a residential treatment facility,
◦ a diagnosis of oppositional/defiant or conduct disorder,
◦ prior history of hospitalization
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Rehospitalized youth were also less likely to have family
involvement
 Chung, W., et. al. (2008) Psychiatric Rehospitalization of Children and
Adolescents: Implications for Social Work Intervention, Journal of Child
and Adolescent Social Work, v.25, pages 483–496
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Beyond the diagnostic criteria there are two
practical characteristics of most of the children
and youth in this subset:
“We don’t know what else to do”
Behavior-based placement disruptions
◦ James (2008) Entry Into Restrictive Care Settings:
Placements of Last Resort? Families in Society, Vol. 89,
No. 3, p. 348
◦ McCurdy (2004) ‘And What About Residential…?’ Reconceptualizing Residential Treatment As A Stopgap
Service For Youth With Emotional And Behavioral
Disorders. Behavioral Interventions, vol. 19, pages
137-158.
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First, match the right services with the right
kids and families
Most of the time, intensive in-home, day
treatment or treatment foster care will be the
best alternative for children with severe
emotional disorders and their families
However, for the subset for whom those
options are not effective, we should use short
term group care as an integral component of
a comprehensive response
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Short-term, highly intensive group care that is
multi-modal, ecological and holistic
Continuous and extensive family involvement
Parallel services with the family and community
to prepare for reconnection while the child is in
group care
Ongoing post-group care services to address
continuing to reinforce and continue to
strengthen the connection with primary
caregivers, to build family resilience and
protective capacity, and to address the child’s
ongoing mental and behavioral health needs.
◦ Hair (2006) Outcomes for Children and Adolescents
After Residential Treatment: A Review of Research from
1993 to 2003. Journal of Child and Family Studies, Vol.
14, No. 4, pp. 551–575
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Make group care a part of a Re-Connection
Engine
Learn to see group care settings not as places to
live, but as components of an integrated, multienvironmental, multi-modal intervention
designed to help children and their families
achieve and maintain positive and productive
permanency, despite the impact of their
emotional and behavioral handicaps as well as
any limitations of their primary caregivers.
Instead of raising other people’s children, find
ways to help those people learn how to, and feel
confident and competent in raising their children
themselves.
From group care
facilities that have
associated therapeutic
and family
permanency services
To family permanency
resources that have
integrated residential
and therapeutic
services
Step One:
Step Two:
Step Three:
Step Four:
Step Five:
Step Six:
Step Seven:
Step Eight:
Step Nine:
Step Ten:
Convene a statewide stakeholder’s group to examine the
current status of high level group care in California
Develop a framework for transforming the nature of group
home services
Gather legislative support for this transformation
Obtain financial support for the transformation effort
Select four demonstration sites who are committed to
carrying out the transformation
Assist each site in developing a community-specific
approach to accomplishing these changes
Work with state entities to help them adjust the fiscal and
regulatory constraints that impede transformation
Test out initial alternative program and funding models
Adjust models to improve effectiveness
Based on these results propose a statewide model
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Target population
Arc of Care
Service Innovations:
◦ Environmental
interventions
◦ Intensive treatment
◦ Parallel services
◦ Post-placement services
Role of the placing
agency
Child and Family
Involvement
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Evaluation:
◦ Permanency, safety, wellbeing
◦ Average length of stay
◦ Re-entry
◦ Family Connection
◦ Client satisfaction
◦ Utilization by county
agencies
◦ Operation by the private
agency
◦ Actual costs
◦ Payments
◦ Impact on state-county
AFDC-FC budgets
◦ Impact on county MH
payments
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Bay Area Consortium (San Francisco, San Mateo, Santa
Clara, Contra Costa and Solano Counties) (about 100
children)
◦ Children 6-12 years of age who are already in or referred to a
level 12 or 14 group home using a regional approach
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Sacramento County (about 24 children to start with)
◦ Children 12-16 who are in a level 12 or 14 home and are likely to
continue in care indefinitely using an integrated care model
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Los Angeles County (about 80 children to start with)
◦ Any child who is currently in level 12 or 14 who cannot be
returned home using SB 163 wraparound alone using res-wrap
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San Bernardino County (about 35 children to start with)
◦ Children 14-17 who have multiple psychiatric hospitalizations and
are currently in a level 14 group home or placed out of state,
using a trauma-focused, CBT model with the team following the
child
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AB 1453 requires each site to prepare three
documents for review by CDSS prior to
implementation:
◦ Voluntary Agreement that describes the new care
system in detail
◦ Alternative Funding Model that explains how the
new system will be funded
◦ Waiver Requests to make it possible to operate the
new system
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After input from a stakeholders’ group, CDSS is
charged with reviewing the VAs, AFMs, and WRs
to see if they meet the statutory requirements
Then CDSS has to determine if the requested
waivers can and should be granted
Upon approval of the VA and AFM and granting
of the waivers, a state-county MOU is created
Counties can then make arrangements with
providers to begin offering RBS enrollment as an
option
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Sites are able to present drafts for sections of
their deliverables to CDSS and the Steering
Committee for iterative feedback
CDSS and its partners are working internally to
prepare for the formal review process
Demonstration sites are working through local
implementation teams and subcommittees to lay
the ground work for implementation
Consultants prepare templates and other tools to
help the demonstration sites and the state
manage the design and implementation process
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Everything takes longer than you would expect
At this point, we are hoping to begin serving
children by July, if not sooner in some places
Transformation is much more complicated than
we imagined when we started
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Lack of easily replicated models
Fiscal constraints
Regulatory restraints
Newton’s first law of motion (organizational inertia)
Inter-system constraints
Despite this and the enormous pressure of the
fiscal crisis, the local teams are plugging along
with dedication and inspiration
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The statute only briefly addressed the mental
health component of RBS
EPSDT is a separately regulated resource, so
it’s operation isn’t affected by AB 1453
This means the RBS providers will continue to
use coordinated but distinct planning for the
MH aspect of each child or youth’s care,
based on individual needs, and in line with
their local MH contracts
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The target populations are already using high
levels of mental health services
Utilization tends to decrease as these youth
achieve permanency
RBS is available as a resource to county MH
agencies
Demonstration sites must explicitly address
both AFDC-FC and EPSDT funded activities in
their VAs and AFMs.
The point of service integration in a multimodal system is to use synergy and efficiency
to obtain better outcomes for the same or
lower costs across the board
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Three agencies in each county use high end
group home placements (MH, JJ, CW)
But group homes are regulated by CW
Each agency accesses group homes differently
Funding can be different depending on which
agency makes the placement
Each county also funds group homes differently
Each group home has a different way of billing
for the services it offers
Each placing agency has different expectations
for the help that will be provided through
placement, and in the way that it manages
ongoing service delivery
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If we do nothing, more than half of the
children in our target populations will
eventually emancipate from care, run away,
enter the criminal just system or graduate to
the streets
We know that as the fiscal crisis deepens the
pressure for more placements will increase
We have a narrow opportunity to make a real
difference in the lives of the children and
families in our community who have the
greatest level of need
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Ultimately we want to design a resource that
can be accessed quickly, consistently and
reliably from multiple systems
So that we can rapidly and effectively
interrupt the negative care trajectory of
multiple and extended group home
placements
And replace it with a positive and sustainable
arc of care that anchors children with their
families, and families with their communities.
Comprehensive Assessment
Residentially-Based Services (RBS)
Youth/Family
referred for
intervention
1. Select Intervention:
“What intervention best meets
the needs of this child/family?”
 Family-Based Support & Services (At Home)
2. Select Intervention Setting:
“Where can this child/family be most
successful in getting their needs met?”
 Residentially-Based Services
 Family-Based Services (Out-of-Home)
3. Match Youth/Family Need
with Program Capability:
“Which RBS program can best
meet child/family needs?”
 Locked Detention
Youth enters RBS
Utilization Effectiveness
After-care
Program and Facility Quality
Mission
Case planning
during RBS
post discharge
Projected discharge date & timeline
Satisfaction:
Youth, family, referring
agency
Youth/Family Outcomes:
Safety, permanency, well-being;
Developmental progress;
Improved condition/behaviors
Cost
Service delivery
Service evaluation
Quality improvement
 Respect
 Child-centered
 Family participation
 Permanent connections
 Developmental focus
 Positive care
environment
 Strength-based
 Reconnect youth with
community ASAP
Values
Administration:
Fiscal, program, personnel,
community responsiveness
Management:
Accountability, collaboration,
communication, supervision
Staffing:
Hire, train, supervise,
coach, evaluate, retain &
advance quality staff
Quality Assurance:
Evidence-based, promising/best
practices; program evaluation;
program improvement
Facility quality
Assess youth/family strengths & needs
Service intervention goals
Cost Effectiveness
RBS
Team decision-making
Evaluated by Community
Care Licensing
Service Quality
Program quality
services &
support
Youth
leaves
residence
Evaluated by Accrediting Body
Youth at home,
in school, out of
trouble
Title
XXII
Regs