Transcript Slide 1

Healthy Transitions Initiative:
An Effective Approach to Mental Health Services
Katie Herring, M.S.
Steven Reeder, M.Ed., CPRP, CRC
Kati Stein, Ph.D.
Sharon Stephan, Ph.D.
Acknowledgements
Maryland’s Healthy Transitions Initiative was funded by
the US Department of Health and Human Services –
Substance Abuse and Mental Health Administration as part
of the Emerging Adults Initiative (Grant Number SM-09008).
Characteristics of
Transition Age Youth with EBD
National Longitudinal Transition Study-2 (NLTS-2) found that
the majority of youth with EBD:
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Male
Living in poverty
Head of household has no education past high school
ADHD
Disability is identified later (age 9 or after)
40% have attended five or more schools
History of social adjustment problems
Suspended or expelled at least once
Outcomes
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It is estimated that at any point in time, 13% of young adults ages 18-26 are
experiencing some form of a mental health condition, and the majority of
these individuals do not receive related services or supports.
The results of the (NLTS-2) indicated that young adults who were
identified as an EBD, and received special education services under the
Individuals with Disabilities Education Act (IDEA):
• Experienced a greater high school dropout rate, and lower post school
employment (42% compared to 66%) than their non-disabled peers or
peers with other disabilities (Wagner & Newman, 2012).
• Furthermore, young adults with serious mental health conditions may
experience unemployment, substance abuse, incarceration, unnecessary
disability, homelessness, and suicide at greater rates than the general
population (Koerner, 2005).
Comparison of Transition Domains Between the General
Population and Young People with Emotional/Behavioral Disorders
70%
63%
60%
58%
50%
56%
45%
General Population
40%
33%
EBD
30%
25%
21%
20%
18%
11%
10%
8%
0%
Dropouts
Employed
Post-Sec.
Ind. Living
Arrested
Challenges
• Parents and youth themselves blamed for the
disability
• Stigma
• Ignorance; disability identified late and
treatment delayed
• Presence of disability is not always obvious
• Limited Family Involvement
• Limited youth involvement and engagement
Barriers to Service Delivery
• Services through special education, the foster care
system, and state child and adolescent mental health
systems often end at the age of 18 or 21, and provisions
for smooth transitions into adult mental health systems
are rare;
• Adult services are often more fragmented than child
mental health services; therefore, individuals may have
to interact with several agencies to enroll in different
programs to get the range of services they need;
• Eligibility criteria are typically much more restrictive in
adult mental health systems as compared to child and
adolescent mental health systems (Koroloff, Davis,
Johnsen, & Starrett, 2009; Koyanagi & Alfano, 2013).
The Emerging Adults Initiative
• The Emerging Adults Initiative (EAI) was a five year
systems change project funded by the Substance
Abuse and Mental Health Services Administration
(SAMHSA). Seven states were awarded funding:
Georgia, Maine, Maryland, Missouri, Oklahoma,
Utah and Wisconsin.
• In Maryland this program is called the Healthy
Transitions Initiative (HTI)
• HTI is a state/community partnership aimed at
addressing issues transition-age youth encounter as
they transition to adulthood.
HTI in Maryland
• The Healthy Transitions Initiative (HTI) is a
program designed to provide services that meet the
distinct needs of transition-age youth (TAY) ages 1625 with emotional and behavioral disorders (EBD)
in Frederick and Washington Counties.
• Evidence-Based Practice (EBP) Supported
Employment + EBP Assertive Community
Treatment + Transition to Independence Process
(TIP) + Peer/Family support
Description of HTI Population
• DSM-IV diagnosis indicates severity of need
– a psychotic disorder (i.e., schizophrenia,
schizoaffective disorder);
– a major mood disorder (major depression, bipolar
disorder); or
– a major anxiety disorder (generalized anxiety
disorder, obsessive compulsive disorder, panic
disorder, post-traumatic stress disorder, or social
phobia) – most have multiple and complex diagnoses.
Description of HTI Population
• Functional Impairment
– A clear, current threat to the ability to live or be maintained in the
community.
– A significant inability to negotiate the developmental tasks of
emerging adulthood and to assume normative adult roles, including
but not limited to: exploring opportunities for employment, school,
housing, and social relationships, and making life course decisions.
This significant inability, or dysfunction, is not solely defined as the
failure to fully meet societal expectations of residential stability, stable
employment, school completion, or establishment of a family.
– A significant inability to manage the symptoms of one’s illness or
modulate one’s behavior in response to social cues or societal norms
(not manifested solely by criminal behavior).
Description of HTI Population
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Multiple psychiatric hospitalizations
Residential Treatment Center placement
Substance Abuse
Aggressive Behavior
Behaviors resulting in danger to self or others
Psychosis
Poor reality testing
High levels of impulsivity, poor judgment, and/or
inability to self protect in community situations
Goals of HTI
• Improve outcomes for TAY with serious mental health
conditions in areas such as education, employment, housing,
mental health and co-occurring disorders, and decrease contacts
with the juvenile and criminal justice system;
• Foster youth self determination;
• Engage and support families;
• Enhance core competencies of behavioral health practitioners in
developmentally appropriate and empirically supported
practices to support the needs of Transition Age Youth;
• Link local implementation to state-level program and policy
development to address broader system and financing issues;
• Disseminate and replicate to other geographic locations
throughout the state.
How is HTI Different?
HTI services and supports are:
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Co-designed and selected by youth
Strengths-Based
Developmentally-Sensitive
Non-Stigmatizing
Culturally Competent
Appealing to youth
Convenient for youth and families
Focused on real life goals/dreams
Facilitative of youth self-determination
Delivered in mental health centers
Focused on skills development
Empirically-supported
Traditional services and supports are:
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Designed and determined by professionals
Disability-/ Deficit-Based
Adult-Focused OR Child-Focused
Unintentionally stigmatizing
Designed for the majority culture
Unpleasant or undesirable to youth\
Convenient for professionals
Focused on treatment goals
Custodial and protective of risk
Delivered in natural settings
Focused on service provision
Based on professional judgment/wisdom
HTI Evaluation Overview
• Quantitative
– National Outcomes Measures (NOMs)
– Individual Interviews – Youth and Caregiver
• Domains include background and demographics; living
situation; education and job training; employment, career,
and finances; parenting; social connectedness; selfdetermination; perceptions of opportunity; efficacy and
empowerment; physical health; satisfaction; mental health
and substance abuse; and criminal justice.
• Qualitative
– Six focus group interviews – two youth focus group interviews
(one in each county); two caregiver group interviews (one in
each county); one staff group interview; one supervisor group
interview.
Quantitative Data Collection
NOMs Collected
Interviews
Conducted
Assessment
Baseline
6-Month
12-Month
18-Month
24-Month
30-Month
36-Month
42-Month
Total
Assessment
Baseline
6-Month
12-Month
18-Month
24-Month
30-Month
36-Month
42-Month
Total
N
160
72
50
35
28
18
12
5
380
Youth
Caregiver
48
27
25
15
16
6
9
1
148
25
19
18
7
7
4
3
1
84
Total
73
46
43
22
23
10
12
2
232
NOMs Analysis
Baseline Demographics
• 56.3% of HTI enrollees are male
• Average age at baseline was 19.4 years
50
African American
17%
45
Number of Youth
40
35
Other Multiracial
4%
30
Hispanic and
Caucasian
5%
25
20
Hispanic/Latino
3%
15
10
African American
and Caucasian
6%
5
0
16
17
18
19
20
21
Age
22
23
24
25
White/Caucasian
65%
Living Situation
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Baseline living situation
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14.4% of youth were not retained in the community for the past 30 days
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8 were homeless
6 were in inpatient mental health care*
6 were in a correctional facility*
1 was in an inpatient substance abuse facility
*1 youth reported being in both inpatient mental health care and in a correctional facility in the past 30 days.
Education and Employment
• TAY under age 18 at baseline
– 78% enrolled in school or job training
– 3% had completed high school
– 11% were employed part-time and 65% were looking for work
• TAY age 18 and over at baseline
– 41% enrolled in school or job training
– 19% were employed part-time, 9% were employed full-time, and 50%
were looking for work
– 71% had completed high school or GED
– 11% had completed some college or university
Substance Use
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Baseline substance use in the past 30 days
Never
Once or Twice
Weekly
Daily/Almost Daily
Missing/Refused
Tobacco
49.4%
6.3%
1.3%
40.6%
2.5%
Alcoholic beverages*
67.5%
18.8%
1.3%
6.9%
5.6%
Cannabis
80.0%
8.8%
2.5%
5.0%
3.8%
Cocaine
96.3%
1.3%
0.0%
0.6%
1.9%
Prescription stimulants
93.8%
1.9%
0.0%
1.9%
2.5%
Methamphetamine
98.1%
0.0%
0.0%
0.0%
1.9%
Inhalants
97.5%
0.6%
0.0%
0.0%
1.9%
Sedatives or sleeping pills
9.0.%
2.5%
0.6%
5.0%
1.9%
Hallucinogens
96.3%
0.6%
0.0%
0.6%
2.5%
Street opioids
96.3%
0.6%
0.0%
0.6%
2.5%
Prescription opioids
92.5%
2.5%
0.6%
2.5%
1.9%
Other**
65.6%
0.6%
0.0%
1.3%
32.5%
Psychological Distress
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Items asked “During the past 30 days, about how often did you feel...
nervous, hopeless, restless or fidgety, so depressed that nothing could cheer
you up, that everything was an effort, worthless?”
At baseline, 73.1% of TAY reported serious psychological distress in the past
30 days.
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Mean scores on the psychological distress scale decreased significantly from baseline
(M=3.01) to the 12-month follow up (M=2.27).
4
3.5
3.35
3.03
3
2.19
2.5
2
1.5
1
0.5
0
Baseline
6-Month
12-Month
Perception of Functioning
• Example items: “I deal effectively with daily problems,” “I am able
to control my life,” and, “My symptoms are not bothering me.”
• At baseline, 55% of TAY reported a positive perception of their
functioning in everyday life.
– TAY were more likely to report positive perception of functioning at 6-month
follow up compared with baseline.
– There was a significant increase in perception of functioning scores for youth
with complete baseline through 18-month assessments.
Perception of Functioning Mean Scores (N=12)
5
4
3.51
3.72
3.89
Baseline
6-Month
12-Month
4.29
3
2
1
0
18-Month
Social Connectedness
• Example items: “I am happy with the friendships I
have,” “I feel I belong in my community,” and, “In a
crisis, I would have the support I need from family or
friends.”
– At baseline, 71% of TAY reported the presence of social
connections to family, friends, and the community.
– TAY were more likely to have a positive outcome on social
connectedness at the 12-month and 18-month follow ups than at
6-months.
Perceptions of Care
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At the 6-month assessment, 92% of TAY reported positive overall perceptions of care.
Staff here believe I can grow, change and recover.
I felt free to complain.
I was given information about my rights.
Staff encouraged me to take responsibility for how I live
my life.
Staff told me what side effects to watch out for.
Staff respected my wishes about who is and who is not
to be given information about my treatment.
Staff were sensitive to my cultural background (race,
religion, language, etc.)
Staff helped me obtain the information I needed so that
I could take charge of managing my illness.
I was encouraged to use consumer run programs
(support groups, drop-in centers, crisis phone line, etc.)
I felt comfortable asking questions about my treatment
and medication.
I, not staff, decided my treatment goals.
I like the services I received here.
If I had other choices, I would still get services from this
agency.
I would recommend this agency to a friend or family
member.
N Minimum Maximum Mean
64
1
5 4.28
62
1
5 4.15
64
1
5 4.23
64
1
5 4.28
40
64
2
1
5
5
3.28
4.36
64
1
5
4.14
64
1
5
4.09
61
1
5
3.64
62
1
5
3.92
63
63
63
1
1
1
5
5
5
4.21
4.29
4.21
63
1
5
4.21
Local Evaluation Interviews
Perceptions of Opportunity
Aspiration
(Importance)
Mean Score
2.90
2.71
2.96
2.92
Perception of
Opportunity
Mean Score
2.58
2.25
2.48
2.63
Significant
Difference?
Yes
Yes
Yes
Yes
2.54
2.29
Yes
t(47) = 2.72, p= .009
…to have a good relationship with
your parent or caregiver
…to have a good relationship with
your significant other
…to have a good relationship with
your children
2.75
2.52
Yes
t(47) = 3.08, p= .003
2.65
2.52
No
t(47) = 1.35, p= .182
2.75
2.77
No
t(47) = -.375, p= .710
…to have a good relationship with
your friends
…to stay out of trouble with the
law
…to stay clean (off drugs and/or
alcohol)
Overall Index
2.67
2.58
No
t(47) = 1.27, p= .209
2.94
2.75
Yes
t(47) = 2.44, p= .018
2.85
2.73
No
t(47) = 1.95, p= .057
2.78
2.55
Yes
t(47) = 5.94, p< .001
Goal
…to have a good job or career
…to graduate from college
…to earn a good living
…to provide a good home for your
family
…to have a good marriage and/or
long term committed relationship
Statistical Estimates
t(47) = 3.92, p< .001
t(47) = 4.88, p< .001
t(47) = 4.86, p< .001
t(47) = 4.01, p< .001
Self-Determination
• “Acting as a primary causal agent in one’s life and making choices
and decisions regarding one’s quality of life free from undue
external influence or interference” (Wehmeyer, 1996)
• At baseline, 51% of TAY reported that generally they “always”
regulated their thoughts, feelings, and actions to work toward goals.
• 19% of caregivers reported that their youth “always” regulated their
thoughts, feelings, and actions to work toward goals.
Youth
Frequency
Caregiver
Percent
Frequency
Percent
On average, always regulate self
24
50.0
On average, always regulate self
5
18.5
On average, almost always regulate
self
20
41.7
On average, almost always regulate self
9
33.3
On average, sometimes regulate self
8
29.6
On average, almost never regulate self
5
18.5
On average, never regulate self
0
0.0
27
100.0
4
8.3
On average, sometimes regulate self
On average, almost never regulate self
0
On average, never regulate self
0
Total
48
0.0
0.0
100.0
Total
Efficacy and Empowerment
• 3 subscales
– At baseline, 86% of TAY reported that they were “mostly
or always” able to self-manage their emotions and mental
health
– 96% reported that they were “mostly or always” able to
self-manage services and supports
– 77% reported that they were “mostly or always” able to
improve or help change service systems
Youth and Caregiver Satisfaction
90
100.0
96.4
100
89.5
82.1
82.0
80
70
60
82.1
73.7
63.2
60.7
55.6
50
40
Youth
30
Caregiver
20
10
0
Qualitative Evaluation
Focus Groups
Frederick County
Washington County
Totals
Female
2
2
4
Male
4
3
7
6
5
11
Female
4
4
8
Male
0
0
0
4
4
8
Female
2
2
4
Male
1
1
2
Total
3
3
6
Overall Totals
13
12
25
Youth
Total
Caregivers
Total
Staff
Results
• Services Provided
• Strengths
• Additional Needs
Services and Supports
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Transportation
Dealing with agencies and services
Assistance during IEP meetings
Help with driver’s education
Studying for and taking the GED
Employment
Housing
Respite & emotional support
Strengths
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Availability and commitment of staff
Flexibility
Different from other service providers
Self-directed funds
Assistance navigating systems and other service
providers
• Supports for caregivers
Additional Needs
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Housing
Increased opportunities for employment
Social interaction and more peer supports
Additional supports for transition age youth with
mild or moderate disabilities
• Smaller, more manageable case funds
• Increased assistance with Individualized Education
Program (IEP) meetings
Suggestions
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Additional group and social activities for youth
Increased supports and information for caregivers
Need for additional resources
Increased assistance with employment & housing
More manageable case loads
Increased availability of housing
The Affordable Care Act
• Under the ACA provision, otherwise independent young adults can
receive health care coverage through their parent’s plan up until the
age of 26.
• Medicaid coverage is now available to children who have aged out
of the foster care system but who are under age 26.
• Under Section 2703 of ACA, the Medicaid Health Home State Plan
Option states have the option to allow adult and child Medicaid
beneficiaries with “at least two chronic conditions, one chronic
condition and the risk of developing a second, or one serious and
persistent mental health condition” to select a specific provider as
their health home to help coordinate their treatments.
• Medicaid expansion allows individuals to be eligible for Medicaid
at incomes up to 138% of the Federal Poverty Level (FPL).
Next Steps in Maryland
• In September 2014, Maryland was awarded a new five year
SAMHSA grant – Now is the Time: Healthy Transitions.
• This new program will be called Maryland Healthy
Transitions (MD-HT) and will serve TAY in Howard, Calvert,
Charles, and St. Mary’s Counties.
• MD-HT will build on the work of HTI by expanding access to
individualized, strengths- and evidence-based supports for
youth and young adults with mental health challenges.
• HTI services will be sustained in Frederick and Washington
Counties.
• The overarching goal of this work is to have best practices for
serving TAY with mental health challenges adopted statewide.
Questions and Comments
Katie Herring
[email protected]
Kati Stein
[email protected]
Steven Reeder
[email protected]
Sharon Stephan
[email protected]
Thank you!