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Begin with the end in mind… Accessing effective psychosocial treatment options Nadia Sexton, Ph.D. Casey Family Programs Senior Fellow to ACYF & CMS Expectation from the top leadership: Make the Case Enlist and align leadership with common language and knowledge Complex Trauma: • Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. Substance Abuse and Mental Health Services Administration (SAMHSA, USDHHS). Adverse Childhood Events: • www.acestudy.org Trauma guided child welfare system: Building Well-Being Through Trauma-Informed Child Welfare Systems : Policy Framework Define: • Well Being • Change Management • Case Practice and Interventions • Fundamentals • Quality Assurance/Performance Improvement • Outcomes • Engagement and Learning • Practice Parameters • AACAP New heroes may be found in the public health, early childhood, community affairs, and public works agencies in your state Capacity of the Workforce Define for the Child Welfare and Psychosocial/Social Services Provider Community • • • • Case Practice and Interventions Fundamentals (screening/assessment, when to dx, consent protocols) Quality Assurance/Performance Improvement Outcomes Check out: http://www.casey.org/Resources/Publications/pdf/Mental HealthPractices.pdf Low Hanging and High Yielding Fruit • • • • Uniform Assessment Definition of youth and family engagement practices Partnership with provider community Partnership with your state’s higher education community Financing A simple start Your state spends money on children in programs: • Who are they and what are they getting? • What is the funding/contracting model? Medicaid Expenditures for Children in Child Welfare On average, states spend three times more for this population than for nondisabled children in Medicaid — approximately $4,336 for children in child welfare versus $1,315 for the general child population without disabilities. R. Geen, A. Sommers, and M. Cohen. Medicaid Spending on Foster Children. The Urban Institute, Brief No. 2, August 2005. Available at: http://www.urban.org/UploadedPDF/311221_medicaid_spending.pdf. In California, for example, Medicaid-eligible children in foster care accounted for 53 percent of all psychological visits, 47 percent of psychiatry visits, 43 percent of the public hospital inpatient hospitalizations, and 27 percent of all psychiatric inpatient hospitalizations among the program’s entire child population. Excerpt from Testimony from John Landsverk, PhD, at Testimony to the Little Hoover Commission Children’s Mental Health in Child Welfare and Juvenile Justice, a Public Hearing on Children’s Mental Health Policy on October 26, 2000, in Sacramento, California. A Pennsylvania study found that Medicaid mental health-related expenditures for children in foster care are nearly 12 times greater than costs for non-foster children. This study found that utilization rates, expenditures, and prevalence of psychiatric conditions for children in foster care were comparable to those of children with disabilities (i.e., children receiving Supplemental Security Income). J. S. Harman, G. E. Childs, and K. J. Kelleher. “Mental Health Care Utilization and Expenditures by Children in Foster Care.” Archives of Pediatrics & Adolescent Medicine, 2000,154:1114-1117. From: Allen, Kamala (2008) Issue Brief: Medicaid Managed Care for Children in Child Welfare; Center for Health Care Strategies, Inc. Paid Claims 2010 Foster Youth by Service source: msis.ms.hhs.gov $4,500,000,000.00 $4,000,000,000.00 $3,500,000,000.00 $3,000,000,000.00 $2,500,000,000.00 Sum of Medicaid/CHIP Sum of EPSDT $2,000,000,000.00 Sum of Home/Community Waivers $1,500,000,000.00 Sum of FQHC Sum of In Pt MH <21 $1,000,000,000.00 $500,000,000.00 $0.00 Financing EPSDT Consider: • • • • • Early Periodic Screening Diagnostic Treatment Screening and Assessment is an entitlement to youth in the public system. Medicaid expenditures on psychotropic medications for children in the child welfare system. Raghavan et al (2012) http://www.ncbi.nlm.nih.gov/pubmed/22537361 RESULTS: Children surveyed in NSCAW had over thrice the odds of any psychotropic drug use than the comparison sample. Each maltreated child increased Medicaid expenditures by between $237 and $840 per year, relative to comparison children also receiving medications. On average, an African American child in NSCAW received $399 less expenditure than a white child…………..Children scoring in the clinical range of the Child Behavior Checklist received, on average, $853 increased expenditure on psychotropic drugs. CONCLUSION: Each child with child welfare involvement is likely to incur upwards of $1482 in psychotropic medication expenditures throughout his or her enrollment in Medicaid. Financing What is child welfare spending on now? How about buying outcomes instead of services? Financing The goal is to spend on trauma informed treatments • Trauma-Informed Treatments place a greater focus on: • Safety • Adult Support • Resilience and Protective Factors • Trauma-Informed Treatments focus less on medications and are less stigmatizing Making Choices: Start Here Making Choices: Start Here Interventions Addressing Child Exposure to Trauma: Child Maltreatment (Part 1) Have a look: Part 1 (in draft) focuses on the comparative effectiveness of interventions that address child exposure to familial trauma in the form of maltreatment, including post-traumatic stress disorder as an outcome of interest. Research protocol: www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-andreports/?productid=846&pageaction=displayproduct subscribe:!: http://effectivehealthcare.ahrq.gov/index.cfm/join-the-email-list1/ Examples for Making Choices Population guided: • Disruptive Behavior http://store.samhsa.gov/product/Interve ntions-for-Disruptive-BehaviorDisorders-Evidence-Based-PracticesEBP-KIT/SMA11-4634CD-DVD Examples for Making Choices Provider Network Guided Examine the data and lessons learned Alternatives to Psychiatric Residential Treatment Facilities Demonstration (PRTF) There is a positive effect of either maintaining or improving children’s functional outcome in juvenile justice, school functioning, substance abuse, and involvement with child protective services.” Examples for Making Choices Building Capacity: The Effective Providers for Child Victims of Violence Program Examples for Making Choices Goal: Increase mental health professionals’ capacity to provide effective treatments to children victimized by violence. Objective: Develop a national training program to: mobilize mental health professionals and allied professionals to embrace evidence-based trauma assessment tools and treatment models increase the number of mental health professionals informed about and prepared to make decisions about adopting family-oriented, culturally sensitive, evidence-based treatments for children who are victims of violence Examples for Making Choices Core Elements for Effective Treatment Adopt empirically-supported assessment tools Be culturally competent Adopt evidence-based treatment models Involve families Collaborate with other professionals and system of care Examples for Making Choices Curriculum Basic overview of the best available science about: Impact of exposure to violence and trauma on children Six Trauma-Focused Assessment Tools Five Trauma-Focused Evidence-Based Treatments Role of Culture and Diversity in Victimization and Treatment Family-Centered, Collaborative Treatment Approach Clinician’s Self-Care www.apa.org/pi/prevent-violence/programs/child-victims.aspx www.Facebook.com/APAEPprogram Places to go… The California Evidence-Based Clearinghouse for Child Welfare Begin with the end in mind. Know your own landscape. Have your data ready: youth, services, $ Find, adopt, charm, and engage partners. Choose and step and make it.