Mission: Protect the Vulnerable, Promote Strong and Economically Self- Sufficient Families, and Advance Personal and Family Recovery and Resiliency. Rick Scott, Governor Esther Jacobo, Interim Secretary Children’s Mental Health System of Care & Wraparound April 23, 2014 Gulf Breeze, Florida
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Mission: Protect the Vulnerable, Promote Strong and Economically Self- Sufficient Families,
and Advance Personal and Family Recovery and Resiliency.
Rick Scott, Governor
Esther Jacobo, Interim Secretary
Children’s Mental Health
System of Care & Wraparound
April 23, 2014
Gulf Breeze, Florida
Today’s Presentation:
2
System of Care (SOC) Overview
Wraparound Overview
Florida SOC & Wraparound Initiatives
Evidence Base and Cost Efficiencies
Next Steps
Contact Information
System of Care
Overview
Why are we here?
Because we are all part of the system that serves children with Serious
Emotional Disturbances (SED) in Florida.
What is our goal?
To integrate and fund best practices in the state’s behavioral health system
for children so they can thrive within their natural support system.
Why is this important to us?
1.Better functional outcomes for children and families;
2.Cost effectiveness; and
3.Increased trust & cooperation throughout the system.
4
Prevalence of Children’s Behavioral
Health Issues
5
In 2011, 5.3% of children and adolescents aged 4-17 experienced
definite or severe emotional and behavioral difficulties, while14.4%
experienced minor difficulties.¹
In 2010, 11% of children aged 8-11 and 12% of adolescents aged 12-
15 experienced past year serious emotional disturbance.²
Half of all lifetime cases of mental illness begin by age 14, but the
median delay between onset and seeking treatment is nearly 10 years.³
¹Source: www.samhsa.gov/data/2012BehavioralHealthUS/2012-BHUS.pdf, site accessed, April 16, 2014
²Source: www.samhsa.gov/data/2012BehavioralHealthUS/2012-BHUS.pdf, site accessed, April 16, 2014
³Source: http://www.nimh.nih.gov/news/science-news/2005/mental-illness-exacts-heavy-toll-beginning-in-youth.shtml
Mental health is the costliest health
condition of childhood
6
$2.90
$3.10
$6.10
$8.00
$8.90
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
$30.00
Bil
lions
of
Doll
ars
Infectious Diseases
Acute Bronchitis
Trauma Related Conditions
Asthma
Mental Health Disorders
Source: http://www.ahrq.gov/research/findings/factsheets/mental/mentalhth/index.html#access
)
Florida Expenditures for Publically
Funded Children’s Services
Annual Cost % of Children &
Adolescents Served
% of Mental Health
Expenditures for Children &
Adolescents
≤ $3,000 93.6% 50%
Between $3,001 and $20,000 6.0% 33%
Between $20,001 and
$200,000*
0.4% 17%
7 Source: Hutchings, G. P., & Cobb, H. C. (2012). Examining the efficacy of Florida’s publicly funded mental health services: The science, the research, the return on investment. Alexandria, VA: Behavioral
Health Policy Collaborative, LLC.
*This group consisted of 224 children and adolescents and accounted for $9.8 million in
expenditures. Approximately 82% of the costs were for residential services.
Why are outcomes so poor and costs so high?
8
Child and family needs are complex:
Youths with serious behavioral health challenges typically have multiple and overlapping problem areas that need attention
Families often have unmet basic needs
Traditional services don’t attend to health, mental health, substance abuse, and basic needs holistically
Families are rarely fully engaged in services They don’t feel that the system is working for them
Leads to treatment dropouts and missed opportunities
Why are outcomes so poor and costs
so high?
9
Systems are in “silos”:
Systems don’t work together well for individual
families unless there is a way to bring them together;
Youth get passed from one system to another as problems get worse;
Families relinquish custody to get help; and
Children are placed out of home.
SOC is a National Initiative
10
• The Comprehensive Community Mental Health Services for Children and
Their Families Program, also known as the Children’s Mental Health
Initiative (CMHI),
• Funded by the Center for Mental Health Services of the Substance Abuse
and Mental Health Services Administration (SAMHSA) since 1993;
• Largest children’s mental health services initiative to date; and
• Endorsed by CMS – Center for Medicaid Services.¹
1 See, http://medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-05-07-2013.pdf, site accessed, April 16, 2014.
What a System of Care Concept
Is Not…
• It is not a “model” or a manualized treatment
• It is not a program that provides a service
• It is not a treatment or clinical intervention
• It is not Wraparound
11
What a System of Care Concept Is…
12
• It is a basis for paradigm shift, ideals and vision.
• It is an organizational framework for system reform
based on a shared, clear set of values and principles.
• It is a guide with flexibility to fit a community based on
their strengths and needs.
System of Care Definition
13
A spectrum of effective, community-based services and supports for
children and youth with or at risk for mental health or other
challenges and their families, that is organized into a coordinated
network, builds meaningful partnerships with families and youth, and
addresses their cultural and linguistic needs, in order to help them to
function better at home, in school, in the community, and throughout
life.
Source: Stroul, B., Blau, G., & Friedman, R. (2010). Updating the system of care concept and philosophy. Washington, DC: Georgetown University Center for Child and Human Development,
National Technical Assistance Center for Children’s Mental Health.
The System of Care Model
14
CHILD AND FAMILY
MENTAL HEALTH
SERVICES
SOCIAL SERVICES
EDUCATIONAL SERVICES
HEALTH SERVICES
SUBSTANCE ABUSE
SERVICES
VOCATIONAL SERVICES
RECREATIONAL SERVICES
JUVENILE JUSTICE
SERVICES
Core Values of SOCs
1. Family Driven and Youth Guided
With the strengths and needs of the child and family determining the types and
mix of services and supports provided.
2. Community Based
With the locus of services as well as system management resting within a
supportive, adaptive infrastructure of processes and relationships at the community
level.
3. Culturally & Linguistically Competent
With agencies, programs, and services that reflect the cultural, racial, ethnic, and
linguistic differences of the populations they serve to facilitate access to and
utilization of appropriate services and supports.
15 Source: Stroul, B., Blau, G., & Friedman, R. (2010). Updating the system of care concept and philosophy. Washington, DC: Georgetown University Center for Child and Human
Development, National Technical Assistance Center for Children’s Mental Health.
Guiding Principles of SOCs
16
1. Broad, flexible array of effective, evidence-informed services and
supports, including traditional and nontraditional services, informal and
natural supports.
2. Individualized services guided by a strengths-based, wraparound service
planning process and an individualized service plan.
3. Least restrictive, most normative environments that are clinically
appropriate.
4. Ensure that families, caregivers, and youth are full partners in
services and policies/procedures at all levels.
5. Cross-system collaboration, linkages across administrative and funding
boundaries and mechanisms for system-level management, coordination, and
integrated care management.
Guiding Principles of SOCs (cont’d)
17
6. Care management for coordination of services.
7. Services and supports needed to meet the social-emotional needs of
young children and their families.
8. Services and supports needed to facilitate the transition of youth and
young adults to adulthood.
9. Incorporate or link with mental health promotion, prevention, and
early identification and intervention.
10. Rights protection and advocacy.
11. Continuous accountability mechanisms at the system level, practice
level, and child and family level.
12. Nondiscrimination.
Source: Stroul, B., Blau, G., & Friedman, R. (2010). Updating the system of care concept and philosophy. Washington, DC: Georgetown University Center for Child and Human
Development, National Technical Assistance Center for Children’s Mental Health.
18
Services
&
Supports
Paradigm Shift
19
From To Funding tied to programs>>>>>>>>>>>>>>>>>>>> Funding tied to families Reactive, crisis-oriented approach >>>>>>>>>>> >>>>Focus on prevention Children out-of-home>>>>>>>>>>>>>>>>>> >>>>Children with families Centralized authority>>>>>>>>>>>>>>>>>>>>>> Community-based ownership Child as focus>>>>>>>>>>>>>>>>>>>>>>>>>> Family and school as focus Fragmented and uncoordinated>>>>>>>>>>>>>>>>> Partnerships Deficit-based>>>>>>>>>>>>>>>>>>>>>>>>>>> Strength-based
20
• MODEL PROGRAM: Integrated System of Care for Children with
Serious Emotional Disturbances and Their Families¹
• Both SOC and Wraparound named as Emerging Best Practice²
• An exemplary program - Wraparound Milwaukee
• Demonstrates successful integration of services and funding
for the most seriously affected children and adolescents.
• The services provided to children (primarily child welfare and
juvenile justice involved):
- Produce better clinical results,
- Reduce delinquency,
- Result in fewer hospitalizations, but
- Are cost-effective.
1 New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832. Rockville, MD: 2003.
New Freedom Commission on
Mental Health Report
2 Emerging best practice is defined by the New Freedom Commission on Mental Health as treatments and services that are promising but less thoroughly documented than evidence-based
practices.
Building Systems of Care
21
System Partnerships with shared values and vision
Population of focus
Coordinating Structures and strategic planning
Multi-level process
State level (policies, financing mechanisms, workforce development)
Local and neighborhood level (plan, implement, manage, and evaluate the system)
Service delivery level (access to a broad array of services, comprehensiveness, quality)
Frontline practice (child and family teams, wraparound process)
Family level
Broad array of services
22
Prevention (screening)
Early Intervention (home visiting, mental health consultation)
Diversion Programs
Wraparound (care coordination and planning)
Peer Support Services
Respite
Mobile Crisis Response
Evidenced Based Practices
Transition Services
Wraparound
Overview
Wraparound
24
Wraparound is how the SOC philosophy is
operationalized at the service level
Wraparound has been most commonly conceived of as an intensive,
individualized care planning and management process
Wraparound is not a treatment per se, but a process that consists of:
A team of people relevant to the life of the youth
Collaboratively develop an individualized plan of care
Implement this plan
Monitor the efficacy of the plan
Work towards success over time
Source: http://www.nwi.pdx.edu/wraparoundbasics.shtml, site accessed April 14, 2014.
10 Principles of Wraparound
25 * Directly crosswalks to System of Care principles
Wraparound Fidelity
26
Caseload sizes of 1:10
Coaching and supervision structure to maintain fidelity, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM)
Use of peer support services (Family Partner)
Monthly family team meetings focused on the Family Care Plan
Code needed for Wraparound services, another code needed for other providers to attend Family Team meetings, (Therapist, behavior analyst, etc.)
Why Wraparound?
27
Improved coordination and cross system collaboration;
Decreased duplication of services;
Increased family involvement;
Better fit between family needs and services and supports;
Increased cultural competence; and
Increased focus on strengths.
Wraparound Outcomes
28
Improved school achievement and
attendance;
Improvement in behavior and
functioning;
Decreased juvenile justice
recidivism; and
Maintenance in less restrictive,
community based placements.
Source: Effectiveness of the wraparound process for children with emotional and behavioral disorders: A meta-analysis, Suter & Bruns 2009
First systematic quantitative review of 7 controlled wraparound studies
Florida’s SOC & Wraparound
Initiatives
Youth and
Families
State and Local Providers Community
Partners Activities
Joint Planning
Resource
Alignment
Shared Outcomes
Florida Children’s Mental Health System of Care
Theory of Change
Inputs and Resources
Statewide Planning Team
Local Planning Teams
State and Local Agencies
Healthier Lives, Reduced Costs
Monitoring Progress and Improving Process
Evaluation
Be One Florida
Culturally relevant evidence supported programs and practices implemented
At each level partners are engaged in learning, planning and change practice.
Comprehensive state and local priorities, benchmarks and outcomes established
Collaborative and effective use of resources increases capacity at local and state levels
30
Florida CMHI-Funded SOC Initiatives
31
1998-2004 Tampa Hillsborough Integrated Network for
Kids (THINK) – Hillsborough County • Population: Children and youth ages 0-21 who meet criteria for
serious emotional disturbance and their families.
1999-2005 Family HOPE (Helping Organize Partnerships for
Empowerment) - Palm Beach County • Population: Children and youth ages 0-21 at-risk of placement in
more restrictive levels of care and duplication of services and their
families.
2002-2008 One Community Partnership - Working Together
For Our Children - Broward County • Population: Children and youth ages 10-18 who meet criteria for
serious emotional disturbance and their families.
Florida CMHI Funded SOC Initiatives
32
2005-2011 Sarasota County Early Childhood Mental Health
Partnership – Sarasota County • Population: Infants and young children ages 0-8 with multisystem
involvement, at-risk of child welfare involvement , diagnosed or
diagnosable using DSM or DC0-3 and their families.
2009-2015 Wraparound Orange – Orange County Children's
System of Care Project • Population: Children and youth ages 0-21 who meet criteria for
serious emotional disturbance and their families. Priority
population includes children under the age of 13 who have been
arrested or have frequent law enforcement contacts.
2009-2015 FACES - Miami-Dade Wraparound Project • Population: Youth in Miami-Dade county age 12-17 and their
families who are dealing with mental health and substance abuse
problems.
Florida CMHI Funded SOC Initiatives
33
2010 – 2016 Families and Children Together (FACT) – Seminole
County • Population: Children & youth and their families ages 5-21 with
complex behavioral health needs & in or at- risk of involvement in
two or more systems.
2010 – 2016 Fostering System of Care Initiative – City of
Jacksonville – Duval County • Population: Children and youth ages 0-21 and their families who
meet criteria for serious emotional disturbance and are at-risk of
involvement with child welfare or juvenile justice or are homeless.
2011 – 2016 Florida Children’s Mental Health System of Care
Expansion Project – Statewide • Population: Children ages 0-21 diagnosed with serious mental
health needs and their families.
Statewide Expansion
34
5 expansion sites from the statewide project:
Pasco & Pinellas Counties (Suncoast Region)
Bay & Washington Counties (Northwest Region)
Leon & Gadsden Counties (Northwest Region)
Volusia, St. John’s, Flagler, & Putnam Counties (Northeast Region)
The Glades (Southeast Region)
Data Presentation
35
Compiled by Dr. Norin Dollard,
Florida Mental Health Institute;
Includes data from past and present
SOC sites and current programs
implementing high fidelity
Wraparound; and
Concentrates on three areas: Quality of SOC implementation,
Fidelity to the Wraparound approach, and
Impact (system changes, youth and family
outcomes, and fiscal impact).
Fidelity assessment – SOCPR - R
36
• System of Care Practice Review – Revised uses a case study
methodology to assess adherence to system of care values and
principles at the direct practice level.
• It relies on interviews with caregiver, youth (if age appropriate), case
manager (or someone who occupies that role), informal supports (if
willing) and review of the case file.
• This assessment is used by Success 4 Kids and Families
(Hillsborough) and was administered as part of One Community
Partnership’s CMHI-funded SOC in Broward County.
Source: http://cfscommunitysolutions.cbcs.usf.edu/oll/SOCPR.html
Definitions of the SOCPR – R Domains
37
• Domain 1: Child-Centered and Family-Focused The needs of the children and families dictate the types and mix of services
provided.
• Domain 2: Community Based Services are provided within or close to the child’s home community, in the
least restrictive setting possible, and are coordinated and delivered through linkages between public and private providers.
• Domain 3: Cultural Competence Agencies, programs, and services are responsive to the cultural, racial, and
ethnic differences of the population they serve.
• Domain 4: Impact The SOC philosophy asserts that the implementation of SOC principles at
the practice level produces positive outcomes for children and families receiving services. This domain has two sub-domains:
o Improvement
o Appropriateness of services
Broward County - One Community Partnership
SOCPR – R Quantitative Analysis
38
Score of 1-3 = low level of SOC implementation
Score of 4 = neutral level of SOC implementation
Scores of 5-7 = enhanced level of SOC implementation
High SD shows high variability in rating across cases
2005 - N=20
Mean (SD)
2006 – N=19
Mean (SD)
2007 - N=20
Mean (SD)
Child-Centered & Family
Focused 4.44 (1.11) 5.03 (1.01) 5.76 (0.87)
Community-Based 5.45 (.64) 5.58 (0.86) 5.68 (0.74)
Culturally Competent 4.19 (1.35) 5.13 (1.46) 5.46 (1.06)
Impact 4.08 (1.55) 4.68 (1.40) 5.13 (1.26)
Source: Florida Mental Health Institute, Broward County SOCPR Study, 2007
Summary of One Community Partnership’s
3 Year SOCPR – R Findings
39
Overall case score moved from neutral implementation range to high implementation (score of 5-7) , increasing one entire point from 2005 to 2007.
Every domain’s score increased each follow-up year.
Almost every sub-domain moved to a higher implementation level (low to neutral or neutral to high) by the end of the third study.
Two sub-domains, Case Management (CCFF) and Sensitivity and Responsiveness (CC), moved from low (2005) to high (2007) implementation.
Informal Supports, the lowest scored sub-domain in 2005, improved by two full points, solidly into the neutral implementation range by 2007.
In general, standard deviations decreased, meaning fewer scores were rated in
the extremes.
SOCPR - R Findings – Success 4 Kids & Families
Mean Domain Scores from FY2012 – 2013
40
Mean (SD) Min Max
Overall Domain Scores - Enhanced
SOC Implementation 5.97 (0.20) Min 5.79 Max 6.21
Domain 1: Child-Centered, Family-
Focused 6.04 (0.38) Min 5.36 Max 6.64
Domain 2: Community-Based 6.21 (0.58) Min 5.36 Max 7.00
Domain 3: Culturally Competent 5.79 (0.18) Min 5.55 Max 6.18
Domain 4: Impact 5.82 (0.13) Min 5.64 Max 5.91
Impact Sub – domain scores Mean SD
Improvement 5.73 (0.13)
Appropriateness 5.91 (0.01)
Source: USF (August 2013). Success 4 Kids and Families System of Care Practice Review Yearly Report FY2012-2013 . Tampa, FL: Author.
Wraparound Fidelity Index, version 4.0
& Wraparound Fidelity Index - EZ
41
Successive versions of the Wraparound Fidelity Index (WFI)
are used in various Florida sites. The WFI assesses adherence
to Wraparound principles through interview or self-report
surveys. All versions include impact / outcome items in
addition to fidelity items.
Source: http://www.nwi.pdx.edu/
Successful Students Program
WFI-EZ Outcome Scores (N = 20)
42
Yes No
D1. Since starting wraparound, my child or youth has had a new placement
in an institution (such as detention, psychiatric hospital, treatment center, or
group home).
10.0% 90.0%
D2. Since starting wraparound, my child or youth has been treated in an
Emergency Room due to a mental health problem.
0.0% 100.0%
D3. Since starting wraparound, my child or youth has had a negative contact
with police.
0.0% 100.0%
D4. Since starting wraparound, my child or youth has been suspended or
expelled from school.
10.0% 90.0%
Source: WFI-EZ Report 7: Section D Outcomes Items Means, Success 4 Kids & Families, Printed: 02/25/2014
One Community Partnership WFI
43
0
10
20
30
40
50
60
70
80
90
100
CombinedRespondents
WrapFacilitators
(N=16)
Caregivers(N=16)
Youth(N=15)
TeamMembers(N=10)
Broward
National Mean
Perc
ent W
rapa
roun
d Fi
deli
ty
Source: Wraparound Fidelity Index, version 4.0, Summary Report Broward County, October 24, 2008, prepared by The Wraparound
Evaluation and Research Team, Department of Psychiatry , University of Washington, Public Behavioral Health and Justice Policy
Overall WFI results
44
Hillsborough County’s Successful Students program is a
truancy intervention utilizing a High Quality Wraparound
approach.
One Community Partnership, Broward County, demonstrates
higher Wraparound Fidelity levels than the national comparisons.
Orange County Wraparound Fidelity was observed at the
same level as the national comparisons.
Sources: Success 4 Kids & Families 2012 Annual Report, WFI report Broward County, 2008, and WFI report Orange County, 2013
National evaluation outcome study
45
County level CMHI grantees are required to conduct
longitudinal outcome studies with enrolled families every six
months. These data address:
Clinical measures and measures of behavior problems and
symptoms;
Child and family functioning; and
Cultural competence.
Currently Required Measures
46
Construct Measured Caregiver Interview Youth Interview
Demographic information
Enrollment and Demographic
Information Form, Caregiver Information Questionnaire
– Revised & Child Information Update Form
Youth Information
Questionnaire - Revised
Child’s living arrangement Living Situation Questionnaire
N/A
Child’s social functioning Columbia Impairment Scale
Substance Use Survey - Revised, GAIN QUICK-R &
Delinquency Survey – Revised
Child’s behavioral strengths
Child’s education information
Child’s clinical symptomatology
Behavioral and Emotional Rating
Scale 2C - Caregiver
Education Questionnaire–Revision 2
Child Behavior Checklist 6-18
Behavioral and Emotional
Rating Scale 2Y- Youth
N/A Revised Children’s Manifest Anxiety Scales 2nd Edition,
Reynolds Adolescent Depression Scale 2nd Edition
Currently Required Measures
47
Construct Measured Caregiver Interview Youth Interview
Parenting stress
Caregiver’s strain related to the
care of the child
Parenting Stress Index
Caregiver Strain Questionnaire
N/A
N/A
Client satisfaction with services
Youth Services Survey for Families
Youth Services Survey
Cultural competence of service delivery
Service contacts in multiple
service sectors
Cultural Competence & Service Provision Questionnaire, Revised
Multi-Sector Service Contacts -
Revised
N/A
N/A
Residential Stability
48
Percent of youth with one living situation in the preceding six months.
Baseline 6 months 12 months 24 months
THINK (N = 27) 85% 78% 70% 77%
One Community Partnership (N = 49) 63% 74% 72% 77%
Wraparound Orange (N = 33) 58% 67% 79% Not
Available
Miami FACES (N = 44) 68% 73% 80% Not
Available
School Disciplinary Actions
49
Percent of youth with no school disciplinary actions.
Baseline 6 months 12 months 24 months
One Community Partnership (N = 30) 54% 73% 67% 63%
Wraparound Orange (N = 39) 28% 49% Not available Not available
Miami FACES (n = 42) 33% 57% Not available Not available
THINK suspensions (N = 41) 35% 66% 54% 47%
THINK expulsions (N = 41) 85% 95 % 90 % 91%
Social Functioning - Arrests
50
Percent of youth arrested in the preceding 6 months.
Baseline 6 months 12 months 24 months
THINK (N= 20) 25% 15% 15% 25%
One Community Partnership (N = 31) 13% 7% 13% 10%
Wraparound Orange (N = 34) 67% 17% 11% Not available
Miami FACES (N = 51) 18% 24% Not available Not available
Clinical Symptomatology
51
For youth in OCP, at 30 months more than 90% had maintained
or improved;
For youth in Miami FACES, at 12 months 90% had maintained
or improved;
For youth Wraparound Orange, at 12 months 100% had
maintained; and
For youth in THINK, at 12 months the average internalizing T-
score (59.1) was no longer in the clinical range (improved).
Child Behavior Checklist – Internalizing Subscale gives an indication of symptoms
and behaviors such as being withdrawn, depressed, and anxious.
Clinical Symptomatology
52
Child Behavior Checklist – Externalizing Subscale gives an indication of inattention
and ‘acting out’ problem behaviors and such as symptoms being physical
aggression, threatening, and oppositional behaviors.
For youth in OCP, at 30 months more than 90% had maintained
(68.3%) or improved (25%) externalizing symptoms;
For youth in Miami FACES, at 12 months 83% had maintained
(60% ) or improved (23%) externalizing symptoms;
For youth Wraparound Orange, at 12 months 94% had
maintained (58% ) or improved (36%) externalizing symptoms;
and
For youth in THINK, the average externalizing T-score decreased
(improved) between baseline and 12 months
Behavioral Strengths
53
Behavioral & Emotional Rating Scales elicit the caregiver’s perception of the youth’s
strengths in interpersonal relationships, family strengths, internal coping and
resilience, school strengths, affective strengths and, if age appropriate, career
strengths.
For youth served in OCP, between baseline and 30 months 79%
maintained or improved
For youth served in Miami FACES, between baseline and 6
months 73% maintained or improved
For youth served in Wraparound Orange, between baseline and
12 months, 84% maintained or improved
For youth served in THINK, between baseline and 12 months
80% maintained or improved
Caregiver Strain
54
Average Global Strain Score utilizing the Caregiver Strain Questionnaire (lower
scores indicate higher functioning)
Baseline 6 months 12 months
THINK
One Community Partnership (N = 45) 9.7 8.4 8.5
Wraparound Orange (N = 27) 7.8 5.8 5.6
Miami FACES (n = 40) 8.9 8.3 7.6
• Global strain includes stresses due to resources (e.g., time & money), and feelings
such as anger or resentment, guilt or fatigue due to care-giving responsibilities.
• The range in scores for the Global Strain scale is 0 to 15.
Cost Savings For Residential Services
In The Southern Region
55
FY 2012 - 2013 FY 2013-2014
Level II Residential Services for Substance Abuse Treatment
Jan – Mar 2013 Apr – Jun 2013 July – Sep 2013 Oct – Dec 2013
# of youth
diverted 2 $27,967.25 15 $220,172.50 3 $32,998.09 7 $70,617.57
Statewide Inpatient Psychiatric Services (SIPP)
Jan – Mar 2013 Apr – Jun 2013 Jul – Sep 2013 Oct – Dec 2013
# of youth
diverted 0 $0 3 $148,500 12 $594,000 5 $305,250
Waiting on methodology and source from Miami Project Director
Evidence Base and Cost Efficiencies
The Comprehensive Community Mental Health Services for
Children and their Families Program Evaluation Findings
2010 Annual Report to Congress
Funded by SAMHSA
57
Gathers and reports on critical information about the system of care approach in serving children with
mental health challenges, its implementation and outcomes across the country and in your own community.
Who was served:
• 62.7% of all children served were male. (n = 28,274).
• Children and youth receiving services were more likely to be under 16 than those of similar age
nationally
• 57.2% of children and youth served were living in poverty
• 26.8% were in legal custody of both biological parents
Source: http://store.samhsa.gov/shin/content//PEP12-CMHI2010/PEP12-CMHI2010.pdf, site accessed, October 28, 2013
Youth Outcomes
58
80.60%
66.30%
61%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Total Problem Score as Measured by the Child Behavior Checklist (CBCL)
Clinical Levels of Behavioral and Emotional Problems Declined
Intake
12 Months
24 Months
(n=1,630) p <.001
0%
5%
10%
15%
20%
25%
30%
35%
Intake 24 Months
30.40%
13.80%
9.40%
3%
Suicidal Thoughts and Attempts Declined
Suicidal Thoughts(n=1,686)
Suicidal Attempts(n=1,685)
p<.001
Youth Outcomes continued…
Education Juvenile Justice
59
83%
63.40%
44.40%
90.20%
75.20%
31.60%
90.10%
75.70%
29.50%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Reg
ular
Att
enda
nce
Goo
d P
erfo
rman
ceSu
spen
ded
or E
xpel
led
School Functioning Improved
24 Months
12 Months
Intake
(n=1,062)
(n=729)
(n=1,105)
76.60%
54.40%
44.50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Engaged in Delinquent Behavior
Engagement in Delinquent Behaviors Declined
Intake
12 Months
24 Months
n=824
p< .001
p< .001
Caregiver Outcomes
60
36.2%
44.8%
56.5%
47.7%
7.3% 7.5%
0%
10%
20%
30%
40%
50%
60%
Intake to 12 MonthsIntake to 24 Months
Change in Caregiver Global Strain*
Strain Lessened
Strain Remained Stable
Strain Worsened
0
1
2
3
4
5
6
7
Intake12 Months
24 Months
6.2
4
2.8
Average Number of Caregiver Work Days Missed Due to Child’s
Behavioral or Emotional Problems*
p < .001 (n = 1,594)
*As measured by the Caregiver Strain Questionnaire
*Average number of work days missed in the previous 6 months
System Outcomes
Cost Savings Service Delivery Ratings
61
$3,623
$2,258
$1,930
$1,313
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
$4,000
Inpatient Care(n=2,246)
Juvenile Arrests(n=1,254)
Estimated Gross Cost Savings per Child or Youth*
6 Months Prior to Intake
18-24 Months AfterIntake
4.0
3.1 2.9
3.0 3.2
3.3
3.0 2.8
4.3
3.4
3.8
3.3
3.7 3.9
3.7 3.7
0
1
2
3
4
5
Average Infrastructure Ratings for Communities Funded in 2005-2006
Beginning of Funding
Middle of Funding
n=30
*From reduction in inpatient hospitalization and juvenile arrests
Wraparound Maine Summary:
Mental Health Service Use and Cost Study
62
Wraparound Maine is a statewide, multi-site initiative that implements high fidelity
Wraparound
Target population includes children & youth, ages 5-18, with serious behavioral
challenges who are in residential treatment or in a juvenile corrections facility or at
risk of such placements
Study included 148 children and youth who entered Wraparound Maine between
7/1/2007 – 6/30/2009
Pre-Post study period included:
1. Pre-Wraparound – a 12-month time period before entry into service
2. Post-Wraparound Initiation – a 12-month time period starting on the date the child
enters Wraparound Maine
Source: www.maine.gov/dhhs/ocfs/wraparound/july_qi_data_snapshot_v3_I3.pdf, site accessed, October 28, 2013
63
Pre-post Wraparound Average Per Child Per Year Mental Health Expenditures
Service Type Pre-Wraparound Average Per Child
Expenditures
Post-Wraparound Initiation
Average Per Child Expenditures Pre-Post Difference
Percent
Change
Targeted Case Management
(Wraparound Maine)¹ $3,858.02 $7,664.15 $3,806.13 99%
Emergency Room (MH) $441.16 $467.47 $26.31 6%
HCT Services $7,456.25 $6,735.99 -$720.26 10%
Crisis Intervention & Resolution $2,343.48 $1,637.15 -$706.33 30%
Residential (PNMI) Services² $60,293.95 $43,027.68 -$17,266.27 29%
MH Outpatient Treatment
(Sec 65) $1,406.07 $1,835.59 $429.52 31%
Medication Assessment & Treatment $810.88 $779.16 -$31.72 4%
Psychiatric Inpatient Treatment $55,488.75 $31,667.34 -$23,821.41 43%
Outpatient Psychiatric Treatment $551.19 $693.23 $142.04 26%
Other MH Services $786.21 $968.82 $182.61 23%
Child ACT $8,712.24 $6,998.02 -$1,714.22 20%
Day Treatment $9,544.98 $7,925.49 -$1,619.49 17%
Day Habilitation $10,545.00 $14,639.64 $4,094.64 39%
Total Mental Health $58,403.91 $41,873.16 -$16,530.75 28%
¹ Targeted Case Management expenditures pre-Wraparound initiation reflect use of non-wrap TCM services. Wraparound Maine services are billed through section 13 Targeted Case Management. The increase in TCM expenditure pre to post reflect the initiation of Wraparound
services.
² Residential Treatment Services includes all PNMI Child Care and Crisis Residential Facility expenditures.
Next Steps
Overarching recommendations
regardless of System Design
65
Amend the State Medicaid Plan to cover a broader array of home and community services (e.g.,SAMH services, family and youth peer support).
Embed intensive care coordination using fidelity Wraparound
Medicaid plan covers a range of crisis options (e.g., newer model of mobile response and stabilization).
Require primary care physicians to screen for behavioral health challenges using standardized screening tools.
Incorporate a standard assessment tool that can be utilized across systems for service planning, ongoing assessment, and to support outcomes tracking (e.g., CANS).
Broaden the Medicaid provider network, expand use of telebehavioral health, and create access to care by identifying funds across systems (child welfare, behavioral health, juvenile justice) and incorporating funding and the population into a single payer system (for Medicaid and non-Medicaid children).
Source: Pires. S. 2013. Human Service Collaborative
Managed care organizations are one of the keys to system reform
66
What can you do?
Join the System of Care Initiatives in your area;
Participate in strategic planning and implementation
System Design and collaboration across all child-
serving systems
Braided funding models
Use the substitution codes for Wraparound, peer
support, respite, and mobile crisis services.
Ensuring provision of high fidelity
Wraparound
67
Formal request for the use of the Wraparound substitution
code including: • Description of population to be served that must meet a minimum set
of eligibility criteria such as:
o Severe emotional disturbance
o Multi-system (or documented risk of) involvement
• Training records in the Wraparound approach
• Plan for ongoing Wraparound coaching that meets a minimum set of
required supervision hours
• Plan for ongoing fidelity evaluation utilizing the WFI with expectation of
scoring no lower than the national average.
Contact Information
Florida SOC Project Managers
69
Bruce Strahl Project Director - Children’s Mental Health System of Care Expansion Project Department of Children and Families [email protected] (850)717-4039 Anne Marie Sheffield. LCSW Project Director – Wraparound Orange Orange County Mental Health and Homeless Issues Division [email protected] (407)836-6507 Nicole Attong, LMHC FACES Project Director South Florida Behavioral Health Network [email protected] (786)507-7453
Tracy Pellegrino, MSW
Project Director – Families and Communities
Together
Community Based Care of Central Florida
(321)441-2090
Vicki Waytowich, Ed D
Project Director – Jacksonville System of Care
Initiative
Partnership for Child Health
(904)630-7274
70
Ute Gazioch Mental Health Lead
Department of Children and Families, Substance Abuse and Mental Health
(850) 717-4322
QUESTIONS?
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