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Arkansas Children’s Behavioral Health Care Commission

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Presentation on theme: "Arkansas Children’s Behavioral Health Care Commission"— Presentation transcript:

1 Arkansas Children’s Behavioral Health Care Commission
Annual Report to the Governor 2013

2 Contents 1 Page Number Title 2 Expanding the Statewide System of Care
6 Wraparound Sites 8 Family Support Activities 10 Family Support Partners 13 Youth Outcome Questionnaire® 15 Arkansas Indicators 17 Youth M.O.V.E. 19 Intensive Family Services 21 Access to Recovery 23 Youth Advocacy Program 25 Arkansas Co-occurring Diversion Initiative 27 Fetal Alcohol Spectrum Disorders 29 Court Team for Safe Babies 30 Behavioral Health Payment Improvement Initiative 33 Atypical Antipsychotics Project 39 Arkansas Building Effective Services for Trauma 41 Conscious Discipline 43 Developmental Disabilities Health Home 45 Child Welfare Waiver Demonstration 47 Juvenile Detention Alternatives Initiative 48 Strategic Prevention Framework Partnerships for Success 51 Arkansas Network for Early Stress and Trauma 52 Positive Learning for Arkansas’ Youngest 54 Second Chance Juvenile Reentry Planning Grant 56 Arkansas Children’s Behavioral Health Care Commission 1

3 Expanding the Statewide System of Care
As a result of a 2011 grant award from the Substance Abuse and Mental Health Services Administration (SAMHSA), the Arkansas Department of Human Services (DHS) Division of Behavioral Health Services (DBHS) has taken a multi-faceted approach to plan for the expansion of a family-driven, youth- guided, and culturally competent System of Care (SOC) across the state of Arkansas by emphasizing: training and certification for service providers, outcome measurement to ensure efficacy, and infrastructure for financial sustainability. These three areas are addressed by work groups that include state SOC, child welfare, juvenile justice staff, youth, families, local and state child serving agencies, and others stakeholders to ensure an inclusive project with widespread input and support. In 2011, the Arkansas Department of Human Services (DHS) Division of Behavioral Health Services (DBHS) submitted an application to the Substance Abuse and Mental Health Services Administration (SAMHSA) for the Expansion of the Comprehensive Community Mental Health Services for Children and their Families Grant. The purpose of the grant is to plan the implementation, expansion, and sustainability of a statewide Children’s System of Care (SOC). DBHS was awarded $724,676 in 2012 to support this two-year project. Implementation of a Statewide System of Care Initiative Key Areas All work groups are addressing strategies to achieve the overall goals of the planning process. These strategies include: Identify additional intensive care coordination services and supports for target population; Increase capacity for Family Support Partners; Develop capacity for Youth Support Partners; Develop a plan to implement policy, administrative and regulatory changes to support SOC service provision; and, Reinforce statewide Cultural Competence and Linguistics efforts. 2

4 Expanding the Statewide System of Care
Outcomes Work Group: The Outcomes Work Group has identified all of the service outcomes that each DHS division in the Arkansas SOC initiative are currently reporting. The work group found that a great deal of data is being collected, but it is often not reported in a manner reflecting outcomes cross divisionally. To address this need, a web based data system was developed to capture the outcome and performance metrics for the current Wraparound services funded through State General Revenue. This system was launched in January 2014 and replaced a current spreadsheet generated report. Future goals of the Outcomes Work Group are to make recommendations regarding integration of these existing service outcomes data to establish clear, reliable and valid measures. These measures should reflect family and youth functioning, clinical functional outcomes, provision and effectiveness of services, and cost and frequency of service delivery. This will be the focus of the second project year. Finance Work Group: The Finance Work Group was combined with an existing committee working on the Behavioral Health Payment Improvement Initiative for Arkansas (APII) . This work group is comprised of representatives from DHS, including DBHS and the Division of Medical Services(DMS). In addition, this work group has presented over 150 meetings with providers, consumers, family members, and other stakeholders to transform the behavioral health system. 3

5 Expanding the Statewide System of Care
In order to assure comprehensive input, a variety of approaches was taken, including public meetings, webinars, ongoing presentations to a wide variety of organizations, and meetings with a clinical advisory work group of stakeholders. The Behavioral Health APII targets Medicaid beneficiaries receiving and in need of behavioral health services. A component of the Behavioral Health APII focuses on efforts of the state and stakeholders developing a plan for the application and implementation of Behavioral Health Homes and a 1915i State Plan Amendment to enhance access to home and community based services. This includes development of qualifications and certification of Behavioral Health Homes and Behavioral Health Agency Providers as well as performing providers who will directly provide services. Training/Certification Work Group: The Training/Certification Work Group developed job descriptions for Family Support Partners and Wraparound Specialists, and the work group is presently working on the job description for Youth Support Partners. The Family Support Partner job description was written to meet the National Family Support Partner Certification developed by the Federation of Families for Children’s Mental Health. The group is presently examining training curricula and certification programs from several states to inform decision making to adopt or develop an Arkansas curriculum. Family and Youth Engagement The 14 Care Coordinating Councils (CCCs) across the state have been engaged in the APII planning process to ensure input and support from families and youth. Each council was asked to invite a family member and a youth to train as liaisons. The liaisons would then facilitate local meetings, such as family nights and roundtable discussions, to both report work group progress and also gather input from a family/youth perspective on proposed strategies and needs in their local communities. These family or youth representatives formed the Family and Youth Expansion Advisory Council. This advisory council meets on a regular basis with other work group representatives to assure the family/youth voice is included in all aspects of the planning process. 4

6 Expanding the Statewide System of Care
Training Opportunities The Family and Youth Communication Liaisons from across the state were able to participate in a Communication Liaison training in February Conni Wells with Axis Inc. (family consultant) and Reyhan Reid, National Youth Technical Assistant Consultant with Georgetown University, provided a two-day training in Little Rock. This event focused on development of communication and facilitation skills, marketing, job role, and job responsibilities. Approximately 30 representatives attended the meeting. The goal of this training was to bring Family and Youth Communication Liaisons together for the purpose of development and explanation of their new role in our statewide planning process and to equip them in completing the tasks of this new role. Additionally, Ellen Kagen, Senior Policy Associate and Director of the Georgetown Leadership program , led a training to assist Implementing Statewide Systems of Care (ISSOC) staff, all work group members, and key state SOC leaders in working to create and recognize the importance of effective leadership during system change. Key components of the training included: Focus on the skills of adaptive leadership; Focus on the leadership skill of transformation management; Focus on the leadership processes of negotiation skills, critical thinking, dispute and conflict management, group facilitation skills, advocacy and inquiry, dialogue and discussion; Focus on developing individual leadership skills of: self-reflection, mental models and assumptions, flexible leadership style, the role of personal values, the role of culture on leadership behavior, developing vision, risk taking and courage, resilience and resolve; Focus on Leadership Feedback (360) using the Leadership Practices Inventory (LPI); and Focus on the leadership skills necessary for building comprehensive systems of care for children and youth and their families. 5

7 Wraparound Sites 2013 Site Audit Results 2.7 2.6 2.4 2.9
Wraparound is a family-driven, youth-guided, team-based approach that wraps services and supports around a family whose child or youth is at risk of removal from their home, school, and community due to severe to moderate behavioral health issues. The purpose of the Arkansas System of Care (AR SOC) is to facilitate the development of local systems of care and provide funding for fourteen Arkansas Department of Human Services (DHS) behavioral health service areas through Wraparound sites. The Arkansas System of Care (AR SOC) includes fourteen Wraparound Sites across the state, covering all 75 counties. Each site has an active Care Coordinating Council (CCC) overseen by the Community Care Director (CCD) and is comprised of members of the community including professionals from an array of private and public agencies as well as youth and family members. During 2013, the Arkansas Department of Human Services (DHS) Division of Behavioral Health Services (DBHS) completed onsite audits of all sites to assess progress. Areas examined during the audit process included the involvement of families and youth and their active participation in CCC and Child and Adolescent Services System Program (CASSP) processes. The DHS SOC staff also evaluated the ability of each site’s CCC to provide oversight to local SOC efforts. 2013 Site Audit Results Overall Sites Average Rating Per Goal Goals: Leadership has developed and runs local CCC or CASSP Region Team meetings, manages flexible funds, and local services and supports. Wraparound Specialist and/or CASSP Coordinators are guiding Wraparound/Multi-Agency Plans of Service (MAPS) meeting per the Wraparound plan Family activities are held regularly to develop family support, education, and governance. Family Support Partner (FSP) supports families with Wraparound and families in the community. Overall Averages: 2.7 2.6 2.4 2.9 Sites Rating Ranges 11.8% of sites rated extremely well 23.5% of sites rated above average 64.7% of sites rated satisfactory 0% of sites rated needing improvement 6 Rating key: 1 Need Improvement 2 Satisfactory 3 Above Average 4 Extremely Well

8 Wraparound Sites The Arkansas Youth Information 7
Throughout the year, DHS provides ongoing technical assistance to Wraparound sites. Three DHS SOC technical assistants are strategically located across the state allowing them to respond quickly and efficiently to the sites in their region. By attending Wraparound meetings, the technical assistants are able to observe the Wraparound process and give feedback to the Wraparound facilitators. They also attend the CCC meetings in their prospective areas as well as complete regular chart reviews. These efforts combined enhance the ability of the Wraparound providers to maintain fidelity to the Wraparound model. Additionally, DHS continues to provide training to SOC providers, including five Wraparound certification trainings and one Family Support Partner (FSP) training in During the year, 118 individuals were trained and certified as Wraparound Facilitators, and six individuals attended FSP training with three becoming certified FSPs. DHS has continued efforts in the development of best practice guidelines for SOC and Wraparound. In 2013, DHS developed and distributed best practice guidelines for working with children and youth during out-of-home placements. This practice allows children and youth to maintain a relationship with their community even when they are not able to live in the community and assists with a smoother transition when returning to the community. The Arkansas Youth Information The Arkansas Youth Information Form is completed by providers and caregivers and measures outcomes at the beginning of Wraparound and at 90-day follow-up intervals. This process provides continuous feedback on how children and youth are progressing in Wraparound services. The five outcome measures were chosen to match national SOC recommended outcomes and include: Hospitalization in an acute psychiatric facility; Suspension or expulsion from school; Custody in Division of Child and Family Services (foster care); Juvenile detention; and, Residential treatment. 7 An analysis of 172 children receiving their second assessment during SFY 2014 between July 1 , and November 30, 2013 indicated results similar to the original findings. The major result was the slightly larger initial percentages. All factors showed decreases by the second assessment. Fewer than half of the children were suspended or in residential treatment during the second assessment; hospitalizations decreased by 14% and slightly fewer children were arrested or in DCFS custody.

9 Family Support Activities
Wraparound places an emphasis on integrating the families and youths into the community and building on their social support networks. Family support activities are provided in order to provide an opportunity to develop new supportive relationships and become part of a larger circle of families with similar experiences and who have faced similar challenges and overcome them. Once the family has developed its own network of informal peer support, they have more confidence to participate more fully in the community as a whole. Family and youth support activities throughout the state vary by provider, as they are based on the communities’ needs and the input of families and youth involved with the Care Coordinating Councils (CCC). The activities allow caregivers and youth opportunities to interact with one another and to provide peer support and encouragement. These events not only provide opportunities for family socialization, but also serve as activities of community integration, which is essential to the recovery journey for our families and youth. Wraparound providers are required to provide family support activities. They are generally held monthly or bi-monthly. The purpose is to provide a regular opportunity for caregivers to learn valuable skills to strengthen their families. These events serve as prevention level activities to offer youth and families support, education, and leadership skills. 8

10 Family Support Activities
In 2013, 224 family and 173 youth events were held, each focusing on unique content pertinent to the community. Some events were for socialization, while others were community integration activities. The youth volunteered in a variety of community activities that range from preparing backpacks with needed school materials with the local fire department to volunteering to man a booth at community events celebrating Children’s Mental Health Month. In some communities, the Family Support Partners (FSP) and participating families take responsibility for hosting the family nights in their communities. The event management responsibility differs by site depending primarily upon the level of family engagement within the group. Each of the 14 service areas receive $2,500 each year to support these activities. Families and youth continue to demonstrate growth, new abilities, and overall success from participating in the family support activities. Year Number of Events Year Number of Events 2013 Family Support Activities 9

11 Family Support Partners
Family Support Partner Training In March 2013, the second annual Family Support Partner (FSP) Training was held. The training consists of six days of intensive training. The first three days focus on the National Alliance on Mental Illness (NAMI) Basics curriculum. NAMI Basics is an educational program for parents and caregivers of children and adolescents living with mental illnesses. The program was developed around elements that have been extensively tested and found to be highly effective, including: Current information on a range of mental illnesses and their impact on the brain; Research on treatments, including evidence- based therapies, medications and side effects; Preparation for interactions with the mental health care system, school system and juvenile justice system; Recognition of mental illness as a continuing traumatic event; Sensitivity to the subjective emotional issues families face; Information for the empowerment of family caregivers as effective advocates for their children; Skills related to day to day as well as crises management and relapse, solving problems and communicating effectively; Examples of strategies to handle challenging behaviors in children and adolescents; and, Information on locating appropriate supports and services within the community. The Arkansas Department of Human Services (DHS) has continued to work with the Family and Youth Support Partners (FYSP) Work Group to establish a network of Family Support Partners (FSP) throughout Arkansas. FSPs are peer counselors from legacy families who model recovery and resiliency in overcoming obstacles common to those who live with children or youth with behavioral health care needs. Legacy family members, those that have had multiple experiences with the mental health and broader social service system, are recruited to serve as FSPs. In this role, FSPs are charged to work alongside Community Care Directors (CCDs) and Wraparound Specialists (WAS) to help engage and support local families in the Wraparound process. 10

12 Family Support Partners
The second three days of the FSP training is based on the Individualized and Tailored Care/Wraparound Parent Partner Training Manual written by parent partner Patricia Miles, which is guided by the following principles. A Parent Partner is the parent of a child with special needs and has experienced first hand the hopelessness and isolation this brings. As a Parent Partner, we choose to go public with our private story. There is a skill in deciding what parts of our story to share and how best to do this. The training should be taught by a Parent Partner. Wraparound Parent Partners are champions for the parents, but also champions for the Wraparound process. Participants attending the March 2013 training included seven previously certified FSPs. There were six persons new to the training, and three of these received FSP certification. This addition to the System of Care (SOC) teams throughout the state provided FSP coverage to ten more counties. A total of 56 counties were served during the year by FSPs. FSP assistance and support were provided to 164 families involved in Wraparound and another 186 families that were not Wraparound clients. 11

13 Family Support Partners
The Family and Youth Support Partner Work Group The Family and Youth Support Partner (FYSP) Work Group merged with the Implementing Statewide Systems of Care (ISSOC) Training and Certification Work Group to research functional duties, job descriptions, training essentials and certification processes for the Family Support Partner and Youth Support Partner. The work group has performed extensive examination of other states policies, existing policy and processes in Arkansas, sought input from the state’s Family and Youth Communication Liaisons, as well as reaching out to peer partner specialists throughout the country. The work group is making recommendations to the DHS for consideration from the information gathered. National Certification DHS encourages the continued growth and education of the FSPs in the state, as their contribution to the wellness of families is proven to be invaluable. This year, the Division of Behavioral Health Services (DBHS) FSP Coordinator became a nationally certified FSP by the National Federation of Families for Children’s Mental Health (Federation). There are only 150 Nationally Certified individuals in the United States. The Federation is a family-run organization linking more than 120 chapters and state organizations. It focuses on the issues of children and youth with emotional, behavioral, and/or mental health needs and their families. The organization works to develop and implement policies, funding mechanisms, and service systems that utilize the strengths of families. The Federation provides managerial and administrative support to its membership base, as well as technical assistance to federally funded SOC communities, as a part of the Comprehensive Community Mental Health Services for Children and Their Families (CMHI) initiative, managed by the Substance Abuse and Mental Health Services Administration (SAMHSA). In 2014 additional FSPs in Arkansas will be seeking certification with the Federation. 12

14 Youth Outcome Questionnaire
In 2012, Arkansas System of Care (AR SOC) staff produced an initial outcomes report with data for all Y-OQs® completed between July 2010 and September The initial report showed results from the parent Y-OQ®. In April 2013, AR SOC staff reported on the youth Y-OQ® Self-Report (Y-OQ® SR) for 3,524 clients having two or more valid Y-OQ® SR assessments. Overall results show an improvement in treatment outcomes (a lower score between the first and last Y-OQ® administration). Compliance Rates To ensure timely Y-OQ® assessments, behavioral health providers are required to administer the Y-OQ® to parents and youth at least once every 90 days. Compliance rates are calculated by comparing the number of completed parent or youth Y-OQs® with the number of clients receiving behavioral health services. The overall compliance rates for each quarter of 2013 show an increase from 74% compliance during the first quarter to 78% during the last quarter, which means the majority of children receiving services are consistently receiving assessments. Achieving adequate compliance rates was a necessary initial step in implementing the YOQ® across the state, before the Arkansas Department of Human Services (DHS) Division of Behavioral Health Services (DBHS) could move to the outcomes phase of data reporting. The improved compliance rates are due in part to DBHS’ efforts to increase technical assistance to providers. The Youth Outcome Questionnaire® (Y-OQ®) is the assessment tool used by behavioral health care organizations to measure the effectiveness of services provided to children and youth. Parents and youth are asked to complete the Y-OQ® at intake and at least every 90 days afterwards until the child or youth is discharged. Feedback from the Y-OQ® allows clinicians to monitor treatment progress and identify cases where clients are not showing improvement. Compliance Rate Percentages Y-OQ® Mean Total Score Percentage 13

15 Youth Outcome Questionnaire
Outcomes The Y-OQ® measures change in children’s symptoms and behaviors. Outcomes are measured after children/youth complete a course of treatment. Children and youth who were not active in behavioral health services for 120 days or more were considered as inactive or “discharged” from services. Outcomes are measured by an increase or decrease in the total Y-OQ® scores. The amount of change is classified into one of four categories: Recovered, Improved, Stable, or Deteriorated. Each category represents clinically significant change and is defined as follows: Recovered: Change in scores is considered similar to children who are not receiving behavioral health treatment. Improved: Change in scores is considered as a clinically significant improvement. Stable: Change in scores indicates there may be some improvement, but not clinically significant. Deteriorated: Change in scores indicates no clinical improvement or an increase in total score. Y-OQ® Outcomes of Inactive Clients Percent of Clients 14 Future efforts will focus on continuing to provide technical assistance to providers regarding proper administration and interpretation for the YOQ ® and conducting additional analysis of YOQ® data along with outcome information for the Arkansas Indicators.

16 Arkansas Indicators In 2012, a work group was convened to review concerns from providers regarding the Arkansas Indicators (AR Indicators). The work group was tasked with reviewing the current AR Indicators and proposing changes in content and method of collection. This work group included staff members from Arkansas Department of Human Services (DHS) and Quality Assurance Officers from Rehabilitative Services for Persons with Mental Illness (RSPMI) provider agencies. Combined with clinical data from the Youth Outcome Questionnaire® (Y-OQ®), the Arkansas Indicators (AR Indicators) provides a comprehensive outcomes measurement process for children and youth receiving behavioral health services. The AR Indicators tool was created to measure client functioning, satisfaction with services, and treatment barriers. The work group began by reviewing the original purpose for the development of the AR Indicators. This included: Gathering demographic data to describe the population of children/youth that are receiving behavioral health services in Arkansas; Monitoring data points by which the Y-OQ® Reliable Change Index outcomes data can be sorted; Measuring child/youth and family functioning; Tracking and reporting state level outcome data; and, Collecting consumer satisfaction data. The work group also completed an analysis of the AR Indicators by reviewing other outcome instruments for comparison. The group examined the worker report from the Ohio Scales and the AR Youth Information Form developed by Arkansas State University (ASU), Office of Behavioral Research & Evaluation (OBRE), and information collected on treatment plans by behavioral health agencies. 15

17 Arkansas Indicators 16 The group made the following recommendations:
All AR Indicator questions should be in the same format and provide a list of choices for reporting the previous 90 days of client activity. Initial administration is to be at the time of intake in order to obtain data on the child’s/youth’s behaviors 90 days prior to treatment. Focus on four areas for questions to include: family, school, legal and community. The suggestion was that all possible alternatives would be given under each question and ranked in the order of most severe possible outcome to the most positive possible outcome. The proposed AR Indicators would be collected in the same way that the current AR Indicators are being collected, in conjunction with the Y-OQ® and questions that were asked redundantly be removed. The satisfaction and barriers sections should be collected using another methodology. Satisfaction questions are currently required by several different entities. Providers requested that these be coordinated by DBHS so family, youth and provider time is used efficiently. That behavioral health providers are given access to provider level data for the AR Indicators so the data could be used for other reporting requirements as well as quality assurance/improvement activities. All work group recommendations were accepted by the Children’s Behavioral Health Care Commission. The new AR Indicators were put into place July 2013 after completing a pilot of the updated tool. All behavioral health agencies transitioned to using the new AR Indicators before the end of August The first rounds of state level aggregate data will be available in the summer of 2014 and will be used in conjunction with Y-OQ® data. DBHS is working with UAMS to produce an alternative satisfaction and barriers section that will be more efficient for families and will eliminate duplications when possible. DBHS is also in the process of constructing methods of access to provider level data that will be available from the data collected. 16

18 Photograph from the 2013 YMA Empowerment Conference
Youth M.O.V.E. Youth M.O.V.E. Arkansas (YMA) has grown to 11 active chapters across the state and continues to expand, making strides through peer-to-peer counseling, speaking engagements, and several statewide initiatives. The focus is to improve services for children, youth, and families by establishing partnerships and gaining the support of respected community leaders to strengthen the systems within programs and agencies addressing the behavioral health needs of area youth. The Winter Leadership Retreat was held in March in Little Rock, Arkansas. This retreat brought members of local YMA chapters serving as officers together for sessions with topics such as: public speaking, officer’s roles, and community service projects. There were 32 youth from the then six active chapters who participated in the retreat. Youth Motivating Others through Voices of Experience (M.O.V.E.) Arkansas (YMA) is a statewide youth-led organization devoted to improving services and supports provided to children and youth in the state of Arkansas. This organization partners with youth, adults, professionals, and other partners to help transform Arkansas’ youth- serving systems. They share their experiences as consumers of child and youth services from various systems (child welfare, behavioral health, juvenile justice, special education) and agencies (private and public) in Arkansas and actively participate in the redevelopment of those systems designed to serve young Arkansans. Youth M.O.V.E. Arkansas is a local affiliate of the national Youth M.O.V.E. organization. Photograph from the 2013 YMA Empowerment Conference 17 Each YMA chapter participated in many different community projects throughout the year. During Mental Health Awareness Week, every chapter held special events in their community with the goal of reducing stigma associated with mental health by providing information. Some chapters co-sponsored events. The Monroe County YMA chapter hosted a one day conference at the Brinkley Convention Center entitled Mentally Emotionally Healthy Communities on the RISE. The conference sessions included: Managing

19 Photographs from the 2013 YMA Empowerment Conference
Youth M.O.V.E. Your Stress Levels; Physical Health in Connecting to Mental and Emotional Health; and Suicide Prevention. Local and statewide service providers participated by setting up information booths. The conference was successful in reaching hundreds of people in the area. Annual Arkansas Youth and Family Empowerment Conference In July 2013, the third Annual Arkansas Youth and Family Empowerment Conference was held at Arkansas State University in Jonesboro, Arkansas, with over 250 youth and adults in attendance. The theme for the conference was Take Chances, Make Changes. For the first time the conference provided two tracks. One track was designed specifically for youth, and a new track was offered for family members. 18 Photographs from the 2013 YMA Empowerment Conference This year a banquet was held before the prom to give the youth a chance to dress up and eat a nice meal before attending the very popular Save the Rave Dance.

20 Intensive Family Services
The Intensive Family Services (IFS) program is primarily intended to prevent out-of-home placements for children whose families are involved with the Arkansas Department of Human Services (DHS) Division of Children and Family Services (DCFS). IFS offers an array of services including time limited counseling and skill building. Services are aimed at ensuring the safety of all family members while helping the family learn how to stay together successfully. Services are available for up to six week; for 24 hours a day; seven days per week; and are provided in family homes or in alternative natural environment settings. All aspects of IFS target the specific needs of families. During State Fiscal Year 2013, Division of Children and Family Services (DCFS) contracted with six Intensive Family Services (IFS) providers and offered service coverage in 61 of the 75 counties in the state. Since 2010, DCFS has used the North Carolina Family Assessment Scale (NCFAS) as the evaluation instrument to track family progress for those that participate in the IFS Program. The NCFAS was developed by the National Family Preservation Network and is being used to monitor programs throughout the United States. Each family that receives IFS, by means of a DCFS referral, is assessed in eight general NCFAS domains at intake and closure of services. There are two additional domains that are applicable only to families with reunification as a goal. Families are assigned a score in each domain from a six-point scale based on the level of family functioning. NCFAS Domains Eight General Domains: Environment Parental Capabilities Family Interaction Family Safety Child Well-Being Social-Community Life Self-Sufficiency Family Health Additional Reunification Domains: Caregiver/Child Ambivalence Readiness for Reunification Contract performance indicators require IFS providers to submit NCFAS data to the DCFS Central Office each month. To measure progress of families that completed IFS during the state fiscal year of 2013, a comparison was made between the “overall” rating scores in the eight general NCFAS domains at intake and at closure. Only families with completed NCFAS records were included in the annual summary report. Please note that additional families participated in the IFS program during the fiscal year; however, due to case specific reasons (such as family relocation, unexpected case changes, and etc.) some families did not have a closing NCFAS and those families were not included in this study. The NCFAS can also be administered to families at an “interim” point during services. A total of 290 families had an NCFAS intake record during SFY 2013, and 201 of those families started and ended services. 19

21 Intensive Family Services
Family Functioning Improvement Between Intake and Closure There was improvement in family functioning in each NCFAS domain between intake and closure of IFS, which indicates that the IFS program yields positive outcomes for families that participate in this program. Below are two graphs showing that families increased in functionality as a result of participating in the IFS program. Family Functioning (Mild Strength, Clear Strength and Baseline/Adequate) Note: In the Mild Strength, Clear Strength and Baseline/Adequate domains, an increase in percentage at closure is indicative of family functioning progress. Mild Problem, Moderate Problem and Serious Problem at Intake and Closure of IFS – 2013 Note: In the Mild Problem, Moderate Problem and Severe Problem domains, a decrease in percentage at closure is indicative of family progress. 20

22 Access to Recovery Outcomes 21
Access to Recovery (ATR) is a four year initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) through September ATR shifts the focus of behavioral health care from acute substance abuse treatment to building on the strengths of clients in recovery and sustained recovery management. Recovery is supported by assisting clients in meeting identified needs through a self-directed recovery plan. This approach has been a success in other states and is being piloted in thirteen counties in Arkansas: Benton, Washington, Crawford, Sebastian, Craighead, Garland, Saline, Pulaski, Lonoke, White, Faulkner, Jefferson, and Independence. Outcomes The Access to Recovery (ATR) initiative has demonstrated a significant impact on substance abuse recovery. The ATR program measures recovery outcomes by comparing various factors relating to employment, housing, substance use, and legal involvement at the time of intake and six months after intake. Since January 31, 2011, through July 31, 2013, Arkansas has served 6,798 clients. A total of 4,505 clients completed their six-month follow-up. One of the most significant improvements is the decrease in number of ATR parents with children in out-of-home placements. Specifically, 1,205 parents had a total of 2,519 children living elsewhere due to a child protective order. Of those with an intake and follow-up survey, 24% had a child living with someone else due to a child protective order at intake compared to 19% at follow-up. More specifically, 888 ATR parents had 1,841 children in child protective custody at intake compared to 643 ATR parents with 1,344 in child protective custody at the six-month follow-up, representing a 27% decrease. 21

23 Access to Recovery ATR Client Demographics: ATR Eligibility: 22
There was a significant increase in the percent of clients with independent housing, from 74% to 90%. The percent of clients employed full or part-time nearly doubled from 23% to 45%. There was a significant decrease in the percent of clients arrested (10 % to 3%) as well as a large decrease in the percent of clients committing a criminal act (33% to 10%). 16% Increase Intake At 6 months 22% Increase 23% Decrease 7% Decrease ATR Client Demographics: ATR Eligibility: Participants must meet the following criteria: (modified March 2013) Eighteen years of age or older, and Reside in one of the pilot counties, and Screen positive for substance use disorder, and Be at or below 200% of federal poverty level, and Be in one of the targeted groups listed below: 61% Male 57% Caucasian 34% 25 to 44 Years of age 22% Less than high school education 48% Completed twelfth grade 77% Had children under eighteen years of age 23% Had a child in child protective custody A combat veteran, or A pregnant woman, or An adult family member of child(ren) with Division of Children and Family Services (DCFS) or Division of Youth Services (DYS) involvement, or at risk for child welfare involvement, or Person with multiple Driving Under the Influence (DUI) or Driving While Intoxicated (DWI) convictions, with the most recent being within six (6) months. 22

24 Youth Advocacy Program
The Arkansas Department of Human Services (DHS) Division of Youth Services (DYS) piloted three Youth Advocacy Programs (YAP) beginning in January The purpose of this initiative was to enhance and expand community-based programs by implementing a model to target juvenile crime and provide positive and cost- effective alternatives to detention in several sites in Arkansas. YAP is an intervention strategy used to assist in stopping the trend of youth violence by offering an intense community-based program for youth at risk of being committed to DYS or youth who are in aftercare and at risk of commitment to DYS. The program is designed to provide opportunities for targeted youth and their families to develop, contribute, and be valued as assets so that communities have safe, proven effective and economical alternatives to institutional placement. An advocate with extensive YAP training will spend ten to fifteen hours per week with youth in structured educational, social, and recreational activities. The Arkansas Department of Human Services (DHS) Division of Youth Services (DYS) launched five Youth Advocacy Programs (YAPs) following the successful completion of three pilot programs conducted in 2010. YAP is an intervention strategy used to assist in halting the trend of youth violence by offering an intense community- based program for youth at risk of being committed to DYS or youth who are in aftercare and at risk of recommitment. The program is designed to provide opportunities for targeted youth and their families to develop, contribute, and be valued. Community-based service providers were contracted to be hosts for the YAP Program in five judicial districts. Since the initial launching of the YAP initiative in 2010, two additional sites were added. By 2012, three of these sites were successfully sustaining a YAP program beyond the pilot period. 23 Judicial District Counties Served District 20 Faulkner, Van Buren, Searcy District 10 Ashley, Bradley, Chicot, Desha, Drew District 13 Dallas, Cleveland, Ouachita, Calhoun, Union, Columbia

25 Youth Advocacy Program
Outcomes Evaluation findings show that the majority of youth participating in this program demonstrated successful outcomes. This was based on data indicating that 63% of the youth participants finished the program successfully. Most of the youth rated the program as a good or excellent experience. The youth also reported that they had a good relationship with their advocate and felt they were treated with respect. A process evaluation showed that overall, the providers met all performance indicators and deliverables outlined in the YAP contracts. Each site delivered its program differently based on the needs of identified youth, desires of the supporting judicial district juvenile court, and the community services available to support the YAP program. The greatest accomplishment for all three sites has been the development of services and resources to better serve the YAP youth participants and their families. All sites have built a strong advocate group within each of their communities to provide guidance and support for youth and their families. Outcomes showed that the youth made the most improvement in general behavior (53%) and goal setting (18%), followed by increased performance in focus, choosing friends, family relationships and school grades at 6% each. Areas that participants felt they needed more improvement were choosing friends (18%), anger management (12%), employment (12%), substance abuse (12%), grades (6%) and overall attitudes (5%). Parents of youth were generally less satisfied with YAP this year (75%) than in year 1 (100%). Areas where parents believe they have improved were in their general behavior (53%), followed by school performance (18%) and substance abuse, attitude, choosing friends, and family relationships each at 6%. Parents indicated that they need to work on personal responsibility (30%), disrespectful behavior (12%) and anger management (12%). The next opportunity for the YAP is to continue offering the program in current sites, strengthening the program by developing aftercare youth support programs that have completed the YAP, and seeking funding to support YAP programs in other areas of the state with larger populations. 24

26 Arkansas Co-occurring Diversion Initiative
The Arkansas Department of Human Services (DHS) Division of Youth Services (DYS) and Division of Behavioral Health Services (DBHS) received planning grant funding in to participate in the Improving Diversion Policies and Programs for Justice Involved Youth with Co-Occurring Mental Health and Substance Use Disorders: An Integrated Policy Academy/Action Network Initiative through DYS and DBHS partnered with Southwest Arkansas Counseling and Mental Health Center (SWACMHC), a local recovery-oriented agency and member of the System of Care (SOC) that operates in southwest Arkansas. Through this liaison, Arkansas piloted the Arkansas Co-occurring Diversion Initiative (ACDI), a juvenile justice diversion program in Judicial District 8 North (JD8N), Hempstead and Nevada Counties. The aim of the ACDI is to coordinate access to effective services in order to divert youth with co-occurring mental and substance use disorders from adjudication. Arkansas chose to develop a comprehensive model at probation-intake to identify and make diversion recommendations for youth with co-occurring disorders. Therefore, Arkansas opted to participate in the cross-site work group, Implementing Screening for Justice-Involved Youth with Co-occurring Mental and Substance Use Disorders. For this initiative, Arkansas convened a core team of senior level officers representing state and local juvenile justice, behavioral health, and family advocacy. An expanded home team was formed consisting of key stakeholders (judges, law enforcement, education, probation/court staff, and prosecutors) to plan and implement the diversion strategy. 25

27 Arkansas Co-occurring Diversion Initiative
The program incorporates mental health, substance use, and co-occurring screening and assessment practices in the juvenile justice system. The program emphasized the use of evidence-based practice, treatment, and trauma-informed services. The model focuses on providing motivational interviewing, family engagement, crisis intervention, and mental health training to specialized juvenile probation-intake officers. Youth eligible for diversion through ACDI are: Identified by the local intake department as being eligible for diversion, deferred prosecution or disposition, or are pending adjudication, and are being supervised in the community by the juvenile court; Found to have a DSM‐IV diagnosis or are screened as potentially having a DSM‐IV diagnosis; At risk of adjudication; and, Have at least one family member or other adult in the household who is willing to actively participate in the program. Youth are screened at probation-intake using a standardized screening procedure and a review of the case history. An interview with the family is held by the juvenile intake officer to provide information to the youth and family about requirements for participation in ACDI. Youth and families that choose to participate are assigned a specialized juvenile probation officer who will coordinate community-based services. Services may include mentors, parent support groups, life skills classes, substance abuse services, education liaison services, and assistance with accessing other community resources. This initiative has allowed DYS, DBHS, courts, school systems, and SWACMHC to plan a program that encourages early intervention for multi-system juveniles with mental health and substance abuse with the ultimate goal to increase the number of youth with co-occurring disorders diverted to appropriate community-based behavioral health services, and to reduce the inappropriate and unnecessary contact of youth with the juvenile justice system. 26

28 Fetal Alcohol Spectrum Disorders
The Fetal Alcohol Spectrum Disorders (FASD) project was funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and administered through the Arkansas Department of Human Services (DHS) Division of Children and Family Services (DCFS) from February 2008 to May As part of the FASD project, a statewide taskforce was created as part of the requirements of the grant. The taskforce consists of agencies, advocates, and families from across Arkansas interested in treatment and prevention of FASD. Recognizing the value of the FASD project, DCFS will continue this work beyond the grant period and expand the project statewide. The DHS Division of Behavioral Health Services (DBHS) plays a key role in the FASD project expansion by providing support through the 13 Regional Prevention Providers (RPP) in the state. The RPPs disseminate information, provide education, and promote awareness of FASD across Arkansas. The Fetal Alcohol Spectrum Disorders Project Goals: Identify children with Fetal Alcohol Spectrum Disorders (FASD) as early as possible to begin necessary interventions Help stabilize the home environment Assist permanency planning with families By identifying FASD early in life, secondary disabilities and related complications may be prevented. There are multiple secondary disabilities and complications associated with FASD that can include: Behavioral health disorders Disrupted school experiences Criminal justice involvement Inappropriate sexual behavior Substance abuse problems Dependent living Employment problems 27

29 Fetal Alcohol Spectrum Disorders
Major Accomplishments in 2013 Arkansas passed Act 1300 on April 10, The Law will require the posting of a warning sign in a private club; and to educate the public concerning the risk of drinking alcoholic beverages during pregnancy. The FASD Taskforce was instrumental in education and support of this legislation. The First Annual Arkansas FASD Conference was held on September 22-25, National Speakers, including Dr. Ken Jones, who first diagnosed FASD 40 years ago, spoke to approximately 85 participants. The conference was sponsored by DHS, National Organization on Fetal Alcohol Syndrome (NOFAS), Arc of Arkansas, and, Midwest Regional Fetal Alcohol Syndrome Training Center (MRFASTC). The State FASD Coordinator and a taskforce member delivered a poster presentation at the First International Conference on Prevention of FASD in Alberta, Canada, in September. The Presentation was sponsored by DHS and the University of Arkansas Medical Sciences(UAMS). To support this effort, the Governor’s Office issued a proclamation designating September 9, 2013, as Fetal Alcohol Spectrum Disorders Awareness Day in the State of Arkansas. The related events gave DBHS the opportunity to distribute 5000 FASD pins and engage 32 churches and city halls from around the state to participate in the international bell ringing ceremony at 9:00 a.m. on the ninth day of the ninth month for FASD Awareness. The FASD Taskforce is in the process of applying to become a 501c3 non-profit organization with plans to become a state affiliate of the National Organization of Fetal Alcohol Syndrome (NOFAS). 28

30 Safe Babies Court Team Training
In 2009, the Arkansas Department of Human Services (DHS) Division of Children and Family Services (DCFS) began implementing the Safe Babies Court Teams model in Little Rock. The Safe Babies Court Teams Project is a system’s change initiative focused on improving how the courts, child welfare agencies, and related child- serving organizations work together, share information, and expedite services for young children. During this reporting period, ZERO TO THREE and the Arkansas Pilot Court Team continued to address the project’s goals of: increasing knowledge about the negative impact of abuse and neglect on very young children; and changing local systems to improve outcomes and prevent future court involvement in the lives of very young children. The Arkansas Pilot Safe Babies Court Team monitors the cases of children, birth to three years of age, who have come into the custody of the Arkansas Department of Human Services (DHS) due to abuse or neglect. Since 2009, the Arkansas Pilot Court Team for Safe Babies, made up of 119 members, has served 33 children, 11 of whom had open cases during the reporting period. Training During the reporting period the Arkansas Pilot Court Team worked to increase knowledge about the negative impact of abuse and neglect on very young children by hosting two trainings on topics related to the needs of maltreated infants and toddlers and their families. Both trainings focused on the social-emotional development of children, infant mental health, and the Court Team solution. The Arkansas Pilot Safe Babies Court Team During the last quarter of 2013, the Arkansas Pilot Court Team project engaged 119 multi-disciplinary partners. Court Team members were engaged on a monthly basis in meetings where Arkansas Pilot Court Team members discussed the development of local resources for families and the progress of the team’s subcommittees. These monthly meetings have proved crucial to the Arkansas Pilot Court Team’s success at improving the outcomes of children and families.  Working with Families The Arkansas Pilot Court Team’s greatest accomplishment was improving and expediting services for children and families. During the last quarter of the year, the Court Team monitored eleven children across eight families. 89% of the children monitored had no more than two changes of placement. 100% of the children monitored during the reporting period spent time with their parents at least two times per week. 100% of children who had siblings participated in visits with their siblings at least twice a week 29

31 Behavioral Health Payment Improvement Initiative
Progress to transform Arkansas’ Behavioral Health System of Care continued in Ongoing collaborative efforts with consumers, advocacy groups, providers, and provider associations have focused on developing a system of care that seeks to improve prevention, early intervention, treatment, screening, and assessment services to promote recovery and resiliency for individuals and families. As a part of Arkansas Payment Improvement Initiative (APII), enhancements to the behavioral health system seek to achieve the triple aim by : Improving the health of populations Improving the experience of care of individuals receiving services Improving quality of care while reducing the growth of health care costs The Arkansas Department of Human Services (DHS) continues to support the APII efforts through multiple strategies. Those strategies specific to the behavioral health delivery system leverage a multi-pronged approach that incorporates episode- based care and population-based delivery models. Episode-based care focuses on acute, post-acute, or select conditions. To date, the behavioral health episodes are Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD). Population-based care focuses on integrated care delivery that meets the comprehensive needs of individuals receiving care and families. Patient Centered Medical Homes (PCMH) and Health Homes are population-based health approaches. Patient Centered Medical Homes (PCMH) and Health Homes, a team-based care delivery system, will provide the basis for: Improved care coordination Facilitation of evidence-based practices Improved practice accountability Implementation of performance-based reporting to improve quality of care 30

32 Behavioral Health Episode Timelines
Behavioral Health Payment Improvement Initiative Behavioral Health Episodes of Care As the Arkansas Department of Human Services (DHS) developed specific behavioral health episode criteria was identified as essential to the initiative based on the following: Standard clinical guidelines that have reliability in predicting level of need and practice patterns; Standard and reliable diagnosis guidelines; Distinctive diagnosis guidelines that are unique from other episodes; Distinctive and consistent episode trajectory across condition-specific profiles; and, Validity of meaningful size for episode condition. Behavioral Health Episode Timelines Behavioral Health Episode Status Attention-Deficit/Hyperactivity Disorder (ADHD) Launched October 1, 2012 Ongoing Oppositional Defiant Disorder (ODD) Performance Period April 1, 2014 – March 31, 2015 Patient Centered Medical Home and Behavioral Health Home In addition to behavioral health episodes, DHS is working to develop integrated care coordination strategies that will support comprehensive care delivery. Two integrated care models to be implemented are Patient Centered Medical Home (PCMH) and Behavioral Health Home with the following expected outcomes: Emphasizing wellness and prevention for better population-based care management; Paying for effective, coordinated episodes of care rather than for individual services; Helping people live as independently as possible; and, Aligning financial incentives to achieve a transformed system. 31

33 Patient Centered Medical Home (PCMH) Behavioral Health Home (BHH)
Behavioral Health Payment Improvement Initiative Patient Centered Medical Home (PCMH) Behavioral Health Home (BHH) Definition: A team-based care delivery model led by a primary care provider who comprehensively manages a patient’s health needs with an emphasis on health care value. Definition: An integrated, care management model that addresses comprehensive care coordination needs including physical health, acute care, behavioral health, and long term services and supports. The BHH also manages core care delivery by ensuring effective treatment of behavioral health conditions, including pharmacy effects. Responsibilities: Managing care for entire patient panel and provide primary accountability of medical care plan and medical outcomes for patient panel Coordinating and integrating care across multidisciplinary provider teams Focusing on prevention and management of chronic disease Providing 24/7 access for all individuals Providing evidence-informed care Providing referrals to high-value providers (e.g., specialists) Providing wellness and preventative care Coordinating intensive behavioral health care for high acuity behavioral health clients in integrated approach with other multidisciplinary team members Coordinating integrated care plan that includes incorporating medical care plan, behavioral health treatment plan, and other specialty care plans and disseminate to full multidisciplinary care team Ensuring adherence to evidence-based and evidence-informed behavioral health treatment practices Serving as accountable provider for behavioral health outcomes for high acuity behavioral health client panel Particularly for the behavioral health population, implementation of these population-based health models will provide integrated care coordination efforts that will: Facilitate access to needed behavioral health services Provide care at the appropriate level of care and in the appropriate setting of care Provide needed care coordination to facilitate appropriate navigation through a challenging system of care Incentivize behavioral health providers to provide quality-driven care based on clinical guidelines and evidence-informed practices Empower individuals and families to take an active role in the delivery of whole- person, person-centered behavioral health care services As efforts continue to improve Arkansas’ Behavioral Health System of Care, information and updates on development efforts can be found at: 32

34 Atypical Antipsychotics Project
Beginning in 2013, the Medicaid pharmacy program has two psychiatrists. One, working half time, is a child psychiatrist who reviews all manual prior authorization requests including: Any request for antipsychotic agent for children under six years of age Doses above established dose edits for any age child Adding a second antipsychotic agent for any age child The manual reviews often require consultation with the prescribing physician regarding diagnosis and/or the medical necessity of the request. Cases are frequently staffed with clinical System of Care staff members who work with community providers and families of children with outlier medication profiles to determine if their current non-medication treatment plans are adequate. The other psychiatrist reviews antipsychotic utilization patterns in children and sends letters to specific providers regarding the therapy, which is followed by a phone call to some of the prescribers. In addition, this physician reviews childrens’ Medicaid drug profiles who are receiving five or more mental health drugs and consults with the prescribers regarding the therapy. The psychiatrist also handles the exception requests from prescribers requesting to skip required metabolic labs for a child. Consultation is provided to the Arkansas Department of Human Services (DHS) Division of Children and Family Services (DCFS) staff regarding psychotropic medication issues in foster children as well as the Value Options Care Coordinator team reviewing complex cases in which there have been multiple hospitalizations and excessive use of medications. Since inception in 2008, the primary goal of the Atypical Antipsychotics Work Group has been to address clinical practice standards for children with serious emotional disturbances (SED) with the goal of ensuring child safety. New policies that were established to address the safe use of psychopharmacological medication in children and youth and require consent and follow-up labs, have raised the awareness among of providers and parents. This attention to safe psychopharmacological practices and engagement with providers regarding alternative non- pharmaceutical therapeutic procedures will lead to better health for children with SED. 33

35 29% Decrease in number of total unduplicated Foster Care recipients
Atypical Antipsychotics Project Changes Implemented in 2013 July 2013: Manual review of prior authorization on all long-acting or depot antipsychotic agents for children under 18 years of age; Additional therapeutic duplication edits were implemented to include long-acting or depot forms of injectable antipsychotic agents to edit against oral antipsychotic agents. One change in therapy per 93 days is allowed at point of sale without a manual review; and Any additional therapeutic duplications with overlapping days’ supply will reject at point-of- sale and require manual review for prior authorization approval or denial by DHS child psychiatrist. October 2013: Age-related dose edits and dose-optimization quantity limit proposals for oral first generation antipsychotic agents for children under 18 years of age; Age-related dose edits and dose-optimization quantity limit proposals age-related dose edits for Fanapt, Latuda, and Saphris for children; Lower the previously approved age:dose edits for second generation antipsychotic agents; Manual review of all requests for children of doses greater than one per day of naltrexone; and, Manual review any requests for children under the age of eighteen years of age for any Alzheimer disease agents (off label use). Education provided on the following issues: Children who have a complex trauma-related diagnosis and are receiving an antipsychotic medication without evidence of a Federal Drug Administration (FDA) approved indication for antipsychotics. The focus of the intervention letter to the prescriber is that antipsychotic agents are not first line treatment for complex trauma diagnoses; trauma-informed care is the first line therapy for complex trauma-related diagnosis without comorbid conditions. The integrated use of trauma-focused screening, functional assessments, and evidence-based practices will likely result in improved social, emotional and health outcomes. Notification that although the patient is receiving a C-II stimulant medication there is no supporting diagnosis of ADHD/ADD or narcolepsy in medical history. The informational letter explains that off label uses, diversion, and abuse are concerns with C-II stimulant medications and that these agents have serious adverse effects and should only be used for FDA approved indications. May 2011 to October 2013 44% Decrease in number of total unduplicated non-Foster Care recipients 29% Decrease in number of total unduplicated Foster Care recipients 34

36 Atypical Antipsychotics Project
Percent of Prescription Eligible (Non-Foster Care) on Antipsychotic Agent: % of Non-Foster Children Under 6 Years of Age on Antipsychotic Drug % of Non-Foster Children 6-12 Years of Age on Antipsychotic Drug % of Non-Foster Children Under Years of Age on Antipsychotic Drug Percent of Prescription Eligible Children (Foster-Care Population) on Antipsychotic Agent: 35 % of Foster Children Under 6 Years of Age on Antipsychotic Drug % of Foster Children Under 6-12 Years of Age on Antipsychotic Drug % of Foster Children Under Years of Age on Antipsychotic Drug

37 Impact In Utilization Change Per Group
Atypical Antipsychotics Project Impact In Utilization Change Per Group The charts below compare antipsychotic utilization rates prior to edits going in effect to the most current period (September - November 2013).  The data demonstrates a decrease in antipsychotic utilization rates for children in all age groups.  Additionally, this decrease is seen regardless of involvement in foster care. Foster Care Children Children Less Than Six Years Of Age Children From Six To Twelve Years Of Age Thirteen To Seventeen Years Of Age -86.02% -38.80% -17.54% Non-foster Care Children Less Than Six Years Of Age Children From Six To Twelve Years Of Age Thirteen To Seventeen Years Of Age -92.69% -49.35% -31.23% 36

38 Atypical Antipsychotics Project
The following graphs demonstrate the timeline for prior authorization (PA) edits on antipsychotic agents and the decrease in utilization for children enrolled in Medicaid. The recipients are unduplicated. CHILDREN IN FOSTER CARE UNDER 6 YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months CHILDREN IN FOSTER CARE 6-12 YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months

39 Atypical Antipsychotics Project
CHILDREN IN FOSTER CARE YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months NON-FOSTER CHILDREN UNDER 6 YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months

40 Atypical Antipsychotics Project
NON-FOSTER CHILDREN 6-12 YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months NON-FOSTER CHILDREN YEARS OF AGE ANTIPSYCHOTIC UTILIZATION TREND OVER TIME # on Antipsychotic # on C-II Stim. + Antipsychotic # on C-II Stim. + Antipsychotic with Behavioral Therapy History in Prior 6 Months # on Strattera + Antipsychotic # on Strattera + Antipsychotic with Behavioral Therapy History in Prior 6 Months

41 Arkansas Building Effective Services for Trauma
Arkansas Building Effective Services for Trauma (AR BEST) is a program devoted to improving outcomes for traumatized children and their families by striving for excellence in clinical care, training, advocacy, and research and evaluation. Since 2009 when AR BEST was first established by the Arkansas State Legislature, multiple stakeholders have collaborated to enhance the community’s response to child physical and sexual abuse as well as other traumatic events. AR BEST, which is housed within the University of Arkansas for Medical Sciences (UAMS) Psychiatric Research Institute (PRI), works closely with Child Advocacy Centers (CAC) of Arkansas, regional community mental health centers (CMHC) and other child-focused agencies. The five goals of AR BEST are as follows: Provide training in evidence-based interventions for advocates, mental health professionals (MHP) and other individuals working with traumatized children. Design, train and implement a statewide screening protocol for use in all CACs and by MHPs who contract with CACs or are located in other clinical settings such as CMHCs. Provide clinical services at UAMS through the PRI or Department of Pediatrics to children who have experienced sexual or physical abuse and follow up services to track progress. Establish a statewide communication system for ongoing training, supervision and consultation to MHPs. Fund MHP’s to provide services at CACs. Trauma-Focused Cognitive-Behavioral Therapy Training MHPs Who Attended TF-CBT Training MHPs with Arkansas Certificates in TF-CBT 40 The majority of clients referred for mental health counseling from CACs are Caucasian females. Nearly three-fourths of clients are referred to counseling or are already in counseling. At intake, the majority of children were experiencing serious behavior problems or significant symptoms of Post-Traumatic Stress Disorder (PTSD), supporting the need for efficient and effective treatment with this population.

42 Arkansas Building Effective Services for Trauma
AR BEST Action Timeline 2013 184 Mental Health Professionals (MHP) from 37 Arkansas counties were trained in Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT). TF-CBT is an evidence-based treatment designed to improve outcomes for children ages three-seventeen exposed to trauma. A total of 674 MHPs from 62 counties have been trained since 2009. 116 MHPs participated in post-training consultation calls with national experts to further their clinical skills and be eligible for national certification in TF-CBT. Since , 275 MHPs have completed this portion of their training. More than 400 individuals attended trainings in Trauma-Informed Practices to better understand the impact of trauma on children and families, identity potential trauma triggers, prevent current service delivery approaches from exacerbating the effects of trauma, and improve continuity of care. Attendees included foster parents, Arkansas Department of Human Services (DHS) Division of Child and Family Service (DCFS) staff, juvenile judges, and Division of Youth Services (DYS) staff. More than 1,000 individuals working with traumatized children have attended Trauma-Informed Practice training since 2009. AR BEST has a secure and confidential web-based system that allows CAC advocates and MHPs to screen and track client and family needs. By the end of this year, advocates had registered 3,633 clients into the AR BEST system. The AR BEST website ( continues to be regularly updated, and it provides trainees and other visitors access to crucial information about the project. Over the past year, the website captured more than 1,600 unique visits. More than 300 children and family members were seen in the UAMS PRI and Department of Pediatrics in the past year to address the effects of trauma. In the past year, all 13 CACs in Arkansas received funding to provide mental health services to children and their families either on site or in closely affiliated clinics. 41

43 Conscious Discipline Training for Arkansas Early Care and Education Providers Conscious Discipline (CD) is a comprehensive classroom management program and a social- emotional curriculum that is based on current brain research, child development information and developmentally appropriate practices. CD has been specifically designed to make changes in the lives of adults first. The adults, in turn, change the lives of children. CD recognizes that being ready for kindergarten isn’t only about learning the ABCs. Children who are successful in school and life have good skills for self-control, problem solving and are able to focus their attention on learning. Through CD training, teachers learn how to build these skills in young children. 2013 Highlights from Conscious Discipline Implementation in Arkansas: “Not only does my class have the tools to work through their conflicts, but I now have them myself.” – CD participant 976 preschool teachers and 33 kindergarten-2nd grade teachers participated in CD training facilitated by staff from Arkansas State University (ASU). This intensive six-day training is offered in three, two-day segments over a period of about six months. Teachers received monthly follow-up coaching to help them implement what they learned in training. 225 teachers attended a one-day CD refresher seminar. The team at ASU facilitated the first CD training in Arkansas for teachers of infants and toddlers, with 140 teachers participating. Researchers and students from the University of Arkansas for Medical Sciences and the University of Arkansas at Little Rock collaborated to learn how teachers trained in 2013 are implementing CD in their classroom. “It was total transformation for me; it changed the way I talked to myself and my kids.” – CD participant 42

44 Conscious Discipline How Conscious Discipline Made a Difference for Teachers: Preschool teachers trained in 2013 were surveyed about their experience implementing Conscious Discipline. Of 249 in the training cohort, 222 participated in the survey. Most trainees teach in Arkansas Better Chance (ABC) programs (71.6%). Teachers responded to a number of survey items about the impact of Conscious Discipline on their classroom and the children they teach. As in the examples shown below, most teachers (>80%) agreed that Conscious Discipline had a positive impact. 43

45 Developmental Disabilities Health Home
The Arkansas Department of Human Services (DHS) Division of Developmental Disabilities Services (DDS) is moving forward with planning and development of the Community First Choice Option, Balancing Incentive Program, and Health Home programs made available to the States under the Affordable Care Act. The Developmental Disabilities Health Home (DDHH) will provide individuals with Intellectual Disabilities/Developmental Disabilities (ID/DD) access to comprehensive care management/care coordination through Medicaid state plan services. The DDHH will provide seamless navigation of medical, behavioral, long term care, and other areas of services for those that have complex needs or require additional layers of support. The DDHH will utilize information from an independent assessment the medical care plan from the patient centered medical home/primary care physician (PCMH/PCP) and input from other providers who mutually serve the individual to create an individual-centered, assessment-driven integrated care plan. 44

46 Developmental Disabilities Health Home
Waiver case managers have provided services, such as: The writing and monitoring of the Waiver Plan of Care; Assessing the quality of services provided; Advocacy; Facilitation during crisis intervention; Education of, and communication with, the individual served and their family/support system; Assurance that documents for maintenance of eligibility are submitted in a timely manner; and, A minimum of once monthly visits with the individual. The DDHH will expand the care coordination team working with the individual and their family/support system. A Registered Nurse (RN) will assume responsibilities within the panel of consumers who have health conditions related to the DDS-eligible diagnosis (e.g. Epilepsy) and other health conditions unrelated to the DDS-eligible condition (e.g. Hypertension, Diabetes, Sickle Cell, Obesity). The RN will assist with coordination of medical visits and assistance with routine health issues; prescription management and education; and will ensure that the plan of care is informed by evidence-based clinical practice guidelines. The RN will also assure through comprehensive transitional care that all medication changes subsequent to physician treatment (inpatient or outpatient) are updated within the provider EHR and that staff are reinforcing the changes with the individual and their family/support system to assure adherence. In addition to the RN, other team members could include behavioral health professionals, pharmacists, social workers, nutritionists, and others based on the need of the individual. Other services available through the DDHH are health promotion; individual and family support services; and referral to community and support services. DDS will provide training and support to providers before implementation of the DDHH, during the crucial first year of service and on an ongoing basis, to assure success in the transformation of provider practices to encompass all facets of the DDHH. DDS anticipates positive outcomes for the individuals served through the DDHH and within the provider organizations. 45

47 Child Welfare Waiver Demonstration
The Arkansas Department of Human Services, (DHS)Division of Children and Families Services’ (DCFS) received approval of the IV-E Demonstration Waiver initial Design and Implementation Plan on July 30, The Waiver allows flexible use of IV-E dollars during the course of the five years. The State anticipates an increase of flexible use during the first two and a half years, which allows the state to use IV E dollars for services currently paid with State General Revenue. This demonstration project will provide statewide child welfare services in both in-home and out-of-home cases. The demonstration includes an array of evidence-based practices (EBP) and evidence-informed practices (EIP) and programs proven to foster improved outcomes related to safety, permanency, and well-being for children and their families. The focus on EBPs or EIPs strengthens the ongoing implementation of the goals and guiding principles of the DCFS Practice Model. This will happen through a comprehensive expansion of practice beginning at the investigation phase and continuing through post- reunification services and/or legal permanence. With this demonstration, DCFS plans to safely reduce the number of children entering foster care, increase placement stability for children in care, and achieve timely permanence for youth by implementing various service interventions, including: Child and Adolescent Needs and Strengths (CANS) Team Decision-Making Nurturing Parenting Program Differential Response Targeted Foster Family Recruitment Permanency Roundtables By implementing the interventions listed above, Arkansas anticipates an enhancement of its child welfare system to one that values families by: Engaging families and encouraging them to have a voice in decisions regarding their cases; Serving children and families in their homes when possible; Working to ensure children’s time in foster care is limited so that every child has timely permanence; and Providing readily available services to help produce the best possible outcomes for the families served by the system. 46

48 Child Welfare Waiver Demonstration
Arkansas will also continue strengthening current initiatives already implemented. These initiatives include: Sustaining Structured Decision-Making; Creating a Trauma-Informed Workforce and Service Delivery System; and, Developing an In-Home Services Program. Target Populations The comprehensive target population for Arkansas’ demonstration project will include all children and families in need of child welfare services statewide. Specifically, the children and families targeted to receive waiver funds will be all children referred for child abuse and neglect or already receiving services during the waiver period regardless of removal status, placement types, services provided, or eligibility for public assistance. DCFS expects that children and families from all 75 counties within the state will be served through the demonstration project. DCFS’ ten geographical service areas will benefit from programs, services, and interventions funded by the waiver. Although Arkansas’ broader target population is inclusive of all client types statewide, specific goals and interventions will concentrate on precise groups of children and families dependent upon their characteristics and needs as outlined in the State’s supporting data. The target populations for the three goals are shown below. 47

49 Juvenile Detention Alternatives Initiative
In 2012, the Arkansas Department of Human Services (DHS) Division of Youth Services (DYS) approached the Annie E. Casey Foundation (AECF) regarding funding the Models for Change Juvenile Detention Alternatives Initiative (JDAI) in Arkansas. JDAI was launched in 2013 in Arkansas. Arkansas’ objective is to work with AECF to implement JDAI and achieve JDAI’s five basic objectives. The JDAI was designed to support the Casey Foundation’s vision that all youth involved in the juvenile justice system have opportunities to develop in to healthy, productive adults. After more than 20 years of innovation and replication, JDAI is one of the nation’s most effective, influential, and widespread juvenile justice system reform initiatives. JDAI focuses on the juvenile detention component of the juvenile justice system because youth are often unnecessarily or inappropriately detained at great expense, with long-lasting negative consequences for both public safety and youth development. The program focuses on developing a risk assessment tool, reducing racial and ethnic disparities, and conducting an assessment of conditions and practices at the juvenile detention centers. Team members from each pilot site will receive training from the JDAI team. Thereafter, each pilot site will send a team to visit a JDAI “model” site. As part of the process, there will be a site governance team of stakeholders (traditional and non-traditional), administrators and staff to support the process. A system assessment and a Detention Utilization Study (DUS) will be done in each county. The detention centers will be required to develop a tool that will allow data to be reported on a quarterly basis. In March 2013, a kick-off meeting was held in Little Rock, Arkansas. Arkansas is replicating the JDAI pilot in two counties in northwest Arkansas, Washington and Benton Counties. These counties represent Judicial Districts 4 and 19 West, respectively. The Benton County and Washington County Juvenile Detention Center sites will be considered as one site due to proximity. The pilot project is slated for eighteen (18) months. Staff members at the Washington and Benton County sites will receive training in all aspect of JDAI. JDAI’S FIVE BASIC OBJECTIVES Reduce reliance on secure confinement Improve public safety Reduce racial disparities and bias Save taxpayers’ dollars Stimulate overall juvenile justice reforms 48

50 Strategic Prevention Framework Partnerships for Success
In September 2013 the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Prevention (CSAP) awarded Arkansas a five year Strategic Prevention Framework Partnerships for Success (SPF-PFS) sub-grant. The SPF-PFS is designed to address two of the nation’s top substance abuse prevention priorities: Underage drinking among persons ages 12-20 Prescription drug misuse and abuse among persons ages The SPF-PFS grant is also intended to bring SAMSHA’s Strategic Prevention Framework (SPF) to a national scale. It is an opportunity for Arkansas to acquire additional resources to implement the SPF process at the state and community level and to promote the alignment and leveraging of prevention resources and priorities at the federal, state, and community levels. The SPF-PFS program will build upon the experience and established SPF-based prevention infrastructures to address two of the nation’s top substance abuse prevention priorities in communities of high need. The program is based on the premise that changes at the community level will, over time, lead to measureable changes at the state level. By working together to foster change, states and their SPF-PFS funded communities of high need can more effectively begin to overcome the challenges underlying their substance abuse prevention priorities and achieve the goals of the SPF-PFS. The SPF represents a five step, data-driven process which is critical to ensure that states and their communities work together to use Data-Driven Decision Making (DDDM) processes to develop effective prevention strategies and sustainable prevention infrastructures. 49

51 Strategic Prevention Framework Partnerships for Success
The Strategic Prevention Framework Process Assessment The assessment phase helps define the problem or the issue that a project needs to tackle. This phase involves the collection of data to: Understand a population’s needs Review the resources that are required and available Identify the readiness of the community to address prevention needs and service gaps. Capacity Capacity building involves mobilizing human, organizational, and financial resources to meet project goals. Training and education to promote readiness are also critical aspects of building capacity. SAMHSA provides extensive training and technical assistance (TA) to fill readiness gaps and facilitate the adoption of science-based prevention policies, programs, and practices. Planning Planning involves the creation of a comprehensive plan with goals, objectives, and strategies aimed at meeting the substance abuse prevention needs of the community. During this phase, organizations select logic models and evidence-based policies and programs. They also determine costs and resources needed for effective implementation. Implementation The implementation phase of the SPF process is focused on carrying out the various components of the prevention plan, as well as identifying and overcoming any potential barriers. During program implementation, organizations detail the evidence-based policies and practices that need to be undertaken, develop specific timelines, and decide on ongoing program evaluation needs. Evaluation Evaluation helps organizations recognize what they have done well and what areas need improvement. The process of evaluation involves measuring the impact of programs and practices to understand their effectiveness and any need for change. Evaluation efforts therefore greatly influence the future planning of a program. It can also impact sustainability, because evaluation can show sponsors that resources are being used wisely. 50

52 Strategic Prevention Framework Partnerships for Success
Arkansas Youth Substance Use Ranking According to the National Survey on Drug Use and Health (NSDUH) report*, State Estimates of the rates of Nonmedical Use of Prescription Pain Relievers, “Arkansas, Colorado, Oregon, and Washington were ranked in the top fifth of States for this measure in age groups 12 to 17, 18 to 25 and 26 or older, as well as for the total population aged 12 or older.” According to the 2012 Arkansas Prevention Needs Assessment (APNA) survey** “Alcohol is by far the most frequently reported substance by Arkansas students. Lifetime prevalence of alcohol ranged from 9.7% for 6th graders to 61.1% for 12th grade students” with “first alcohol more than sip occurs at 12.8 years, and the first regular use of alcohol at 14.2 years.” However, for each grade level, alcohol use decreased significantly since 2011 (Grade 6 from 12.9% to 9.7%; Grade 8 from 32.3% to 26.6%; Grade 10 from 53.4% to 47.9%; Grade 12 from 65.9% to 61.1%) Alcohol Use Declines per Grade Level Since 2011 51 *Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (January 8, 2013). The NSDUH Report: State Estimates of Nonmedical Use of Prescription Pain Relievers. Rockville, MD **2012 Arkansas Prevention Needs Assessment (APNA) Survey.

53 Arkansas Network for Early Stress and Trauma
Children five and younger have the highest risk for abuse and neglect, yet most professionals in Arkansas are not well trained in working with young children and their families to improve outcomes while preventing the potential for future trauma. Proven, evidence-based mental health treatments are available, such as Parent-Child Interaction Therapy (PCIT) and Child-Parent Psychotherapy (CPP), which reduce the effects of trauma in children and families. Arkansas Network for Early Stress and Trauma (NEST) was initiated in 2013 and is a collaborative between the University of Arkansas for Medical Sciences and two regional, community mental health centers, Mid-South Health Systems (MSHS) and Ozark Guidance Center. Arkansas NEST is a Category III site within the National Child Traumatic Stress Network and is funded for four years by the Substance Abuse and Mental Health Agency (SAMHSA). The three primary goals of Arkansas NEST are to: Train and monitor fidelity for a minimum of 70 mental health professionals (MHPs) to implement PCIT and CPP; Provide culturally competent, client-centered, family-focused, evidence-based assessment and treatment to 340 traumatized young children; and, Develop and conduct trauma-informed care presentations and trainings to key stakeholders involved in the care of young children who have experienced trauma such as courts, child welfare, child advocacy centers, early childhood education, and veteran/military systems. First Year Progress 19 Mental Health Professionals (MHPs) trained in Parent-Child Interaction Therapy (PCIT) 22 MHPs trained in Child-Parent Psychotherapy (CPP) 197 children screened for the appropriateness of PCIT and CPP 50 children enrolled and received PCIT or CPP 1,657 key stakeholders involved in the care of young children who have experienced trauma trained or attending presentations. 52

54 Positive Learning for Arkansas’ Youngest
Project PLAY (Positive Learning for Arkansas’ Youngest) is an Early Childhood Mental Health Consultation program funded by Arkansas Department of Human Services Division of Child Care and Early Childhood Education. Project PLAY facilitates collaboration between early child care programs and specially trained mental health professionals located within the Community Mental Health Centers shown on the map below. The goals of Project PLAY are two-fold: Promote positive social and emotional development of children through changes in the early learning environment. Decrease problematic social and emotional behaviors of young children in early child care settings by building the skills of child care providers and family members. Why Does Arkansas Need Project PLAY? Studies of Arkansas preschool children show that sixteen percent have serious problems with emotions and behavior More children are expelled from Arkansas preschools than from Kindergarten through twelfth grade Research shows that positive teacher-child interactions are more important to improving child outcomes than other factors such as teacher education 53

55 Positive Learning for Arkansas’ Youngest
679 Site Visits Project PLAY consultants made 679 site visits to provide consultation services and provided 90 teacher trainings. General services included classroom observation, coaching and training on promoting good behavior and healthy development, promoting teacher stress management and team-work, and advising on child care center policy. Child-focused support services included child observation and assessment, developing child behavior and classroom management plans, facilitating parent-staff communication, and providing referrals to services. Project PLAY has a focus on supporting children in foster care. Project PLAY delivered trainings to over 800 participants about meeting the needs of foster children in child care and other settings. Approximately 80% of child care programs served by Project PLAY serve foster children. 90 Trainings 800 Participants Project PLAY Impact The Project PLAY evaluation study was designed to assess change over time in teachers, classrooms, and children. Part of the evaluation includes independent observations of the classroom by trained research assistants. A summary of the results are shown below: Improvements in Teachers’ Interaction with Children: For the Project PLAY teachers who completed consultation, there were significant improvements in the following areas: Increase in teachers’ positive interactions with children Increase in teachers’ spending time caring for the children and participating in activities with the children Decrease in use of punitive behaviors, such as yelling or using harsh words Improvement in appropriate use of directions and classroom rules Improvement in Child Behavior: Project PLAY measures child behavior using three different approaches. All three approaches suggest that children’s behavior significantly improved over the course of the Project PLAY Partnership: Classroom Level Pro-Social Behaviors (playing nicely, interacting well with friends and staff) Classroom Level Behavior Problems (verbal and physical aggression and other disruptive behavior) Severe Behaviors (for children identified by the teacher as having serious problems on a standardized measure of child behavior problems) 54

56 Second Chance Juvenile Reentry Planning Grant
The Arkansas Department of Human Services (DHS) Division of Youth Services (DYS) was awarded a Second Chance Planning Grant by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) in The Arkansas Reentry Planning Team sought assistance from the National Reentry Center and the Council of Juvenile Correctional Administrators in the development of its comprehensive reentry plan. Over the last year, the Arkansas Reentry Planning Team has met to establish and increase collaborations, develop a comprehensive reentry system, and train providers in the newly developed reentry system. The primary purpose of the initiative was to develop a comprehensive reentry system. Throughout the planning process, a number of activities and trainings were conducted to facilitate DYS’ implementation of a comprehensive reentry plan. Training Throughout the span of the grant period, October 1, 2012, to September 30, 2013, DYS and its stakeholders participated in multiple trainings. The intent was to assist in building community capacity by offering training through Juvenile Justice Professionals in the state in the following programs. These trainings will help train direct service providers in the use of programs to be incorporated into DYS’ long-range reentry efforts: Graduated Sanctions Performance Based Standards Restorative Way – Peace Making Circles Girls Circle Boys Council Motivational Interviewing Youth Level of Service/Case Management Inventory (YLS/CMI) assessment tool use Mentoring Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) Trauma Informed Care Best Practices in Juvenile Justice Family Engagement Disproportionate Minority Contact 55

57 Second Chance Juvenile Reentry Planning Grant
Technical Assistance In addition to trainings, the Reentry Taskforce was involved in multiple planning meetings/retreats. On-site technical assistance (TA) from the National Reentry Resource Center was provided with the following strategic planning priorities identified: Ensure the organizational structure of the Task Force is effective and sustainable; Clarify the description of a strategic plan; and Describe the role of community stakeholders, local level organizations or agencies in identifying assets, barriers, and gaps to reentry and developing an action plan. As part of the federal OJJDP TA process, the Policy Analyst from the Council of State Governments Justice Center, and Director from the Council of Juvenile Correctional Administrators, facilitated a retreat with DYS staff. . A variety of individuals participated in the retreat representing community based providers, court staff, probation officers, juvenile detention centers, and the juvenile ombudsman. The planning activities helped the task force develop a viable plan for action and develop a framework for a comprehensive reentry system in Arkansas. 56

58 The Arkansas Children’s Behavioral Health Care Commission 2013
Commissioner: Representing: Kim Arnold Arkansas National Alliance on Mental Illness Dr. Jim Aukstuolis Arkansas Behavioral Health Care Dr. Steven Domon Arkansas State Hospital, Department of Human Services Jonathan Dunkley Arkansas Department of Human Services Adella Gray Former School Counselor Consevella James Treatment Homes, Inc. Georgia Rucker Family Advocate Dr. Tom Kimbrell Arkansas Department of Education Dr. Teresa Kramer University of Arkansas for Medical Sciences Carol Amundson Lee Save the Children – Western Arkansas Karen Massey Southwest Arkansas Educational Cooperative Carol Moore Dayspring Behavioral Health Dr. Tommy Roebuck Former Legislator and Dentist Rhonda Sanders Arkansas Foodbank Joyce Soularie Arkansas’ Family Support Partner Coordinator Honorable Joyce Williams Warren Sixth Judicial Circuit Court Judge Dr. Gary Wheeler Arkansas Department of Health 57

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