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Creating a System of Care: A Partnership Between Title V and SAMHSA

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1 Creating a System of Care: A Partnership Between Title V and SAMHSA
Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health Specialty Clinics Gary Lippe Dept. of Human Services, NE Iowa

2 Susan Stromberg October 16, 2007
Comprehensive Community Mental Health Services for Children and Their Families (Systems of Care) Susan Stromberg October 16, 2007 I am a project officer in the Child, Adolescent & Family Branch. We administer several programs: Statewide Family Networks – funding and technical assistance for family organizations to provide advocacy and support. Circles of Care – grants to tribes and tribal organizations to develop infrastructures that will better serve the mental health needs of Native Americans CA-SIGs – building state infrastructure to help youth with co-occurring mental health/substance abuse needs. Comprehensive Community Mental Health Services for Children and Their Families---change slide

3 The Comprehensive Community Mental Health Services for Children and Their Families Program (Children’s Program) Encourages the development of home and community-based systems of care SOCs meet the needs of children and adolescents with serious emotional disturbances and their families SOC communities are administered in States, political subdivisions of States, Native American tribes or tribal organizations, and U.S. territories The Children’s Program supports the development of systems of care in states, counties, tribes and tribal organizations. Our system of care grant in Iowa covers 10 counties – Dr. Lobas will talk about them.

4 Systems of Care Systems of care are developed on the premise that the mental health needs of children, adolescents, and their families can be met within their home, school, and community environments. These systems are developed around the following principles: child-centered family-driven strength-based culturally competent Additionally, interagency collaboration is embedded within these systems. In systems of care, the premise is that, whenever possible, the mental health needs of children and their families can best be met in the community. Interagency collaboration, including the vital link with the physical health care providers, is essential.

5 Systems of Care Program Framework
Accountability through outcome evaluation Comprehensive array of services Cross-agency coordination Cultural competence Early identification and intervention Family partnerships Home and community-based services Least restrictive service environments Strength-based individualized service planning We have a rigorous program evaluation, the results of which are published in annual reports to Congress. We know that Systems of Care work. The comprehensive array of services includes both formal and informal services. Partnerships are developed among all child-serving agencies, such as education, juvenile justice and primary health. I’ll talk more about some of these principles…

6 System of Care Model CHILD AND FAMILY
MENTAL HEALTH SERVICES EDUCATIONAL SUBSTANCE ABUSE VOCATIONAL RECREATIONAL OPERATIONAL SOCIAL Here is another depiction of the system of care model. Instead of looking at a menu of services already available, the service plan is developed according to the needs of the family. The child and family are at the center of the service plan.

7 + Do the Math. Children’s Mental Health suffering from a lack of:
services for children & adolescents non-restrictive settings full community-based service array interagency coordination family involvement cultural competence Need for SYSTEMS OF CARE!! + There have been calls for reform in children's mental health in the United States since the 1960s. In nearly all the reports and documents advocating system change, the major themes were the same. They were that: • Most children in need simply weren't getting mental health services • Those served were often in excessively restrictive settings • Services were limited to outpatient, inpatient, and residential treatment - few, if any intermediate, community-based options were available • The various child-serving systems sharing responsibility for children with mental health problems rarely worked together • Families typically were blamed and weren't involved as partners in their child's care • And agencies and systems rarely considered or addressed cultural differences in the population they served The proposed solution to these systemic problems were comprehensive, coordinated, community-based systems of services and supports, which eventually became known as "systems of care"

8 System of Care Core Values
Community based Child and family focused (family driven and youth guided) Culturally and linguistically competent The core values of the system of care philosophy specify that services should be: * Community based * Child centered and family focused, and * Culturally and linguistically competent A set of 10 principles have been developed which lay out some basic beliefs about the way the system of care should operate.

9 System of Care Guiding Principles
Comprehensive array of services Individualized care Least restrictive setting Family and youth involvement Service integration Comprehensiveness - A broad array of services-well beyond the inpatient, outpatient, and residential treatment that traditionally were available. Individualization - Not a cookie cutter approach, but services and supports designed to fit each child and family's needs. Least restrictive setting - Highly intensive treatment services do not necessarily or always require restrictive settings. More normative settings are possible and effective. Family and Youth Involvement - Families (or other caregivers) and youth should be active participants in all aspects of the planning and delivery of services for their own children and also in planning, operating, and overseeing services at the system level. In a word, parents should be partners in the system of care. Service Integration - Implementing structures and processes to ensure that the various child-serving agencies and programs work together to develop and oversee systems of care.

10 System of Care Guiding Principles
Care coordination Early identification and early childhood intervention Smooth transitions Rights protection and advocacy Nondiscrimination 6. Care Coordination [Case Management] - Assuring the coordination of multiple services at the level of the child and family. When I was a CPS worker, a youth had a separate worker for different systems. We did not coordinate. 7. Early Identification [Early Childhood Services] - A balance between services designed for early identification and intervention and those designed for youth already identified as seriously disturbed. And appropriate mental health services for infants, toddlers, and preschoolers and their families. 8. Smooth Transitions - Incorporating services for youth who are aging out of the children's service system, to ensure that they have the independent living and vocational skills that they need, as well as appropriate services and supports from the adult service system. 9. Rights Protection and Advocacy - Protecting the rights of children, and advocacy to provide a voice in support of systems of care 10. Nondiscrimination - Equal access to quality services for all children, including those with cultural or linguistic differences, co-occurring disorders, physical disabilities, and other special needs.

11 System of Care Concept is…
A framework and guide, not a prescription Flexible and creative Adaptive to family and community needs Consistent in philosophy It is important to remember that the system of care concept is a framework and a guide, not a prescription. It is not a "model" to be "replicated." Different communities have implemented systems of care in very different ways - no two are alike. The system of care in New York City will not look like the system of care in Iowa. It is the philosophy and the value base that is the constant.

12 Systems of Care Resilience, Leadership & Transformation
What is involved? Rethinking traditional approaches Strengths-based Family driven & youth guided Embracing culture Who is involved? Youth Adults Families Providers Communities We think of Systems of Care as surrounded by three key components – Resilience, Leadership and Transformation. Resiliency We must listen and learn from youth and adults about their management and coping strategies, and then incorporate those into better service delivery designs. We know from ongoing research that resiliency requires a positive, strengths based approach; a focus on competence and positive development; a shift from thinking about resilient children to viewing resilience as a dynamic process; and interventions that build competence and skill, reduce risk and enhance protective processes. Leadership Systems of care is about thinking outside the box and taking risks, and questioning traditional methods and practices for serving youth and families. Transformation – And finally, transformation. The New Freedom Report guides our work in Mental Health System Transformation. Transformation Systems of Care Leadership Resilience Fulfilling Potential

13 Systems of Care Resilience, Leadership & Transformation
What is involved? Rethinking traditional approaches Strengths-based Family driven & youth guided Embracing culture Who is involved? Youth Adults Families Providers Communities And the foundation underlying all of this is the opportunity to fulfill the potential of youth, adults, families and communities. Now, who needs to be involved in systems of care? First and foremost, youth, adults and families receiving services need to be front and center in the decision-making and design of whatever service delivery system is developed – no exception to this rule. In addition to youth and families being served, the community needs to be involved. The community in which families live provides the richest context and most intricately woven fabric within which an individual and family can thrive. That community needs to be part of the process. Finally, though not any less important, the providers and policymakers who are charged with managing public funds to help make this happen are important partners. Transformation Systems of Care Leadership Resilience Fulfilling Potential

14 Every state has had at least one!
System-of-Care Communities of the Comprehensive Community Mental Health Services for Children and Their Families Program Lyons, Riverside, & Proviso, IL Milwaukee, WI Illinois (Chicago area) Northwoods Alliance, WI Lake County, IN Willmar, MN Sault Ste. Marie Tribe, MI Lancaster County, NE Marion County, IN Albany County, NY Nebraska (22 counties) Detroit, MI Bismarck, Fargo, & Minot, ND Cuyahoga County, OH Sacred Child Project, ND Southern Consortium & Stark County, OH Oglalla Sioux Tribe, SD Northern Arapaho Tribe, WY Allegheny County, PA Montana & Crow Nation Passamaquoddy Tribe, ME Erie County, NY u Maine (4 counties) Vermont 1 (statewide) King County, WA u Vermont 2 (statewide) Clark County, WA u u New Hampshire (3 regions) Four Counties, OR u Worcester, MA Clackamas County, OR u u Rhode Island 1 (statewide) Lane County, OR u u Rhode Island 2 (statewide) Connecticut (statewide) This graphic shows all of the areas of the United States who have had, or currently have, a funded system of care grant or cooperative agreement. Every state has had at least one! Also funded are Puerto Rico and Guam. Idaho Mott Haven, NY u New York, NY United Indian Health Service, CA u Westchester County, NY u Burlington County, NJ Glenn County, CA South Philadelphia, PA Sacramento County, CA Delaware (statewide) u u Baltimore, MD Napa & Sonoma Counties, CA Montgomery County, MD Contra Costa County, CA u u Washington, DC Oakland, CA u Alexandria, VA San Francisco, CA u Charleston, WV Monterey County, CA u Edgecombe, Nash, & Pitt Counties, NC California 5 (Santa Cruz, San Mateo, Riverside Ventura, & Solano Counties) North Carolina (11 counties) North Carolina (10 counties) Santa Barbara County, CA u 3 counties & Catawba Nation, SC Clark County, NV u Charleston, SC San Diego County, CA Greenwood, SC Rural Frontier, UT Gwinnett & Rockdale Counties, GA Pima County, AZ Navajo Nation u Eastern Kentucky Las Cruces, NM u El Paso County, TX Kentucky (8 counties) Hillsborough County, FL Colorado (4 counties) West Palm Beach, FL Yukon Kuskokwim Delta Region, AK Denver, CO Birmingham, AL Broward County, FL Wichita, KS Nashville, TN Oklahoma Louisiana (5 parishes) Fairbanks, AK Travis County, TX Jackson, MS Funded Communities Ft. Worth, TX St. Louis, MO Date Number Date Number Guam Wai'anae & Leeward, HI Parsons, KS St. Charles County, MO Missouri Choctaw Nation, OK Puerto Rico u u u

15 Systems of Care as a Transformation Strategy
Vision & Beliefs + Actions x (CQI)2 Moving from family involvement to family driven Family Involvement Customer focused Family driven Bridging Systems Gary Blau, our Branch chief has developed a “Transformation formula”. He stated that: Transformation = Vision + Beliefs + Actions X Continuous Quality Improvement squared. This is how we envision transformation: Family involvement - moving from family involvement to family-driven. Youth Guided - Fully embracing the youth we work with, who are soon to be the adults many of you will work with. Technical assistance - emphasizing the importance of technical assistance to states and communities to promote the modeling of successful approaches to building systems of care. Research - applying quality research to everything we do. Establishing key benchmarks that help us better define the meaning of “Best Practice.” Research is going on at the Research and Training Centers at the University of South Florida and at Portland State University. System of care transformation – We focus on sustainability. Cultural competence - moving from concept to reality. We are developing a cultural competence primer – a “how-to guide” for implementation. Youth Involvement Fully embracing youth involvement Integrating technical assistance activities Technical Assistance Opening the data set Establishing key benchmarks Research System of Care Transformation Sustainability - defining how systems of care contribute Cultural Competence Moving from concept to reality. Tools & strategies

16 National Wraparound Initiative
Setting standards Developing materials that are user-friendly System of Care sites typically use a wraparound process. There are many models out there. We are very excited that we have implemented a Wraparound Initiative, partnering with the University of Washington, Portland State and the Federation of Families for Children’s Mental Health to create an implementation tool kit on wraparound services.

17 Continuous Quality Improvement
Embracing CQI and the Benchmarking Initiative Quickly – we have a CQI Progress Report that is organized into 5 Key Areas of Performance that will help us better understand how to improve: System Level Outcomes Child and Family Outcomes Satisfaction with Services Family and Youth Involvement Cultural and Linguistic Competency, and Evidence-based practice.

18 Program Administrators
CQI Feedback National T.A. Community Program Administrators Improvement Continuous Quality Strategies to Improve Cultural Context Program Performance CQI Communication Feedback Process We implemented a feedback process designed to develop a communication infrastructure that supported the use of the CQI Progress Report as continuous quality improvement tool. The feedback process was developed to engage community-level representatives, national technical assistance providers and program administrators in dialogue around program performance and to identify strategies to improve performance in key areas.

19 Indicator 32 - Caregiver and Other Family Involvement in Service Plan
Increase family involvement in developing the service plan, either through attending planning meetings or approving treatment plans. Benchmark: 100% Let’s look at just one of the indicators to give you an idea of how what we are looking at. This particular indicator looks at Caregiver and other family involvement in service plans. One of the hallmarks of a systems of care approach is that families define who will be involved in the development of their service plan. This is one of many ways we use to assess whether or not this is really happening. For each indicator there is a section that describes what can be done to exceed the benchmark as well as specific information about how the benchmark was evaluated. Source and Item(s) Enrollment and Demographic Information Form (EDIF): Item 14 Definition Percentage of cases where the caregiver participated in developing the child’s service plan. Time period Intake into services Calculation Number responding yes to edif14a or edif14c/# responses to edif14a and edif14c

20 Systems of Care Work! Reductions in use of restrictive levels of care and residential placements across systems Cost reductions and cost avoidance Improved clinical and functional status Decreased juvenile recidivism and incarceration Improved school attendance and achievement We are seeing positive signs that children and families who are involved in systems of care show improvements in a range of outcome domains, including: Reductions in either the cost of care or the use of restrictive levels of care Improvements in clinical and functional status. * Decreased juvenile recidivism and incarceration rates * Better school attendance and achievement.

21 Family driven means… A cornerstone of any system of care development effort is working to become family-driven. The definition we use to guide our work in this area reads: Family-driven means families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation. Over the past 20 years we have moved from knowing that we needed to involve families to recognizing today that if the transformation is to be successful, families must drive what is developed and delivered. This is probably the area of work that, at first, may appear to be most difficult, but will ultimately be most rewarding. Family-driven means families have a primary decision making role in the care of their own children as well as the policies and procedures governing care for all children in their community, state, tribe, territory and nation.

22 Youth MOVE Beginnings Norman story.
We HAVE to involve youth in decisions about their care. In that same vein, we are similarly committed to youth as well. During this past two years we have witnessed the emergence and growth of our first National Youth Movement for Mental Health. Originally started as a committee, and then the National Youth Development Board, this group has grown leaps and bounds. Now operating as Youth MOVE (Motivating Others through Voices of Experience) this group has created a definition of Youth Guided Care, and has developed the characteristics of what it means to be youth guided, youth directed and even youth driven, depending on the developmental level of each person. Youth MOVE is made up of a diverse group of youth coordinators and young people from system of care communities across the nation. The purpose of the organization is to unite the voices and causes of youth; act as consultants to youth, professionals, families, and other adults; and be more involved in the politics and legislation of mental health policies. To support a national youth movement, Youth MOVE also assists in developing the Youth Leadership Program at meetings; creating youth movement principles and policies; and developing training tools, guides, and other documents. Youth MOVE staff are also national consultants who travel throughout the country to coach others in the area of authentic youth involvement. As proud as I am about the evolution of Youth MOVE, I am even more proud that this emerging organization is now leading the discussion about youth involvement in systems of care. Youth MOVE

23 Youth Involvement in Systems of Care
A starting point for understanding youth involvement and engagement in order to develop and fully integrate a youth-directed movement within local systems of care. A wonderful resource for you to identify specific strategies for fully developing your Youth Guided component of your transformation strategy is to review the recently produced monograph - Youth Involvement in Systems of Care. You can download the guide at

24 We know that much more needs to be done in the area of reducing disparities and enhancing cultural and linguistic competence among policy-makers, administrators and service providers. We must develop specific approaches that contribute to the goal of eliminating disparities across issues of race, ethnicity, geography, and socio-ecomic status. The more we can incorporate a culturally and linguistically competent approach in the work we do the more we can build trust among our colleagues, community partners and the families and youth who are integral to a transformed system of care.

25 Transformation Resources
Got a question about a family-driven, youth-guided system of care? Start here Systems of care is not a program. It is a philosophy of how care should be delivered. Systems of Care is an approach to services that recognizes the importance of family, school and community, and seeks to promote the full potential of every child and youth by addressing their physical, emotional, intellectual, cultural and social needs.

26 Work together There is strength in numbers…
This slide was in Gary Blau’s presentation. I liked the picture, so I kept it in. Thank you!

27 System of Care: Partnership between SAMHSA, DHS, and CHSC
Jeffrey Lobas, MD, EdD.

28

29 Child Health Specialty Clinics
Iowa’s Title V Agency for Children with Special Health Care Needs Funded through IDPH, categorical grants, contracts, reimbursement for services Administratively housed in the Dept. of Pediatrics at the University of Iowa

30 Title V Children with Special Health Care Needs
Child Health Specialty Clinics (CHSC) Direct Services Enabling Services Population Based Services Infrastructure Building

31 CHSC Mission The Child Health Specialty Clinics (CHSC) mission is to improve the health, development, and well-being of children and youth with special health care needs in partnership with families, service providers, communities and policy makers.

32

33 Child Health Specialty Clinics
Mason City Spencer Sioux Center Oelwein Elkader Dubuque Ft. Dodge Waterloo Sioux City Carroll Iowa City Des Moines Davenport Council Bluffs Chariton Creston Ottumwa Burlington Shenandoah Regional Centers Satellite Centers Central Office

34 Some of the Programs and Services CHSC Offers
ABCD II Project Birth to Five Services Health and Disease Management Continuity of Care Program Family to Family Support Integrated Evaluation and Planning Clinics Regional Autism Services Program Telehealth Iowa Medical Home Initiative Early ACCESS

35 History of CHSC and Children’s Mental Health
1997-Needs Assessment 1999-Future Search 2001-Governor’s White Paper 2002-Creston Project 2003-Magellan and CHSC 2004-CHSC Statewide Implementation 2005-Oversight Committee 2007-SAMHSA System of Care

36 Creston Project Evaluation of Statewide Services
Research on a Delivery Model Statewide Implementation “Spread Strategy” Collaborative approach

37 Evaluation of Service Delivery for CHSC
Focus Groups Structured Interviews with Families and Community Leaders Outcome Research Flow and Time Studies Satisfaction Surveys

38 Patient Data Patients seen July 2004 – June 2005 Burlington 85 Carroll 84 Council Bluffs 119 Creston 196 Davenport 20 Dubuque 71 Fort Dodge 219 Mason City 555 Ottumwa 175 Sioux City 150 Spencer 631 Waterloo 16 Total 2321

39 Most Common Primary Diagnosis at CHSC
ADHD (all types) 63% Conduct / Oppositional Defiant Disorders 7% Reaction Attachment Disorders 5% Developmental Disorders 4% PDD Spectrum and other Child Psychosis 3% Total with behavioral or mental health diagnosis 93%

40 Outcomes Research Key Components of Intervention Model
Multidisciplinary Team Enhanced care coordination. Initial on-site psychiatric assessments, if indicated by intake procedures; Telehealth/telepsych patient follow-ups; Telehealth consultations to primary care and other service providers; Educational events targeting service providers; Best practice/care guidelines; Systemic data collection regarding patient/family outcomes and service delivery processes; and A community advisory board and consumer participation

41 Enhanced Care Coordination
Care Plan development Arrangement of Service Delivery Alignment of advocacy across systems Collaboration with family and physicians Crisis intervention plan Follow-up with family and team

42 CANS DATA Problems* 4% -30% Mental health* 3% -23%
Degree of Clinical Change (percent) at Discharge for Children who Received CBHP vs. Usual Care Enhanced Program Dimensions Key Components (1-8) Usual Care    (N=25)   (N=34)  Problems* 4% -30%  Mental health* 3% -23%  Substance use* 22% -56%  Risk Behaviors 10% -4%  Functioning* 24% -18%  Caregiver capacity* 11% -7%  Strengths 9% -9%   *significant difference between groups (p<.05) 

43 CANS DATA Children who received CBHP services were more severe from children who received usual care across several factors including: Being more often abused (68% v. 8%) Had used psychiatric inpatient care (24% v. 0%) This increasing identification of children with complex behavioral health needs significantly affected the potential degree of clinical change at discharge. As a result, the CBHP was the most effective model in improving both the functional and strengths/supports dimensions in CANS-MH scores.

44 CANS DATA CANS-MH score results from the CBHP data is comparable to a recent comprehensive review of level of care needs across the New York state system of mental health utilizing the CANS instrument. Data suggests that IEPC is similar to the intensity of services provided by the Intensive Case Management levels of care in New York.

45 Findings A multidisciplinary team approach was very effective
Care coordination and follow-up of services was important to patient outcomes Appropriate triage at intake yielded greater efficiency and more effective results to patients Tele-health is an extremely valuable tool in providing services to underserved areas of the state Clinical guidelines enhance care

46 Findings There is great variability among regional centers in many areas which makes quality assurance difficult to achieve The role and methods of triage has to be standardized and more training needs to be provided Increased cost efficiency can be gained through standardized methods of triage, appropriate use of team, standardization of forms and dictation methods and gaining reimbursement for services by non-physician providers Highest level of unmet need was identified as availability of child psychiatry

47 Conclusions A standardized approach is needed at all centers which would include: Comprehensive triage and follow-up plan Availability of a multidisciplinary team at each regional center Utilization of standardized history forms and clinical tools - Vanderbilt; CHSC Med Hx; Beh Hx; Social Hx: and School Hx forms Standardized dictation methods into the PEDS centralized transcription and issuance of reports

48 CHSC Challenges and Barriers
Inadequate Resources (Long-waiting lists) Minimal services available Emergency and Crisis Intervention Wrap-around Services Social Marketing and Outreach

49 Evolution of Service Model
Oversight Committee Discussions between CHSC, DHS, SAMHSA Development of Proposal SAMHSA System of Care

50 Children’s Mental Health System of Care
Early Identification Primary Care Schools Juvenile Justice Child Welfare/ DHS Community Mental Health Agencies Families Family/Youth Advocacy Orgs

51 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Multidisciplinary Team Juvenile Justice Child Welfare/ DHS Community Mental Health Agencies Families Family/Youth Advocacy Orgs

52 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator Team Multidisciplinary Team Navigator Team Outreach/ Lighthouse Juvenile Justice Child Welfare/ DHS Community Mental Health Agencies Families Family/Youth Advocacy Orgs

53 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator Team Multidisciplinary Team Navigator Team Outreach/ Lighthouse Juvenile Justice Rx and and Care Plan Family Team Meeting Care Coordination (Process) Monitor and Feedback Intake/ Triage Evaluation and Dx Child Welfare/ DHS Community Mental Health Agencies Families Family/Youth Advocacy Orgs

54 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator Team Multidisciplinary Team Navigator Team Outreach/ Lighthouse Juvenile Justice Care Coordination (Process) Family Team Meeting Monitor and Feedback Intake/ Triage Evaluation and Dx Rx Care Plan Child Welfare/ DHS Community Subspecialty and Primary Care Mental Health Agencies Families Family/Youth Advocacy Orgs

55 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator Team Multidisciplinary Team Navigator Team Outreach/ Lighthouse Juvenile Justice Care Coordination (Process) Intake/ Triage Evaluation and Dx Rx and Care Plan Family Team Meeting Monitor and Feedback Child Welfare/ DHS Community Subspecialty and Primary Care Mental Health Agencies Community Based Wraparound Services Families Family/Youth Advocacy Orgs

56 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator’s Team Multidisciplinary Team Navigator’s Team Outreach/ Lighthouse Juvenile Justice Family Team Meeting Care Coordination (Process) Monitor and Feedback Intake/ Triage Evaluation and Dx Rx and Care Plan Child Welfare/ DHS Community Subspecialty and Primary Care Mental Health Agencies Community Based Wraparound Services Families Family/Youth Advocacy Orgs Emergency and Crisis Management

57 Children’s Mental Health System of Care
Implementation and Coordination Monitor and Follow-Up Evaluation, Assessment and Diagnosis Treatment and Care Plan Early Identification Community Circle of Care Child Health Specialty Clinics Primary Care Schools Navigator Team Multidisciplinary Team Navigator Team Outreach/ Lighthouse Family Team Meeting (Local) Juvenile Justice Treatment and Care Plan Care Coordination (Process) Monitor and Feedback Intake/ Triage Evaluation and Dx Child Welfare/ DHS Community Subspecialty and Primary Care Mental Health Agencies Community Based Wraparound Services Families Family/Youth Advocacy Orgs Emergency and Crisis Management Quality Assurance and Evaluation

58 Community Circle of Care:
Partnership, Collaboration, Integration

59 Community Circle of Care
Systems of Care Work Community Circle of Care DHS Iowa Department of Human Services

60

61 ACCESS One phone number . No wrong door Easy access in the community

62 Navigation

63 COORDINATION

64 INDIVIDUALIZED SUPPORTS

65 Systems of Care Professionals and Families Share Common Goals
We believed As helping professionals and children’s mental health advocates, we share goals with families and communities that we serve. Ultimately, we want children and youth in our communities to reside in safe and stable homes. We want their families to be able to provide for their physical, social, and emotional needs. And we want to do our best to ensure that children and families can stay together while they work through their challenges.

66 We want children and youth to be in safe and stable homes
We want to assist families to meet their children’s needs We seek family preservation or reunification if the child has been removed

67 Meeting the mental health needs of children, youth, and families is critical to achieving these goals We believed As helping professionals and children’s mental health advocates, we share goals with families and communities that we serve. Ultimately, we want children and youth in our communities to reside in safe and stable homes. We want their families to be able to provide for their physical, social, and emotional needs. And we want to do our best to ensure that children and families can stay together while they work through their challenges.

68 What Works? When children and youth with serious mental health needs receive coordinated services, their functioning substantially improves at school, at home, and in their community. So…. What works for these children and youth……. A national survey of youth whose caregivers were investigated by child welfare agencies showed that one-third had been exposed to impaired parenting skills, while two-thirds were victims of alleged neglect.* Cross-agency collaboration can help address not only the needs of children, but also the mental health and substance abuse needs of their families and caregivers.* Fortunately, when children and youth with serious mental health needs receive coordinated services through multiple child- and family-serving agencies and organizations—such as juvenile justice, education, child welfare, mental health, public health, etc.—they can and do get better. Source Burns, B. J., Phillips, S. D., Wagner, H. R., Barth, R. P., Kolko, D. J., Campbell, Y., & Landsverk, J. (2004). Mental health need and access to mental health services by youths involved with child welfare: A national survey. [And Commentary, J. S. Lyons & L. Rogers, The U.S. child welfare system: A de facto public behavioral health care system]. Journal of the American Academy of Child and Adolescent Psychiatry 43(8), , as reported in Data Trends, September 2004, No. 104, University of South Florida, *Data Trends #104, September 2004, University of South Florida

69 A System of Care Is… A community partnership among families, youth, schools, and public and private organizations which provide coordinated mental health services. Our partners include: Families Education Provider Agencies Mental health and substance abuse professionals Juvenile justice Primary health care Faith community Other community organizations Child welfare At the community level, a system of care is a partnership of child- and family-serving agencies and organizations, who, incidentally, usually find themselves serving the same children. By working together, they are able to build on each partner’s strengths to provide care that is more comprehensive and effective. This coordination also helps reduce the stress on children, youth, and families because they do not have to meet competing demands of agencies that would otherwise be working independently. All of these system of care partners, are important. As you know, the family will eventually receive services from one of these entities and that front line professional is the first to meet an individual family and assess their needs. Child welfare personal have a unique position if they are the first called to intervene with a family. The child welfare worker is in a position to take the most global look at a family ,particularly due to the in home nature of the service and crisis situation that generally precedes child welfare involvement. Whoever that entry worker is for the family, they provide an important link to the family receiving the needed care and supports that will help them function better and stay together. This information informs the system of care and lead to the success of the coordinated services. The beauty is that the family only has to tell their story once.

70 A System of Care Is… Guided by Core Values
Family-driven and youth-guided Researched and evidenced based Supports Individualized for each family Wrap around services provided Culturally and linguistically competent Community-based .

71 Benefit: Homes Are Stable
The percentage of children and youth who lived in multiple settings decreased by 11 percent over 12 months. Children in systems of care have increasing stability in their homes. An evaluation of children in systems of care showed that the percentage of children in multiple living arrangements decreased 11 percent in 12 months. Although these data do not indicate why children and youth were living in multiple settings in the first place, it does correlate to some important federal child welfare indicators, such as stability of placements and prevention of out of home placement. Source: CMHS National Evaluation: Aggregate Data Profile Report, Grant Communities Funded from 1997 to 2000, data as of October, 2005. Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005

72 Benefit: Families Are Stronger
Caregiver strain is reduced in many families. More than a quarter of families had higher functioning after 30 months; more than half remained stable. Addressing the mental health needs of children and families through a system of care helps reduce overall strain in the household. More than 93 percent of families and caregivers reported either decreased or stabilized strain associated with caring for a child with a serious emotional disturbance when assessed after entering services. Family functioning improved for more than a quarter of the families involved in a mental health initiative system of care over 30 months, and remained stable in over half of the families. Source: CMHS National Evaluation: Aggregate Data Profile Report, Grant Communities Funded from 1997 to 2000, data as of October, 2005. Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005

73 Benefit: Families Have More Resources
Caregiver job, vocational, and educational skills improve. Incomes increase. Families have more time and support. Children’s mental health needs can take a toll on caregiver employment and income as families miss work to deal with issues at home and at school. Within the first 18 months of services, around one-third of caregivers reports improvements on a number of work-related outcomes, such as improvements in job-related, vocational and educational skills; increases in earnings; and decreases in absenteeism.  Caregivers with an annual income of $15,000 or less are significantly more likely to report improvements in vocational and educational skills and increases in earnings. Sources: Skills and incomes: Analysis of National Evaluation data from communities funded between 1997 and 2000, data as of October, 2005. Time and support: CMHS National Evaluation: Aggregate Data Profile Report, Grant Communities Funded from 1997 to 2000, data as of October 2005. Sources: CMHS National Evaluation: Updates from the National Evaluation, Services Evaluation Committee Meeting, 2004 CMHS National Evaluation: Aggregate Data Profile Report, 2004

74 Community Circle of Care A care coordination, wrap around system of care
Our new project, Community Circle of Care, is a SAMHSA funded children's mental health initiative awarded in order to design a better system of care for children who experience mental health and behavioral challenges. Our project is a 6 year, 16 million dollar project. It is funded by a combination of federal, state, and local dollars.. Community Circle of Care Community Circle of Care Community Circle of Care

75 Outcome: Improved Access to Needed Services
Decisions about services are made based on what the family needs; funding is secured through the care coordinator which eliminates time and effort for the family. Services are identified and service gaps are filled whenever possible. Decisions about services are made based on what the family wants and needs and funding is secured through the care coordinator which eliminates time and effort for the family. By making more services and supports available to children, youth, and families, families are more likely to stay together. In those cases when children and youth are placed out of the home, the length of placement is reduced. In some instances, the length of placement can be reduced by half.

76 Outcome: Empowered Caregivers
Decisions about services are family driven. Parent voice is integral to the developing system and to system change at the local and state level Families have access to other caregivers who have experience parenting a child with mental health and behavioral challenges.

77 Outcome: Coordinated Services
Child welfare, health care, education, and mental health professionals work closely together. Mental health services are introduced in homes by system of care representatives including parents who have caregiver experience with a child who has mental health and behavioral challenges. Professionals who work in the system of care are offered technical assistance to better understand and serve their clients in a family centered approach. Needed child and family services are more accessible. Coordinated services are important because they give helping professionals a resource for addressing mental health needs that, when unmet, affect the overall well-being of families. A Funded system of care is able to bring additional needed supports and services to families, which may not have been possible had the family had one service entity that was unaware of additional resources and additional funding.

78 Outcome: Decreased Out-of-Home Placements
Early mental health intervention helps children, youth, and families stay together. Early mental health intervention reduces the length of time for out-of-home placement. By making more services and supports available to children, youth, and families, families are more likely to stay together. In those cases when children and youth are placed out of the home, the length of placement is reduced. In some instances, the length of placement can be reduced by half.

79 Outcome: Individualized services and supports for each family
Supports based on family needs Wrap around services Services developed in response to needs

80 What Our Partnership Could Accomplish
Coordinated, community-based services that support families in need Collaborative, individualized plans of action for families in their local community A community support structure that is accessible and family-focused As partners, we can help children, youth, and families with serious mental health needs reach their full potential. At the same time, our partnership can help each of our organizations reach their full potential in serving children, youth and their families.

81 Mental Health: Perspective of State Title V

82 Title V Performance Measures
Summary Numbers 2001 2006 % Change # of States with>1 perf. Measure relevant to mental health 24 36 50% Total perf. Measures relevant to mental health across States/Territories 30 57 90% # States/Territories with>1 priority need relevant to mental health 49 63% Total # priority needs relevant to mental health across States/Territories 39 101 159%

83 AMCHP’s Role AMCHP’s strategic plan identified emotional behavioral health as a priority focus area Develop Key Partnerships- Public Health, Mental Health Systems, Private Sector AMCHP in partnership working for policy and legislative reforms AMCHP convened a series of meetings with NASHP, SAMHSA, MCHB to produce “roadmap” Developing common set of principles

84 Key Partners Maternal and Child Health Bureau
Substance Abuse and Mental Health Services Administration National Academy of State Health Policy Georgetown Child Development Center Family Voices Federation of Families

85 A Common Set of Principles
A continuum of services relating to mental health; Strengthening the interface between public health and mental health, including prevention Increasing protective factors and risk reduction. Mental Health and Primary Care (Medical Home)

86 Current Activities Developing A Public Health Approach to Mental Health Collecting and Disseminating Best Practice Models Development of Monograph Conceptual Framework for PH approach Continuum of Services Common language

87 Next Step: Engagement Strategies to Engage Stakeholders formally and informally Stakeholder Meeting Focus Groups Interviews Document Review Surveys Presentations

88 Challenges for Leadership
Dialogue between cultures Trust and understanding Value


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