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Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health Specialty Clinics Gary Lippe Dept. of Human Services, NE Iowa.

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Presentation on theme: "Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health Specialty Clinics Gary Lippe Dept. of Human Services, NE Iowa."— Presentation transcript:

1 Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health Specialty Clinics Gary Lippe Dept. of Human Services, NE Iowa

2 Comprehensive Community Mental Health Services for Children and Their Families (Systems of Care) Susan Stromberg October 16, 2007

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

4 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. Systems of Care

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

6 System of Care Model CHILD AND FAMILY MENTAL HEALTH SERVICES EDUCATIONAL SERVICES HEALTH SERVICES SUBSTANCE ABUSE SERVICES VOCATIONAL SERVICES RECREATIONAL SERVICES OPERATIONAL SERVICES SOCIAL SERVICES

7 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!! +

8 System of Care Core Values Community based Child and family focused (family driven and youth guided) Culturally and linguistically competent

9 System of Care Guiding Principles Comprehensive array of services Individualized care Least restrictive setting Family and youth involvement Service integration

10 System of Care Guiding Principles Care coordination Early identification and early childhood intervention Smooth transitions Rights protection and advocacy Nondiscrimination

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

12 Systems of Care Systems of Care Resilience, Leadership & Transformation Leadership Transformation Resilience What is involved? Rethinking traditional approaches Strengths-based Family driven & youth guided Embracing culture Who is involved? Youth Adults Families Providers Communities Fulfilling Potential

13 Systems of Care Systems of Care Resilience, Leadership & Transformation Leadership Transformation Resilience What is involved? Rethinking traditional approaches Strengths-based Family driven & youth guided Embracing culture Who is involved? Youth Adults Families Providers Communities Fulfilling Potential

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

15 Systems of Care as a Transformation Strategy Customer focused Family driven Bridging Systems Vision & Beliefs + Actions x (CQI) 2 Family Involvement Moving from family involvement to family driven Fully embracing youth involvement Opening the data set Establishing key benchmarks Sustainability - defining how systems of care contribute Integrating technical assistance activities Moving from concept to reality. Tools & strategies Youth Involvement Technical Assistance Research System of Care Transformation Cultural Competence

16 National Wraparound Initiative Setting standards Developing materials that are user-friendly

17 Embracing CQI and the Benchmarking Initiative Continuous Quality Improvement

18 National T.A.CommunityProgram Administrators Improvement Continuous Quality Strategies to Improve Cultural Context Program Performance CQI Feedback

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% 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

21 Family driven means… 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 Beginnings 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.

24

25 Transformation Resources Got a question about a family-driven, youth-guided system of care? Start here

26 Work together There is strength in numbers…

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

28

29  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 Child Health Specialty Clinics

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

31  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. CHSC Mission

32

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

34 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 Some of the Programs and Services CHSC Offers

35  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 History of CHSC and Children’s Mental Health

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

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

38 Patients seen July 2004 – June 2005 Burlington 85Carroll 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 Patient Data

39 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% Most Common Primary Diagnosis at CHSC

40 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 Outcomes Research

41  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 Enhanced Care Coordination

42 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 Behaviors10%-4% Functioning*24%-18% Caregiver capacity*11%-7% Strengths 9%-9% *significant difference between groups (p<.05) CANS DATA

43  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. CANS DATA

44 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. CANS DATA

45 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 Findings

46 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 Findings

47  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 reportsConclusions

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

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

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

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

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

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

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

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

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

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

58 Community Circle of Care: Partnership, Collaboration, Integration

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

60

61 ACCESS

62 Navigation

63 COORDINATION

64 INDIVIDUALIZED SUPPORTS

65 Systems of Care Professionals and Families Share Common Goals

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

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. *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

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

71 Benefit: Homes Are Stable The percentage of children and youth who lived in multiple settings decreased by 11 percent over 12 months. Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005

72 Caregiver strain is reduced in many families. More than a quarter of families had higher functioning after 30 months; more than half remained stable. Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005 Benefit: Families Are Stronger

73 Caregiver job, vocational, and educational skills improve. Incomes increase. Families have more time and support. Sources: CMHS National Evaluation: Updates from the National Evaluation, Services Evaluation Committee Meeting, 2004 CMHS National Evaluation: Aggregate Data Profile Report, 2004 Benefit: Families Have More Resources

74 Community Circle of Care A care coordination, wrap around system of care Community Circle of Care

75 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. Outcome: Improved Access to Needed Services

76 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. Outcome: Empowered Caregivers

77 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. Outcome: Coordinated Services

78 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. Outcome: Decreased Out-of-Home Placements

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

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

81 AMCHP Association of Maternal & Child Health Programs Mental Health: Perspective of State Title V

82 AMCHP Association of Maternal & Child Health Programs Title V Performance Measures Summary Numbers % Change # of States with>1 perf. Measure relevant to mental health % Total perf. Measures relevant to mental health across States/Territories % # States/Territories with>1 priority need relevant to mental health % Total # priority needs relevant to mental health across States/Territories %

83 AMCHP Association of Maternal & Child Health Programs 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 AMCHP Association of Maternal & Child Health Programs 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 AMCHP Association of Maternal & Child Health Programs 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 AMCHP Association of Maternal & Child Health Programs 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 AMCHP Association of Maternal & Child Health Programs Next Step: Engagement Strategies to Engage Stakeholders formally and informally –Stakeholder Meeting –Focus Groups –Interviews –Document Review –Surveys –Presentations

88 AMCHP Association of Maternal & Child Health Programs Challenges for Leadership Dialogue between cultures Trust and understanding Value


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