1. Pennsylvania Council of Children Youth and Family Services Children’s Behavioral Health Services Policy Day June 13, 2011 Discussion with Office of Mental Health and Substance Abuse Services

2. Agenda Environmental Scan Call for Change BHRS RTF FBMHS Evidence Based Practices School Based Behavioral Health Outpatient Services System of Care Tri-Care

3. DPW Principles Integrated, Coordinated and Seamless Service System Focus on Consumer Needs: Quality, Independence, Flexibility and Service Coordination Provide value through Financial Integrity and Consumer Appropriate Care Personal Responsibility

4. Call for Change in Children’s Behavioral Health Develop the capacity for the system to be youth and family driven. Ensure ready access to a cost-effective array of quality services including assessment, treatment and support services that help to sustain and nurture family and community ties. Establish the infrastructure (financing, policies, training, etc.) to implement a system of comprehensive, integrated, cost- effective array of services. Develop a public health approach to social and emotional wellness for children, youth and families. Develop increased capacity for service systems to meet the needs of transition age youth and young adults through cross systems collaborative relationships and initiatives.

5. BHRS Brief Overview Brief Overview Intersection of Policy and Finance Intersection of Policy and Finance Identification of Major Strategies Identification of Major Strategies

6. Therapeutic Support Services 06–0707–0808–0909–10 Dollars $303M$284M$274M$244M Users 26,26626,15325,19724,394

7. BHRS Totals 06–0707–0808–0909–10 Dollars $575M$581M$617M Users 53,70054,39457,43660,824

8. Goals Realign BHRS to become a more clinically appropriate, high quality service. 1. Realign BHRS to become a more clinically appropriate, high quality service. 2. Promote use of evidence based practices and the full array of clinic and community-based services for children. 3. Assure more cost effective delivery of BHRS.

9. Realign BHRS Streamline the process for accessing BHRS; Streamline the process for accessing BHRS; Allow Mobile Therapy (MT) to be delivered independently, with appropriate licenses/oversight; Allow Mobile Therapy (MT) to be delivered independently, with appropriate licenses/oversight; Develop focused modalities under existing BHRS, rehabilitation, and clinic service definitions to target specific populations and to conditions that can be expected to benefit; Develop focused modalities under existing BHRS, rehabilitation, and clinic service definitions to target specific populations and to conditions that can be expected to benefit;

10. Realign BHRS Administrative Requirements Simplify BHRS prescription process by replacing requirements for updated prescriptions, evaluations and treatment plans (packets) with a data-driven process to identify case and provider outliers; Simplify BHRS prescription process by replacing requirements for updated prescriptions, evaluations and treatment plans (packets) with a data-driven process to identify case and provider outliers; Restructure the ISPT process to allow an array of interagency planning approaches including High Fidelity Wraparound. Restructure the ISPT process to allow an array of interagency planning approaches including High Fidelity Wraparound.

11. TSS in Schools Develop and expand school-based behavioral health services as preferred alternatives to individual TSS; Work with BHMCOs and provider agencies to expand traditional outpatient and to implement innovative approaches in schools. Encourage other best practice efforts such as outpatient satellites, or Mobile Therapy in schools.

12. Address needed changes in bulletins, contracts Identify financial barriers or disincentives and extend current rate review by Mercer to all of BHRS; Identify financial barriers or disincentives and extend current rate review by Mercer to all of BHRS; Eliminate regulatory requirements that run counter to family and youth-driven service needs; Eliminate regulatory requirements that run counter to family and youth-driven service needs;

13. Appendix T requires that less intensive services must first be tried prior to a recommendation for FBMHS A psychiatrist, physician or licensed psychologist determines that the child is eligible and recommends the FBMHS program A psychiatrist, physician or licensed psychologist determines that the child is eligible and recommends the FBMHS programAND Other less restrictive, less intrusive services have been provided and continuation in this less intensive level of care cannot offer either an expectation of improvement or prevention of deterioration of the child’s and the family’s condition Other less restrictive, less intrusive services have been provided and continuation in this less intensive level of care cannot offer either an expectation of improvement or prevention of deterioration of the child’s and the family’s condition

14. Residential Treatment Facilities There has been a dramatic change in the RTF system over the past 4 years; There has been reduced use due to development of evidence based practices such as Multi-Systemic Therapy and efforts in Child Welfare and Juvenile Justice;

15. Changing Field July 2009 we had 2,807 Accredited and 1,281 non-accredited 4,088 beds total beds in 2009 March 2011 we have 1,960 Accredited and 501 non-accredited, a total of 2,461 beds in 2011 a decrease of 1,627 beds in two years

16. Accredited RTFs 06–0707–0808–0909–10 Dollars $239M$232M$218M$187M Users 5,0584,6324,2133,691

17. Non-Accredited RTFs 06–0707–0808–0909–10 Dollars $48M$41M$43M$37M Users 1,5931,3201,3011,098

18. Budget Work Plan There are still counties where there are additional opportunities for cost savings and that is reflected in the 11/12 budget. We will work with these counties and their Managed Care Organizations to support them in making the necessary changes. The Money Follows the Person initiative may provide an opportunity for counties to expand community based alternatives for these counties.

19. Proposed Regulations for RTFs 1.Comments to the proposed RTF regulations have identified many issues, most of which we can easily address in the next draft. 2.In addition to the organizational change that will be required, there are significant financial implications. 3.We have to gather more information and do some more work before are ready to discuss a new draft with stakeholders.

20. FBMHS Discussion Current situation with FBMHS Proposed change to more supervision based model Actions

21. Family-Based Mental Services 06–0707–0808–0909–10 Dollars $62M$76M$88M$97M Users 6,5728,0799,0489,803

22. Current Situation 3 Training centers One exam (only taken by Mental Health Workers) New modalities (IICAP, ABFT) Intensity of need appears to have increased

23. Current Status of Change Children’s Bureau working with 3 training directors collectively. Learning more about strengths and opportunities to improve FBMHS. Partial implementation of the paradigm shift by the three training centers has begun. Identification of continuing agenda with training centers, to achieve improved overall quality and core standards.

24. Moving FBMHS closer in implementation to other Evidence Based family empowerment models Increasing responsibility of the clinical supervisors at FB agencies, with increased training and support for supervisors by the training centers. Increasing accountability at multiple levels: – Training center faculty: increased accountability to FB supervisors at various agencies, and to new FB staff. – Agency supervisors: to their staff, and to families served. – Therapists: to each other as team members, to their supervisor, and to families served.

25. Supervision based model, emphasizing the supervisor’s role and accountability for therapists’ completion of outcome measures and their competency in delivering clinical treatment – Increased role of supervisor, when their therapists present to training center staff. – Certification of supervisors. – Continued expectation of continuing education and professional development, by agency supervisors and agency therapists alike. – Use of fidelity and outcomes tools by therapists, who are trained by center staff.

26. Rolling Implementation Gradual reallocation of resources and expectations. New training for supervisors and also for new FB staff, with some training being done on-line and reduction in the standard of hours of staff training. Testing use of FB fidelity instruments to maintain accountability to the model. Use of a range of outcome measurements, with baseline established at initiation of service, to maintain clinical accountability. Gradual implementation of changes, with modification based on mutual learning. Overall goal: For changes to be efficient and cost-neutral.

27. School Based Services

28. Student Assistance Program In FY 09/10, 111,881 students state wide were referred to school Student Assistance Program teams for consultations. Of those students 26,681 students were referred for drug and alcohol or mental health assessments in the SAP program. 17% were determined to have a primary problem of Drug and Alcohol issues; 70% were determined to have a primary problem of Mental Health issues.

29. School-Wide Positive Behavior Support (SWPBS) Positive Behavior Interventions and Supports is an evidence-based approach for establishing the social culture needed for schools to be effective learning environments for all students. Positive Behavior Interventions and Supports helps schools teach students expected behaviors and social skills, creates student behavioral health and academic support systems, and applies data-based decision-making to discipline, academics, and social/emotional learning.

30. Expanding in Pennsylvania Data for the 10-11 school year indicate that SWPBS is operating in141 schools buildings: Elementary 92; Middle 32; High Schools 17

31. Evidence Based Practices

32. .

33. MST A total of 2397 youth and 4222 parents/caregivers were served in 2010. A total of 1838 new youth were admitted to MST programs in 2010, 1230 (67%) of whom would have otherwise been placed out-of-home according to the provider.  The majority of referrals came from Children & Youth Services (43%) and Juvenile Probation (46%). A smaller number of referrals came from schools (3%) and other sources (8%).

34. MST Completions Of the 1709 youth that had the opportunity to complete MST (i.e., were not administratively discharged) in 2010: – 1388 youth (81%) were successfully discharged. The average length of stay for successful cases was 3.6 months which is consistent with the MST model. – 321 youth (19%) were unsuccessfully discharged. Of these youth, 202 (63%) were placed out of home. The average length of stay for unsuccessful cases was 2.8 months.

35. Of the 455 youth discharged from MST between October-December, 2010 Over 80% had no new criminal offense during treatment. 80% remained drug free, as evidenced by negative drug screen(s) during their last three months in MST. Nearly 80% improved school attendance and nearly 80% improved school performance. 70% had families that improved family functioning, defined as improved parenting skills and/or improved family relationships.

36. FFT A total of 1661 youth and 2038 parents/caregivers were served in 2010. A total of 1462 youth were admitted to FFT in 2010, 158 (11%) of whom would have otherwise been placed out-of-home according to the provider. 28% of referrals came from Children Youth & Services, 6% came from schools, 53% came from Juvenile Probation, and 13% came from another source.

37. A total of 1175 youth were discharged from FFT in 2010. Of the 1120 youth that that had the opportunity to complete FFT (i.e., were not administratively discharged) in 2010: – 801 youth (72%) were successfully discharged. The average length of stay for successful cases was 3.7 months, which is consistent with the FFT model. – 319 youth (28%) were unsuccessfully discharged. Of these youth, 63 (20%) were placed out of home. The average length of stay for unsuccessful cases was 2.6 months.

38. Of the 330 youth discharged from FFT Between October-December, 2010): 95% had no new criminal offense during treatment Nearly 70% remained drug free, as evidenced by negative drug screen(s) during their last three months in FFT Over 60% improved their school attendance and nearly 70% improved their school performance.

39. MTFC A total of 54 youth and 96 parents/caregivers were served in 2010. A total of 45 new youth were admitted to MTFC in 2010, 34 (76%) of whom were at imminent risk of being placed in a more restrictive setting prior to treatment.

40. Of the 34 youth discharged from MTFC across 2010 97% had no new criminal charges during treatment 71% decreased their antisocial behavior 68% improved their overall behavior 100% remained drug free (as evidenced by negative drug screen(s) during their last three months in MTFC) 71% improved on school attendance and 73% improved on school performance

41. Parent Child Interaction Therapy PCIT was developed for children between the ages of 2 and 7 years who have externalizing behavioral problems. It has been used in families with histories of physical abuse and children with developmental disabilities. In PCIT, parents are taught specific skills to establish or strengthen a nurturing and secure relationship with their child while encouraging prosocial behavior and discouraging negative behavior.

42. Parent Child Interaction Therapy is expanding rapidly PCIT is in 12 counties and 21 agencies. Allegheny County began in 4 agencies with foundation funds Through the Heinz Endowment, OMHSAS and OCDEL have supported 8 agencies: Value Behavioral Health has expanded in several of its counties in the western part of the state CCBHO is expanding in the 23 county state option

43. Pennsylvania Agencies Providing Parent-Child Interaction Therapy Last Updated - May 14, 2011

44. High Fidelity Wraparound There are 10 counties involved in High Fidelity Wraparound, the 5 System of Care Counties: and 6 others: Allegheny, Bucks, Delaware, Fayette, and Northumberland. Over 500 youth and their families have been served since the initiation of HFW in 2008. We are working with counties/BHMCOs to expand the availability of HFW to more counties. Philadelphia will be the next county!

45. System of Care Update We continue work with building the infrastructure in the first 5 counties; Successful Conference in May with the 5 counties, and with counties that are doing High Fidelity Wraparound; Submission of a proposal to SAMHSA for a planning grant to expand Systems of Care throughout the Commonwealth.

46. Pennsylvania System of Care Expansion Proposal SLT Planning Consultants Tri-West Project Director FLST RPG CBH Counties RPG CBHNP Counties RPG MBH Counties YLST RPG II CCBHO Counties RPG VBH Counties RPG I CCBHO Counties

47. Military Families SAMHSA has identified eight Strategic Initiatives, with Military Families being one of them, to help individuals with mental and substance abuse disorders and their families build strong and supportive communities, prevent costly and painful behavioral health problems, and promote better health for all Americans. The Military Families Initiative is intended to support America's service men and women — Active Duty, National Guard, Reserve, and Veterans — together with their families by leading efforts to ensure that needed behavioral health services are accessible and that outcomes are positive.

48. Pennsylvania Facts There are approximately 31,000 military children living in the Commonwealth of Pennsylvania. Pennsylvania provides the nation’s highest number of National Guard troops and the third largest number of all personnel serving in the military effort.

49. Informational Packet from SAMHSA Contains information on the TRICARE healthcare entitlement, the provider categories that may be authorized, services that may be reimbursed, and the forms required in the certification application.

50. Hang in There