Implementing Effective Intensive Home-Based Treatment Programs Rick Shepler, Ph.D., PCC-S Patrick Kanary, Director Center for Innovative Practices Begun Center for Violence Prevention Case Western Reserve University

Workshop Focus Areas Intensive Home-based Treatment: best practice for youth with multiple and complex needs and their families. IHBT model components Implementation considerations including staffing, team composition, policies, risk management, and funding Central program role for IHBT supervisor: active supervisory clinical oversight IHBT fidelity and outcome measures IHBT training focus areas

It takes a community …. Shared burden- shared risk No single system can manage the multiple issues of at-risk youth and their families alone Mutual responsibilities: we all play a role Youth and family Providers Child-Serving Systems Community (supports)

Critical Service in a Comprehensive System of Care IHBT expands the continuum of care to increase the availability of the less restrictive service options for youth at-risk of out-of-home placement due to behavioral health issues. Pivotal: most intensive community-based option prior to more restrictive placement options

Intensive Home-Based Treatment Services IHBT is an intensive, time-limited mental health service for youth with serious emotional disabilities and their families, provided in the home, school and community where the youth lives, with the goal of stabilizing mental health concerns, and safely maintaining the youth in the least restrictive, most normative environment. Comprehensive set of mental health services integrated into a seamless set of services delivered to the family. Main Purposes: Placement prevention Reunification Stabilization and safety Definition of IIHS

Effective Alternative to Custody Relinquishment Youth can remain in their homes and receive the necessary behavioral health services needed for community stability. Reduced out of home placements 86% in recent 15 site IHBT evaluation (total youth served)

Do What Works Evidence shows that offering a full range of community-based alternatives is more effective than hospitalization and emergency room treatment The Commission’s final report endorses the expansion of home and community-based services and the move toward the use of evidence-based practices President’s New Freedom Commission on Mental Health Transition to importance of evidenced-based practice and utilization of outcomes

Percentage of children still at home post-Intensive Family Preservation Services State Months Post IFPS % In Home Kansas 12 91% Wayne Co., Michigan 6 88 Kentucky 87 Marion Co., Indiana 83 North Carolina 82 Missouri 79 Washington 77 Mean 84%

Michigan Families First Effectiveness Study (Blythe and Jayanarte 2002) Randomly assigned high-risk families to either family preservation services (home-based) or traditional child welfare services including foster care. At 6 months after IFPS, 88% of children were living at home compared to only 17% in the non-IFPS group. At 12 months, 93% of IFPS children were at home compared to 43% of non-IFPS children. Family preservation evidence www.nfpn.org

IHBT Grant Study 2009 (394 Youth Served) Placements Avoided 86% of youth served, all at-risk of out of home placement, were maintained at home and in the community at discharge 100% of youth ages 4 to 6 remained in their homes safely School Success Passing grades increased from 65 to 77%; Disciplinary problems decreased from 68 to 49%; Juvenile Justice Outcomes 50% drop in youth arrested (44% to 21%);youth on probation (27.5 to 13%);youth detained (13.5% to 7.1%) 12/24/2018

Aggregate Ohio Scales Scores At Admission and Discharge—Parent Ratings During IHBT, parents rated youth as having fewer problems and better functioning. They were also more hopeful and more satisfied at the conclusion of treatment than at admission. Mean values are shown above the bars, and p values (significance levels) of differences between admission and discharge using paired samples t tests are shown below the graph. Not only are the differences statistically significant; they also show meaningful clinical change. Based on 309 cases p<.0001 p<.0001 p<.0001 p<.0001

Aggregate Ohio Scales Scores At Admission and Discharge—Worker Ratings The worker ratings are concordant with the parent ratings, showing significant (and clinically meaningful) improvement in functioning and decrease in problems. Based on 296 cases p<.0001 p<.0001

Demonstrate Program Effectiveness MST Dashboard FY 09, FY 10, FY 11 Indicator Value (Target) Total Cases Discharged 1598 Percent of youth at home 87.84% (90%) Percent of youth in school 86.89% (90%) Percent of youth with no new arrests 77.79% (90%) Percent of youth completing treatment 85.39% (85%) Average Adherence Score 0.703 (0.61) 12/24/2018

IHBT Benefits IHBT offers direct service supports to other child-serving systems (education, juvenile justice, child welfare) and assists them in safely maintaining youth safely in less restrictive settings. Increases positive outcomes for their system (school success; decreased arrest rates, decreased abuse and neglect, etc.) Saves their system money IHBT actively assesses and manages youth and family risk Mental health stabilization Family Stability Reduced involvement in Juvenile Justice System Increased school success Positive outcome and cost benefit to the family and other child-serving systems

Weighing the Costs “The question is not whether we can afford to invest in every child; it is whether we can afford not to.” Mariann Wright Edelman “It is easier to build strong children than to repair broken men.” Frederick Douglas

New Evidence on the Monetary Value of Saving a High Risk Youth (Cohen & Piquero, 2008) Estimate the present value of saving a 14-year-old high risk juvenile from a life of crime to range from $2.6 to $5.3 million (p. 25)

IHBT as Alternative to Out of Home Placements Foster Care Therapeutic Foster Care Group Home Psychiatric Hospitalization Residential Treatment Facilities (Unlocked to locked) Incarceration

What Cost Analysis Shows “Intensive Family Preservation Programs that adhere closely to the Homebuilders model significantly reduce out-of-home placements and subsequent abuse and neglect. We estimate that such programs produce $2.54 of benefits for every dollar of cost.” Washington State Institute for Public Policy (WSIPP): (Miller, 2006) 

Fiscal Impact for System Stakeholders (2008 Data) Placement Type Average Cost Per Diem Annualized Cost System(s) Impacted Foster Care Level IV $123.90 $45,224 Local Job and Family Services Group Home $125 $45, 625 Local Job and Family Services; Juvenile Courts Residential Treatment (non- secure) $200.56 $73,204 Local Job and Family Services; Juvenile Courts; School Systems Residential Treatment (secure) $335 $122,275 Juvenile Commitment $440 $145,200 ODYS; Local Juvenile Courts IHBT (average cost per treatment episode) $7,500 All 12/24/2018

Cost Benefit Estimate from IHBT Grant Over $16.4 million in placement costs saved at the cost of approximately $3 million (IHBT for 394 youth) Total Cost Benefit over $13.4 million saved for 394 youth served (IHBT grant 2009) The total cost savings per youth is $34,154 For every dollar spent in IHBT/MST there was a return of $5.55 or 555% in placement costs avoided. 12/24/2018

Key Home-based Service Models Homebuilders (1974): Original home-based model; often referred to as family preservation; target population is youth at-risk for abuse and neglect (length of stay- 4 to 6 weeks) Kaleidoscope (1973) Karl Dennis; wraparound model developed (no eject no reject policy) Philadelphia Child Guidance Model: Structural Family Therapy home-based therapy model Multisystemic Therapy (MST): EBP for juvenile justice 3- 5 months IHBT: Ohio’s intensive home-based treatment model: for youth with SED who are at-risk of placement; returning from placement; or have a significant safety/risk issue that potentially puts them at risk of placement Integrated co-occurring treatment (ICT): for youth with co-occurring substance use and mental health disorders (3 to 6 months) Key home-based models.

IHBT: Service Access Service delivered where the youth lives and functions: home, school, and community at times that are convenient to the family Access to information Family dynamics and interactional patterns Recovery environments Access to people Family School Court Community Natural supports Access for interventions: implemented where behaviors occur

Intensive Home-Based Service Delivery Model Location of Service Home and Community Intensity Frequency: 2 to 5 sessions per week Duration: 4 to 8 hours per week Crisis response & availability; active safety planning and monitoring 24/7 Active safety planning & monitoring Ongoing Small caseloads 4 to 6 families per FTE; 8 to 12 for team of two Flexible scheduling Convenient to family Treatment duration 3 to 6 months Systemic engagement and community teaming Child and family teaming; skillful advocacy; family partnering; culturally mindful engagement Active clinical supervision & oversight 24/7 availability; field support; individual & group Program structure and credentials Licensed BSW and above; MA preferred Program size: 4 to 8; .5 to 1 FTE IHBT Supervisor Individual provider versus teaming approach Comprehensive service array Crisis stabilization, safety planning, skill building, trauma-focused, family-focused; resiliency & support-building interventions; cognitive interventions

Differences Between IHBT & Traditional Services Services delivered in the home and community 24/7 availability & response by IHBT team Frequency & duration matches need Flexible Scheduling Lead role in service coordination Small Caseloads <8 Time-limited Comprehensive mix of services Outpatient Clinic-based No 24/7 availability by team One hour weekly appointments Appointments during office hours Limited opportunities for collaboration Large Caseloads >30 Services are ongoing Therapy only

Differences Between IHBT & Family Preservation Target population: youth with serious emotional disabilities Goal: Stabilize youth mental health concerns; reduce out of home placements; increase functioning Intensity: 4 to 6 hours per week Small Caseloads <8 LOS: 3 to 6 months Credentials: BSW and above; MA preferred Comprehensive mix of services: trauma-focused; family-focused; skill building; crisis stabilization; resiliency & support building interventions Family Preservation Target population: families at-risk of abuse and neglect Goal: Reduce abuse and neglect; increase family stability Intensity: 4-10 hours a week per family Caseload: 2 to 4 LOS: 1 to 3 months Credentials: BSW and above; BSW most common Skill building focus; parenting focus; crisis stabilization

Typical Youth Served Youth with Serious Emotional Disturbance (SED) with functional impairments Less intensive services were unsuccessful Multiple system involvement At-risk of placement due to safety issues Multiple risk factors; Few protective factors Skill set deficits Youth need additional supports, active facilitation, and accommodations for success

Parents and Families System has not engaged youth and family effectively Families who have difficulty with service access (work, transportation, poverty) High stress – Low resource High family conflict Current parenting skill set unsuccessful in dealing with youth's mental health needs Parents need significant levels of support (few external supports) Trust issues with the “system”

IHBT Eligibility Criteria Youth with serious emotional disorders At risk for out-of-home placement; or Returning from out of home placement; or has significant behavioral health concerns that require active and intensive safety planning, crisis stabilization, and monitoring Youth Is under the age of 18; or Youth age 18 through 21 who are still living at home and attending high school or under the jurisdiction of another child serving system

IHBT Service Progression and Processes Engagement and Assessment (High Intensity) Engagement (youth, family, & collaborative partners) Crisis Stabilization and Safety Planning Assessment Treatment (High to Medium Intensity) Evidenced-based individual and family treatments and supports Skill Building, Skill Consolidation, and Generalization Enhancement of Positive Support Network Preparation of Continuing Care and Support Needs (Decreasing Intensity) Solidify continuing care and support needs Linkages, Closure, & Follow-up Increased reliance on informal supports 3 main phases of work: 1st phase (2 to 4 weeks) is focused on positive engagement; stabilization of presenting crises and safety needs; and thorough assessment; establish collaborative relationships with other system providers 2nd phase: (middle 6 to 8 weeks) Treatment: individual and family therapy; skill building & generalization 3rd phase (2 to 4 weeks) Enhancement of Positive Support Network: Build supports comprised mainly of informal supports (family, faith, and friends). Ritual closing celebrating successes.

Single Point of Clinical Responsibility IHBT providers take a lead role in facilitating the coordination of formal and informal services and supports, as guided by the youth and family.

System of Care Service Philosophy IHBT Model Components Resiliency-Oriented Perspective Home-Based Service Delivery System of Care Service Philosophy Multidimensional Assessment Comprehensive Treatment Array Matched to Needs and Strengths

System of Care Principles and Values Least restrictive environment Treatment responsiveness and persistence Advocacy and protection of rights Integrated, coordinated, and comprehensive services Culturally and linguistically competent services Strength-based perspective Youth-guided and family driven services Youth and family partnerships

Developmental & Resiliency Focus Resource and support building Risk reduction & asset promotion Facilitation of accommodations across life domains Build developmental skill sets Assess and address for trauma

Multidimensional Assessment Symptom Patterns and Diagnoses Contextual Functioning: Degree of functional impairment per life domain Developmental and Cognitive Functioning: (cognitive functioning, emotional, & behavioral maturity) Risk and Recovery Environments: Environmental risk and recovery conditions (e.g. trauma, safety, negative influences, family conflict, poverty)

Contextual Assessment School Informal Supports + + Family - + - Youth - Peers Community + + - - + + = Protective Factors - - = Risk Factors Copyright 2006, 2009 Center for Innovative Practices Work

Comprehensive Treatment Matched to Need Recovery & Resiliency ECOSYSTEMIC FUNCTIONING BASIC SKILLS BASIC NEEDS & SAFETY Youth and Family Need Hierarchy (Shepler, 1991, 1999)

Polices that support IHBT implementation Clear program LOS guidelines with procedures for continuing stay Flexible work hours Rotating coverage for on-call Cell phones Laptops Safety policies for workers Supervisor dedicated to the program Reasonable productivity requirements

Risk Management IHBT programs require active risk management Dedicated supervisor to IHBT team is an insurance policy Protected clinical supervision time Child and family teaming to share the risk Assess for safety and risk with every family Active safety planning Proactive safety monitoring Regular communication with system partners

Target Outcomes Increase functioning in major life contexts: Living at home or in a permanent home setting Attending and achieving at school/work Reduced involvement in the JJ system Reduced use/no use of substances No new abuse or neglect No new trauma Participating in positive family, peer, and community life Improved family recovery environment Accessing resources and natural supports as needed to maintain gains and prevent recidivism Youth’s lives are complex; compounded by fact they have multiple disorders Multiple disorders; Multiple contextual environments (family, neighborhood, peers, school, community) Different developmental stages Different learning styles and capacities Varying levels of resources, supports, and assets Varying degrees of risk

Training areas Family systems Risk assessment and crisis stabilization Parenting skills and supports for children/adolescents with SED Cultural competency Intersystem collaboration and coordination Trauma-informed care Educational and vocational functioning Strength-based assessment and treatment planning Co-Occurring Disorders Behavioral Health and Juvenile Justice Ethics in IHBT Supervising IHBT

Lessons Learned: IHBT Implementation Issues Technical Assistance is needed to maximize effectiveness of IHBT Agency/program level funding requires more than Medicaid A uniform data collection system is necessary in order to provide timely clinical feedback and track quality improvement Stakeholders/funders increasingly relying on data to make financial decisions Multiple partners and multiple systems are needed to support implementation High level training and ongoing coaching and monitoring of fidelity

Proven Formula Effective intervention practices and programs + Effective implementation practices = Good outcomes for children and their families No other combination of factors reliably produces desired outcomes for children, families, and caregivers NIRN The usability of a program has little to do with the weight of the evidence regarding program outcomes Evidence on effectiveness helps us select what we want implement Evidence on outcomes does not help us implement the program

The best is to have a strong program implemented well Implementation is Essential (Reduction in Recidivism from Control Group Rates) The best is to have a strong program implemented well The effect of a well implemented weak program is as big as a strong program implemented poorly Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

ODMH committed to adding IHBT to Medicaid service menu by FY ‘13 IHBT workgroup completed its review ODMH conducting rate setting exercise Next Steps: Prepare SPA and submit to CMS Training and roll out Current IHBT status Approximately 20+ certified IHBT sites 16 MST teams for 10 counties Other non-certified in home programs So, where is Ohio on IHBT?

More Information: Patrick Kanary patrick.kanary@case.edu Richard Shepler richard.shepler@case.edu Center for Innovative Practices Begun Center for Violence Prevention, CWRU