1. The Evidence Base for Effective Services in the Community The example of Psychological Centers’ Intensive Home-Based Services (CCBS)

2. What’s the problem? 16-22% of US children have some mental health issue 16-22% of US children have some mental health issue Psychiatric hospitalization accounts for 70% of mental health care costs Psychiatric hospitalization accounts for 70% of mental health care costs 30-50% of hospitalized children/adolescents are re-hospitalized within one year 30-50% of hospitalized children/adolescents are re-hospitalized within one year

3. What are the services? PC CAITS/EOS II PC CAITS/EOS II –Focused on family system/empowering caregivers –Targets factors that place youth at risk PC EOS PC EOS –Same focus, but with use of behavior assistants to provide daily “clinician extension” to empower and guide caregivers in working with the children

4. What’s the difference? EOS vs. CAITS BAs are in the homes when the families need help (which is often NOT 9-5) BAs are in the homes when the families need help (which is often NOT 9-5) BAs receive specific training BAs receive specific training –Parent behavior management –Functional behavior analysis –Facilitating parent self-regulation –Legal and ethical issues –Many, many others …

5. What’s the difference? EOS vs. CAITS THE BEHAVIOR ASSISTANT

6. What’s the difference? EOS vs. CAITS In CAITS, PC uses the 18 available case management hours to allow BAs to do parent training In CAITS, PC uses the 18 available case management hours to allow BAs to do parent training In EOS, BA hours are used flexibly throughout treatment—based on what is being targeted for a specific client in a specific week In EOS, BA hours are used flexibly throughout treatment—based on what is being targeted for a specific client in a specific week

7. Where did we get the data? This is an ongoing program evaluation project This is an ongoing program evaluation project Data is collected from charts when child is discharged Data is collected from charts when child is discharged Outcome phone calls are placed at 3, 6, and 12 months post-discharge Outcome phone calls are placed at 3, 6, and 12 months post-discharge We ask if the child has been hospitalized or placed out of the home We ask if the child has been hospitalized or placed out of the home

8. Who are the children? 2-20 years old (average age = 9) 2-20 years old (average age = 9) 54% Anglo, 23% Latino/a, 9% African-American, 8% Bi/multi 54% Anglo, 23% Latino/a, 9% African-American, 8% Bi/multi 40% Providence, 20% Pawtucket/CF, 20% Warwick/Cranston, 10% North 40% Providence, 20% Pawtucket/CF, 20% Warwick/Cranston, 10% North 52% have 2 or more sibs in the home (25% have 3 or more) 52% have 2 or more sibs in the home (25% have 3 or more)

9. What is the severity? HALF of all CCBS clients have been previously hospitalized HALF of all CCBS clients have been previously hospitalized Half are diagnosed with a disruptive behavior disorder Half are diagnosed with a disruptive behavior disorder 15% have an internalizing disorder 15% have an internalizing disorder 25% have BOTH internalizing and externalizing disorder diagnoses 25% have BOTH internalizing and externalizing disorder diagnoses –Combined: 3/4 externalizing, 2/5 internalizing

10. Who are their caregivers? 78% are mothers, many single 78% are mothers, many single 60% self-report a mental health dx 60% self-report a mental health dx 20% report MORE than one 20% report MORE than one Caregivers with diagnoses in more than one category tend to have kids with previous hospitalizations Caregivers with diagnoses in more than one category tend to have kids with previous hospitalizations

11. Who gets what service? 56% receive CAITS only 56% receive CAITS only 24% receive EOS only 24% receive EOS only 20% receive EOS and CAITS as a step-down 20% receive EOS and CAITS as a step-down Average length of stay in any CCBS program is slightly less than 3 months Average length of stay in any CCBS program is slightly less than 3 months

12. Who gets what service? Children referred to CAITS tend to be younger (average age = 8; average age of child referred to EOS = 10) Children referred to CAITS tend to be younger (average age = 8; average age of child referred to EOS = 10) CAITS-referred children are less likely to have had a previous hospitalization … CAITS-referred children are less likely to have had a previous hospitalization … BUT, 31% of CAITS referrals have at least one prior hospitalization (12% >1) BUT, 31% of CAITS referrals have at least one prior hospitalization (12% >1) 71% of EOS referred children have a previous hospitalization (38% >1) 71% of EOS referred children have a previous hospitalization (38% >1)

13. So … what happens after? Post- Discharge: Percent Hospitalized n 3 months 7%111 6 months 11%113 12 months 11%55

14. What about the kids who were hospitalized before? 3 months post-discharge: SampleNTime % re-hosp Saunders, 2003 ~4000 14 days 13-15% Fontanella2006881 3 months 22% Blader,2003109 30% PC CCBS 53 3 months 15%

15. 6 months post-discharge: SampleNTime % re-hosp Arnold, 2003 180 6 months 19% PC CCBS 56 6 months 18% Brinkmeyer200445 9 months 32%

16. 12 months post-discharge SampleN % re-hosp Solomon 1993 4533% Asarnow 2002 2835% Blader 2003 10936% Fontanella 2006 88138% Bloom 1982 8843% PC CCBS 2612%* * This number should be interpreted with caution given initial difficulties contacting caregivers

17. What about CAITS vs EOS? At 3 months:

18. CAITS vs. EOS 6 months post-discharge

19. What predicts hospitalization (from published studies)? Previous hospitalization and other out of home placements Previous hospitalization and other out of home placements Diagnosis—disruptive behavior Diagnosis—disruptive behavior PARENTING PARENTING –Parent-child relationship –Parent punishment style –Parent engagement

20. Conclusions? Based on results from PC CCBS services: Effective, parenting-focused services can significantly reduce risk of rehospitalization Based on results from PC CCBS services: Effective, parenting-focused services can significantly reduce risk of rehospitalization HOWEVER, children who have been previously hospitalized should receive an appropriate level of care, such as services that include well-trained behavior assistants facilitating parenting effectiveness HOWEVER, children who have been previously hospitalized should receive an appropriate level of care, such as services that include well-trained behavior assistants facilitating parenting effectiveness

21. What next? We keep collecting data We keep collecting data –this is a moving target (e.g., funding cuts to BA services resulted in changes to services) We want to know: We want to know: –Are there significant differences in hospitalization rates for CAITS vs. EOS? –Does a parent engagement intervention decrease hospitalization post-discharge?

22. ACKNOWLEDGEMENTS KATIE FISCHER Monica Beebe Jo-Ann Clinton Jaime Viti Imari Barboza Stephane Colato

23. ACKNOWLEDGEMENTS THE ENTIRE CCBS STAFF: THANK YOU FOR YOUR INCREDIBLE WORK WITH THESE FAMILIES!!!