1. Acute Mental Health Care Services for Children in Pinellas County (Florida)
Annette Christy, Ph.D.
John Petrila, J.D., LL.M
Kristen Hudacek, Psy.D.
Diane Haynes, M.A.
Department of Mental Health Law and Policy
Louis de la Parte Florida Mental Health Institute
Community Partner
Personal Enrichment Through Mental Health Services
Thomas Wedekind, ACSW
Anne Pulley, B.S.

2. Acknowledgement
This project was funded by the USF Collaborative for Children, Families and Communities with Funds from the Pinellas County Juvenile Welfare Board
The Pinellas County specific archival data analyses were made possible by the Pinellas County Data Collaborative
Portions of the Baker Act data processing and entry were funded by a National Institute of Mental Health Grant to Paul Stiles (R01MH060217)

3. The burden of suffering experienced by children with mental health needs and their families has created a health crisis in this country. Growing numbers of children are suffering needlessly because their emotional, behavioral, and developmental needs are not being met by those very institutions which were explicitly created to take care of them. It is time that we as a Nation took seriously the task of preventing mental health problems and treating mental illness in youth.
The Report of the Surgeon General’s Conference on Children’s Mental Health, Satcher, 2001, p. 3

4. Study Components
Review of records for 35 children who had a recent Baker Act examination
Archival Database Analysis
Statewide
Analysis of Baker Act Data
Analysis of Medicaid and FL Department of Children and Families claims data
Pinellas County
The above sources, plus…..
Additional data sources available via the Pinellas County Data Collaborative

5. Baker Act Examinations
The Baker Act is the term applied to Florida’s civil commitment statute
Individuals can undergo a short-term, involuntary psychiatric or “Baker Act” examination of up to 72-hours if:
The are a person with mental illness
There is evidence of harm to self, harm to others and/or self neglect
Examinations may be initiated by:
law enforcement officials
mental health professionals
judges
Individuals are examined in ~115 Baker Act Receiving Facilities that are designated by the Florida Department of Children and Families

6. Baker Act Reporting Center
Legislative reforms were implemented in 1996 in response to elder abuse related to Baker Act examinations
A form documenting each examination was required to be sent to the Florida Agency for Healthcare Administration
FMHI agreed to serve as the repository for these data and has been receiving data from 1997 to present
These are data on short-term examination (not longer term commitment)
Florida is the only state to have a central repository of client level data on short-term, involuntary psychiatric examination

7. Baker Act Data
From 1997 to present the Baker Act reporting center has received over ½ million Baker Act examination forms.
We currently receive over 100,000 forms annually
This represents approximately 430 forms received on average every business day
Approximately 16% of forms received are for examinations of children
~80,000 forms received documenting examinations for children from 1997 through 2002
~17,000 forms documenting examinations for children likely received in 2003

8. Volume of Baker Act Data
# of forms received
1997: 69,235
1998: 73,900
1999: 78,064
2000: 83,989
2001: 95,900
2002: 105,046
2003: ~109,000

9. Percentage Baker Act Data Adults vs. Children Statewide
Data for children represented 15-17% of the data received in the past 3 and a half years

11. Record Reviews

12. Record Reviews 35 Children from the PEMHS Crisis Stabilization Unit
Parent/Guardian Consented
Children Assented (only after permission from parent/guardian to approach child)
First two months focused on consenting only children in the foster care system
Due to time and cost constraints, then attempted to consent/assent every child
Review of PEMHS record for the Baker Act examination from which the child was recruited into the study

13. Record Reviews 40% (n = 14) of children had a history of abuse
26% (n = 9) sexual abuse
23% (n = 8) physical abuse
11% (n = 4) emotional abuse
The most common presenting problem was suicidal ideation/gestures (n = 19; 54%)
Just prior to their examination 80% of children (n = 28) were living with family
Children had between one and four Axis I diagnoses (Mean = 2.31)

14. Record Reviews - Diagnoses
Diagnosis N %
Adjustment Disorder 15
42.86
Depression
Oppositional Defiant Disorder 9
25.71
Conduct Disorder 8
22.86
ADHD
Bipolar Disorder 7
20.00
Intermittent Explosive Disorder 6
17.14
Post Traumatic Stress Disorder 5
14.29
Dysthymic Disorder 4
11.43
Anxiety 1
2.86
Psychosis
Schizoaffective Disorder

15. Record Reviews The most common referral sources were:
Police % (n = 12)
Medical Facilities 34% (n = 12)

16. Record Reviews The most common referral sources were:
Police % (n = 12)
Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement

17. Record Reviews The most common referral sources were:
Police % (n = 12)
Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented

18. Record Reviews The most common referral sources were:
Police % (n = 12)
Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented
Insurance Status
51% Private Insurance
26% Medicaid as Primary (6% as Secondary)

19. Record Reviews The most common referral sources were:
Police % (n = 12)
Medical Facilities 34% (n = 12)
43% (n = 15) had past or current justice system involvement
46% (n = 16) had past or current substance abuse documented
Insurance Status
51% Private Insurance
26% Medicaid as Primary (6% as Secondary)
63% Receiving TANF benefits at time of exam

20. Record Reviews - Medications%
DDAVP
desmopressin acetate 11
31.43
Zyrtec 1
2.86
Trileptal 9
25.71
Zantac
Risperidal
Wellbutrin
Lexapro 8
22.86
Prozac
Zoloft 6
17.14
Prolixin
Depakote
Lithobid
Strattera 4
11.43
Haldol
Paxil
Effexor
Pamelor
Cogentin
Tenax 3
8.57
Avitan
Seroquel
Atenolol
Vistaril 2
5.71
Abilify
Desyrel

21. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data

22. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years

23. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type
57% (n = 32 exams) Law Enforcement
41% (n = 23 exams) mental health professional
2% (n = 1) judge

24. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type
57% (n = 32 exams) Law Enforcement
41% (n = 23 exams) mental health professional
2% (n = 1) judge
Evidence Type
88% (n = 49) Harm 2% (n = 1) Harm and Neglect
9% (n = 5) Neglect 2% (n = 1) No Evidence type

25. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type
57% (n = 32 exams) Law Enforcement
41% (n = 23 exams) mental health professional
2% (n = 1) judge
Evidence Type
88% (n = 49) Harm 2% (n = 1) Harm and Neglect
9% (n = 5) Neglect 2% (n = 1) No Evidence type
Harm Type
66% (n = 33) harm to self
24% (n = 12) harm to self and others
8% (n = 4) harm only

26. Record Reviews – Baker Act Data
32 children had ssn’s necessary for identification of Baker Act Data
These 32 children had 56 examinations over a period of almost three years
Certificate Type
57% (n = 32 exams) Law Enforcement
41% (n = 23 exams) mental health professional
2% (n = 1) judge
Evidence Type
88% (n = 49) Harm 2% (n = 1) Harm and Neglect
9% (n = 5) Neglect 2% (n = 1) No Evidence type
Harm Type
66% (n = 33) harm to self
24% (n = 12) harm to self and others
8% (n = 4) harm only
Repeated Examinations
1 exam 38% (n = 12) 5 exams: 3% (n = 1)
2 exams: 13% (n = 13) 7 exams: 9% (n = 3)
3 exams: 6% (n = 2)
4 exams: 3% (n = 1)

27. Archival Database Analyses

28. Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence

29. Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations
1 exam: 67% 4 exams: 3%
2 exams: 18% 5 or more: 5%
3 exams: 6%

30. Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations
1 exam: 67% 4 exams: 3%
2 exams: 18% 5 or more: 5%
3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = years

31. Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations
1 exam: 67% 4 exams: 3%
2 exams: 18% 5 or more: 5%
3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = years
Certificate Type
62% Law Enforcement
33% Mental Health Professional
4% Judges

32. Archival Database Analyses
1,559 children with 2,696 Baker Act examinations during three fiscal years (July 1999 through June 2002) in Pinellas County Facilities and/or with a Pinellas County Residence
Repeated Examinations
1 exam: 67% 4 exams: 3%
2 exams: 18% 5 or more: 5%
3 exams: 6%
Gender: 50% Male Age: Average age at time of first examination = years
Certificate Type
62% Law Enforcement
33% Mental Health Professional
4% Judges
Evidence Type
89% Harm Only
5% Neglect Only
4% Both Harm and Neglect
1% Evidence Type Missing

33. Baker Act Exams for Children in 2002 – By Month Statewide

34. Pinellas County Cross System Analysis
Data Set
Label
General Description of Data
Baker Act BA
A statewide database containing information about short-term, involuntary psychiatric examinations
Child Welfare
Data only available from July 1999 to Nov 2000 CW
A statewide databases containing child (only) information on abuse allegations and demographics (founded/unfounded investigation, type of abuse and results or actions taken)
Emergency Management System
EMS
Pinellas County-wide emergency medical service information system containing demographic and situational information on 911 calls where ambulance was sent out, whether or not someone was transported via ambulance.
Department of Children and Families Integrated Data System
IDS
An automated data system of the Florida Department of Children and Families containing information about alcohol, drug abuse & mental health services at state funded providers.
Medicaid Claims
MDC
A statewide database containing Medicaid physical and Mental health claims data

35. Pinellas County Cross System Analysis
The majority of children with a Baker Act examination in the three fiscal years also had data in one of the four other data systems
18% - only Baker Act data 8% other data systems
31% - 1 other data system 14% - 4 other data systems
29% - 2 other data systems N CW
IDS
MDC
EMS
All Children
1,559
27.33%
72.61%
40.99%
Girls
778
31.75%
68.51%
38.43%
Boys
781
22.92%
76.70%
43.53%

36. Archival Analyses – IDS Data Fiscal Years 1999, 2000 and 2001
Pinellas Statewide
41% % Crisis Support/Emergency
41% % Crisis Stabilization
18% % Medical Services
18% % Outpatient Individual
18% % Treatment Alternatives for Safer Communities
17% % In Home and Onsite Services
16% % Case Management
6% % Assessment
6% % Substance Abuse Detoxification
5% % Intervention
5% % Intensive Case Management

37. Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total Cost
Pinellas Statewide Pinellas Statewide
TOTAL COST FOR 3 YEARS $8.2 M $208 M
78% % Counseling Therapy and Treatment Services $505, $6.5 M
5.2% %
76% % Evaluation and Testing Service $155, $3.6 M
1.6% %
74% % Treatment Planning and Review $113, $1.7 M
1.2% %
45% % Targeted Case Management $1.7 M $22.8 M
17.6% %
40% % Children’s Behavioral Health $1.2 M $16.9 M
12.1% %
36% % Child Ancillary Inpatient Services $75, $1.8 M
0.8% %

38. Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total Cost
Pinellas Statewide Pinellas Statewide
34% % Hospital Outpatient Mental Health Services $96, $1.8
1.0% %
33% % Physician’s Services $24, $497,000
0.3% %
26% % Child Inpatient Care ` $1.7M $50.0 M
17.8% %
26% % Other Mental Health $74, $894,000
0.8% %
25% % Emergency Mental Health Services $18, $1.0 M
0.2% %
24% % Physician’s Services Clinic or Outpatient $16, $497,000
0.2% %

39. Archival Analyses – Medicaid Data Fiscal Years 1999, 2000 and 2001
% Children w/ Service Cost and % of Total Cost
Pinellas Statewide Pinellas Statewide
19% % Lab with Mental Health Diagnosis $4, $376,000
0.1% %
17% % Rehabilitative Services $115, $2.7 M
1.2% %
13% % Behavioral Health Overlay Services $608, $10.3 M
6.3% %
10% % Day Treatment Services $154, $6.3 M
1.6% %
6 % % Therapeutic Foster Care $1.5 M $22.3 M
15.9% %
6% % Substance Abuse Inpatient $156, $35.0 M
1.6% %

40. 7 Key Findings

41. Key Finding #1 – System Findings
Multiple programs are accessed by children at PEMHS
The type and timing of the services are based on factors such as whether children are in the dependency system, their legal status (voluntary vs. involuntary), their needed level and type of care, and availability of services
Interaction of staff from PEMHS and from the Family Continuity Program (FCP) is key to the access and continuity of care for some children

42. Key Finding #2 – Certificate and Evidence Type
Baker Act examinations of children were more likely to be initiated by law enforcement officials and to be based on evidence of harm than examinations for adults, suggesting that a focus on factors related to law enforcement initiated Baker Act examinations would help us to better understand examinations of children and associated factors

43. Key Findings #3 - Seasonality
The number of Baker Act examinations for children was less in the summer, both statewide and for Pinellas County
Although cause and effect cannot be determined from this correlational finding, they suggest some seasonality in Baker Act examinations for children and is highly suggested that school is involved in this seasonality

44. Key Findings #4 – Repeated Examination
Thirty-three percent of the children with a Baker Act examination over a three- year period in Pinellas County experienced more than one examination during this time period
Focused attention on this subset of children with multiple involuntary examinations is warranted, given that the purpose of crisis stabilization units is to offer emergent care – not the longer term care that may be needed by many of these children
Multiple examinations may suggest discontinuity of care
Additional focus on this subpopulation could yield information about the causes of repeated examinations and ways to intervene to prevent them

45. Key Findings #5 – History of Trauma
The finding that 40% or the children from the case studies had experienced sexual, physical and/or emotional abuse suggests that trauma is an important factor to address when planning and implementing care for some children who receive acute mental health care

46. Key Findings #6 – Therapeutic Foster Care
The 41 children who experienced at least one Baker Act examination over a three- year period in Pinellas County who also had Medicaid reimbursed therapeutic foster care accounted for 6% of the children with Medicaid reimbursed services, but their therapeutic foster care reimbursed care of over $1.5 million accounted for almost 16% of the cost of Medicaid reimbursed services
Almost 5% of children statewide with at least one Baker Act examination over a three-year period had Medicaid reimbursed therapeutic foster care services, at a cost of over $22 million representing almost 11% of Medicaid reimbursed services
The high cost of these services for a relatively small number of children, particularly in Pinellas County compared to statewide, suggests that a focus on healthcare needs for children in this group may be warranted
This may be particularly important within the current context of privatization of foster care across Florida and the focus on integration of the foster care and behavioral health care system

47. Key Findings #7 – Intensive Case Management
The use of case management and intensive case management is lower than we expected for the population of children who had contact with the involuntary, acute-care system
For example:
At least one case management claim over three years:
16% Pinellas
40% Statewide
At least one intensive case management claim over three years:
5% Pinellas
2% Statewide

48. Contact Information
Annette Christy
FMHI:
Baker Act Reporting Center:
Click on “Documents” link to go to page with pdf file of complete report
Collaborative for Children, Families and Communities: