1. Transforming Children’s Mental Health Care in America April 20, 2006 Gary M. Blau, Ph.D. Child, Adolescent and Family Branch Center for Mental Health Services Substance Abuse and Mental Health Services Administration

2. “I think you should be more explicit here in Step Two.” Secret Formula for Transformation

3. Child, Adolescent Service System Program (CASSP) – 1984 – Comprehensive Community Mental Health Services Program for Children and Their Families – 1993 – Circles of Care – 1998 – Beginnings ~

4. Fiscal Year (FY) 2005 budget $106,000,000

5. System-of-Care Communities of the Comprehensive Community Mental Health Services for Children and Their Families Program Phase I (1993–1999) California 5 (Riverside, San Mateo, Santa Cruz, Solano, & Ventura Counties) Santa Barbara County, CA Napa & Sonoma Counties, CA Wai‘anae & Leeward, HI Lyons, Riverside, & Proviso, IL Sedgwick County, KS Southeastern Kansas Maine (4 counties) Baltimore, MD Navajo Nation Las Cruces, NM Mott Haven, NY Edgecombe, Nash, & Pitt Counties, NC Bismarck, Fargo, & Minot, ND Southern Consortium & Stark County, OH Lane County, OR South Philadelphia, PA Rhode Island 1 (statewide) Charleston, SC Alexandria, VA Vermont 1 (statewide) Milwaukee, WI Phase II (1997–2004) Birmingham, AL San Diego County, CA Hillsborough County, FL Eastern Kentucky Passamaquoddy Tribe, ME Detroit, MI Sault Ste. Marie Tribe, MI St. Charles County, MO Lancaster County, NE Nebraska (22 counties) Clark County, NV North Carolina (11 counties) Sacred Child Project, ND Clackamas County, OR Allegheny County 1, PA Rhode Island 2 (statewide) Travis County, TX Rural Frontier, UT Vermont 2 (statewide) Clark County, WA King County, WA Wisconsin (6 counties) Northern Arapaho Tribe, WY Phase III (1999–2006) Yukon Kuskokwim Delta Region, AK Pima County, AZ Contra Costa County, CA United Indian Health Service, CA Denver area, CO Delaware (statewide) West Palm Beach, FL Gwinnett & Rockdale Counties, GA Lake County, IN Marion County, IN Montgomery County, MD Worcester, MA Willmar, MN Hinds County, MS New Hampshire (3 regions) Burlington County, NJ Westchester County, NY North Carolina (11 counties) Greenwood, SC Oglalla Sioux Tribe, SD Nashville, TN Charleston, WV Phase IV (2002–2010) Fairbanks Native Association, AK Glenn County, CA Monterey, CA Sacramento County, CA San Francisco, CA Urban Trails, Oakland, CA Colorado (4 counties) Connecticut (statewide) Washington, DC Broward County, FL Guam Idaho Chicago, IL Northern Kentucky Southeastern Louisiana Southwest Missouri St. Louis, MO Montana & Crow Nation Albany County, NY Erie County, NY New York, NY Cuyahoga County, OH Choctaw Nation, OK Oklahoma (5 counties) Mid-Columbia Region (4 counties), OR Puerto Rico South Carolina (3 counties & Catawba Nation) El Paso County, TX Ft. Worth, TX Phase V (2005–2011) Mississippi River Delta area, AR Butte County, CA California Rural Indian Health Board, Inc., CA Los Angeles County, CA Placer County, CA Southeastern Connecticut Sarasota County, FL Honolulu, HI McHenry County, IL Augusta area, ME Worcester County, MA Ingham County, MI Kalamazoo County, MI Minnesota (4 counties) Blackfeet Tribe, MT Monroe County, NY Mecklenburg County, NC Multnomah County, OR Allegheny County 2, PA Beaver County, PA Rhode Island 3 (statewide) Yankton Sioux Tribe, SD Maury County, TN Harris County, TX Wyoming (statewide)

6. ~ Achieving the Promise: Transforming Mental Health Care in America ~ “We envision a future when everyone with a mental illness will recover, a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports - essentials for living, working, learning, and participating fully in the community.”

7. The Federal Action Agenda Key Points Mental illness & emotional disturbances are treatable National Strategy for Suicide Prevention Help states implement comprehensive state mental health plans Mental health practice that is culturally competent and evidence-based Improve interface between primary care & mental health services Focus on early intervention Expand “Science-to-Services agenda Increase employment of people with psychiatric disabilities Information system to better manage services & improve confidentiality

8. T = (V+B+A) x (CQI) 2

9. Child, Adolescent & Family Level Create positive experience with services & supports Promote family strengths Develop child & youth potential & well- being Practice Level Ensure effective and accessible service delivery Ensure sufficient and trained workforce Promote culturally & linguistically responsive service practices System Level Raise awareness about child & youth mental health issues Ensure collaborations to integrate mental health as a component in overall health Ensure access to resources to address child and family mental health issues Programs Children’s Mental Health Initiative Circles of Care Partnerships for Youth Transition Statewide Family Networks Child & Adolescent State Infrastructure Grants Branch Functions Technical Assistance for grant preparation Oversee all implementation requirements of grants, cooperative agreements and contracts Extensive Partner Network Communications Technical Assistance Research / Evaluation Agreements with other federal agencies Child, Adolescent & Family Level Significant improvement in behavior & emotional functioning of children Increased satisfaction with services Family & youth have a decision- making role in service planning Practice Level Increased use of evidence-based practice Increased workforce training Practice reflects the cultural and linguistic characteristics of the population being served System Level Increased sustainability of grantees Increased collaboration across federal agencies Sustained or increased funding available for the support of programs

11. 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.

12. Family driven means that families take the lead in… Choosing supports, services, and providers; Setting goals; Designing and implementing programs; Monitoring outcomes; and Determining the effectiveness of all efforts to promote the mental health and well being of children and youth.

13. Youth Guided means that youth take the lead in… Educating all professionals and adults who work with young people on the importance of engaging and empowering youth.

14. 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. http://www.tapartnership.org/

15. Cultural & Linguistic Competence Reduce disparities and enhance cultural and linguistic competence among policy-makers, administrators and service providers. Enhance organizational capacity for cultural and linguistic competence. Increase awareness and knowledge of factors that contribute to disparities. Develop specific approaches that contribute to the goal of eliminating disparities.

16. Promote the active training of providers on state-of-the art, culturally and linguistically competent clinical practice. Clinical Excellence

17. Promote the local and national evaluation of research data to identify evidence-based practices.Develop a research agenda to enhance the understanding of how to develop and provide effective, efficient and coordinated services within Systems of Care. Priority list of research areas to guide the national evaluation. Searchable electronic knowledge management system. Infrastructure for supporting activities of a National Evaluation Data Users Group. CQI report card. Evidence Based Practice

18. Through Fiscal Year (FY) 2005: 73,383 children served Average # of children served per year = 11,278 Average Federal expenditure per child across program years = $13,039 or ~ $150/week in services per child (estimated length of stay ~ 17 months)

19. Cost Savings from Reduction in Inpatient Hospitalization: Intake to 12 Months* (n =3,563) * Average difference in inpatient hospitalization days multiplied by the national daily cost estimate. The Agency for Healthcare Research and Quality (AHRQ) estimated the national average daily cost of inpatient hospital care in 2002 was $1,501 per day (AHRQ, 2004). Average per child cost savings = $2,776.85

20. Cost Savings from Reduction in Arrests: Intake to 12 Months* (n =3,563) * Average difference in number of arrests multiplied by the national cost estimate. The Bureau of Justice Statistics estimated the average cost per juvenile arrest was $4,149 in 2000 (CASA, 2004). Average per child cost savings = $784.16

21. Adjusted and Unadjusted Between-Site Differences in Expenditures: Entry to 12 Months * $1579 $-687 $-60 $294 $-258 $868 $-102 Core MHS Juvenile Justice Child Welfare Special Education Inpatient MHS All Sectors (Unadjusted) All Sectors (Propensity Score) $0$500$1000$1500$2000$-500$-1000 Average Costs Per Participant  Funded community spent more on mental health and special education per child.  Comparison community spent more on juvenile justice, child welfare and inpatient per child.  After statistical adjustment, overall costs across all sectors essentially the same.

22. Reduction of Juvenile Justice Involvement  Initial involvement and recidivism rates for serious crimes decreased significantly in funded community.  Recidivism rates for serious crimes increased in comparison community

23. Changes in Juvenile Justice Involvement Rates over Time The proportion of youth charged with crimes decreased significantly* during the first 18 months of services in the Jefferson county system of care. Conversely, the rates of juvenile justice involvement among youth in Montgomery county increased.

24. Continuous Quality Improvement (2) It is imperative that we apply a CQI mindset to every initiative, program, or practice approach we take. We must constantly be asking ourselves “How can we make what we are doing better?” CQI - requires that you raise the bar even higher, and ask yourself how you could make it even better!

25. Specific continuous quality improvement efforts Startup Teams for new sites Expanding populations of concern for system of care communities Expanding target population to include those youth who have, or who are at risk of having a serious emotional or behavioral disorder Advancing the concepts of Family Involvement/ Family –Driven & Youth Guided within the systems of care. Reducing disparities and enhancing cultural and linguistic competence within the Comprehensive Children’s Mental Health program. Developing a research agenda to enhance the understanding of how to develop and provide effective, efficient and coordinated services within systems of care.

26. HowHow can are we weimprove? doing? Family-driven Youth-guided Cultural & linguistic competence Evidence- based / Clinical excellence Continuous quality improvement Transformation Score Card

27. From Ordinary…

28. To Extraordinary…

30. Remember ~ youth and families are at the core of all that we do Rededicate ~ to system of care values and principles Rejoice ~ Our accomplishments, our spirit, and our resiliency Oh yeah, have some fun… but don’t play with Kryptonite

31. Turn a bad hair day into a new style… Remember, Rededicate, Rejoice & Transform