Creating a System of Care: A Partnership Between Title V and SAMHSA

1. Creating a System of Care:A Partnership Between Title V and SAMHSA Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health Specialty Clinics Gary Lippe Dept. of Human Services, NE Iowa

2. Comprehensive Community Mental Health Services for Children and Their Families(Systems of Care) Susan Stromberg October 16, 2007

3. The Comprehensive Community Mental Health Services for Children and Their Families Program (Children’s Program) • Encourages the development of home and community-based systems of care • SOCs meet the needs of children and adolescents with serious emotional disturbances and their families • SOC communities are administered in States, political subdivisions of States, Native American tribes or tribal organizations, and U.S. territories

4. Systems of Care • Systems of care are developed on the premise that the mental health needs of children, adolescents, and their families can be met within their home, school, and community environments. • These systems are developed around the following principles: • child-centered • family-driven • strength-based • culturally competent • Additionally, interagency collaboration is embedded within these systems.

5. Accountability through outcome evaluation Comprehensive array of services Cross-agency coordination Cultural competence Early identification and intervention Family partnerships Home and community-based services Least restrictive service environments Strength-based individualized service planning Systems of Care Program Framework

6. MENTAL HEALTH SERVICES OPERATIONAL SERVICES SOCIAL SERVICES CHILD AND FAMILY RECREATIONAL SERVICES EDUCATIONAL SERVICES VOCATIONAL SERVICES HEALTH SERVICES SUBSTANCE ABUSE SERVICES System of Care Model

7. Do the Math. Children’s Mental Health suffering from a lack of: • services for children & adolescents • non-restrictive settings • full community-based service array • interagency coordination • family involvement • cultural competence Need for SYSTEMS OF CARE!! +

8. System of Care Core Values • Community based • Child and family focused (family driven and youth guided) • Culturally and linguistically competent

9. System of Care Guiding Principles • Comprehensive array of services • Individualized care • Least restrictive setting • Family and youth involvement • Service integration

10. System of Care Guiding Principles • Care coordination • Early identification and early childhood intervention • Smooth transitions • Rights protection and advocacy • Nondiscrimination

11. System of Care Concept is… • A framework and guide, not a prescription • Flexible and creative • Adaptive to family and community needs • Consistent in philosophy

12. Systems of Care Resilience, Leadership & Transformation What is involved? • Rethinking traditional approaches • Strengths-based • Family driven & youth guided • Embracing culture Who is involved? • Youth • Adults • Families • Providers • Communities Transformation Systems of Care Leadership Resilience Fulfilling Potential

13. Systems of Care Resilience, Leadership & Transformation What is involved? • Rethinking traditional approaches • Strengths-based • Family driven & youth guided • Embracing culture Who is involved? • Youth • Adults • Families • Providers • Communities Transformation Systems of Care Leadership Resilience Fulfilling Potential

14. System-of-Care Communities of the Comprehensive Community Mental Health Services for Children and Their Families Program Lyons, Riverside, & Proviso, IL Milwaukee, WI Illinois (Chicago area) Northwoods Alliance, WI Lake County, IN Willmar, MN Sault Ste. Marie Tribe, MI Albany County, NY Lancaster County, NE Marion County, IN Nebraska (22 counties) Detroit, MI Bismarck, Fargo, & Minot, ND Cuyahoga County, OH Sacred Child Project, ND Southern Consortium & Stark County, OH Oglalla Sioux Tribe, SD Northern Arapaho Tribe, WY Allegheny County, PA Passamaquoddy Tribe, ME Montana & Crow Nation Maine (4 counties) u Erie County, NY Vermont 1 (statewide) King County, WA u Vermont 2 (statewide) New Hampshire (3 regions) Clark County, WA u u Worcester, MA u Four Counties, OR u Rhode Island 1 (statewide) u Clackamas County, OR Rhode Island 2 (statewide) u u Lane County, OR Connecticut (statewide) Idaho Mott Haven, NY u New York, NY United Indian Health Service, CA Westchester County, NY u Burlington County, NJ u South Philadelphia, PA Glenn County, CA Delaware (statewide) Sacramento County, CA u u Baltimore, MD Napa & Sonoma Counties, CA Montgomery County, MD Contra Costa County, CA u Washington, DC u u Oakland, CA Alexandria, VA San Francisco, CA Charleston, WV u Monterey County, CA Edgecombe, Nash, & Pitt Counties, NC u California 5 (Santa Cruz, San Mateo, Riverside Ventura, & Solano Counties) North Carolina (11 counties) North Carolina (10 counties) Santa Barbara County, CA u 3 counties & Catawba Nation, SC Clark County, NV u Charleston, SC San Diego County, CA Greenwood, SC Rural Frontier, UT Gwinnett & Rockdale Counties, GA Pima County, AZ Navajo Nation Eastern Kentucky u Las Cruces, NM u Hillsborough County, FL El Paso County, TX Kentucky (8 counties) West Palm Beach, FL Colorado (4 counties) Birmingham, AL Denver, CO Broward County, FL Yukon Kuskokwim Delta Region, AK Nashville, TN Wichita, KS Louisiana (5 parishes) Oklahoma Funded Communities Fairbanks, AK Jackson, MS Travis County, TX St. Louis, MO Date Number Date Number Ft. Worth, TX St. Charles County, MO Parsons, KS 9-1-93 4 2-1-94 7 9-1-94 9 11-1-94 2 9-1-97 9 10-1-98 13 11-1-98 1 9-30-99 20 5-1-00 1 7-1-00 1 10-1-02 18 9-30-03 7 9-30-04 4 Wai'anae & Leeward, HI Guam Missouri Choctaw Nation, OK Puerto Rico u u u

15. System of CareTransformation CulturalCompetence Systems of Care as a Transformation Strategy Vision & Beliefs+Actionsx(CQI)2 Moving from family involvement to family driven FamilyInvolvement • Customer focused • Family driven • Bridging Systems YouthInvolvement Fully embracing youth involvement Integrating technical assistance activities TechnicalAssistance Opening the data set Establishing key benchmarks Research Sustainability - defining how systems of care contribute Moving from concept to reality. Tools & strategies

16. National Wraparound Initiative • Setting standards • Developing materials that are user-friendly

17. Continuous Quality Improvement • Embracing CQI and the Benchmarking Initiative

18. Continuous Quality Improvement Community ProgramAdministrators National T.A. Program Performance Strategies to Improve Cultural Context CQI Feedback

19. Indicator 32 - Caregiver and Other Family Involvement in Service Plan Increase family involvement in developing the service plan, either through attending planning meetings or approving treatment plans. Benchmark: 100%

20. Systems of Care Work! • Reductions in use of restrictive levels of care and residential placements across systems • Cost reductions and cost avoidance • Improved clinical and functional status • Decreased juvenile recidivism and incarceration • Improved school attendance and achievement

21. Family driven means… • 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.

22. Beginnings Youth MOVE

23. 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/

25. Transformation Resources Got a question about a family-driven, youth-guided system of care? Start here www.systemsofcare.samhsa.gov

26. Work togetherThere is strength in numbers…

27. System of Care: Partnership between SAMHSA, DHS, and CHSC Jeffrey Lobas, MD, EdD.

29. Child Health Specialty Clinics Iowa’s Title V Agency for Children with Special Health Care Needs Funded through IDPH, categorical grants, contracts, reimbursement for services Administratively housed in the Dept. of Pediatrics at the University of Iowa

30. Title V Children with Special Health Care Needs Child Health Specialty Clinics (CHSC) Direct Services Enabling Services Population Based Services Infrastructure Building

31. CHSC Mission The Child Health Specialty Clinics (CHSC) mission is to improve the health, development, and well-being of children and youth with special health care needs in partnership with families, service providers, communities and policy makers.

33. Child Health Specialty Clinics Mason City Spencer Sioux Center Oelwein Elkader Dubuque Ft. Dodge Waterloo Sioux City Carroll Iowa City Des Moines Davenport Council Bluffs Chariton Creston Burlington Ottumwa Shenandoah Regional CentersSatellite CentersCentral Office

34. Some of the Programs and Services CHSC Offers • ABCD II Project • Birth to Five Services • Health and Disease Management • Continuity of Care Program • Family to Family Support • Integrated Evaluation and Planning Clinics • Regional Autism Services Program • Telehealth • Iowa Medical Home Initiative • Early ACCESS

35. History of CHSC and Children’s Mental Health 1997-Needs Assessment 1999-Future Search 2001-Governor’s White Paper 2002-Creston Project 2003-Magellan and CHSC 2004-CHSC Statewide Implementation 2005-Oversight Committee 2007-SAMHSA System of Care

36. Creston Project Evaluation of Statewide Services Research on a Delivery Model Statewide Implementation “Spread Strategy” Collaborative approach

37. Evaluation of Service Delivery for CHSC Focus Groups Structured Interviews with Families and Community Leaders Outcome Research Flow and Time Studies Satisfaction Surveys

38. Patient Data Patients seen July 2004 – June 2005 Burlington 85 Carroll 84 Council Bluffs 119 Creston 196 Davenport 20 Dubuque 71 Fort Dodge 219 Mason City 555 Ottumwa 175 Sioux City 150 Spencer 631 Waterloo 16 Total 2321

39. Most Common Primary Diagnosis at CHSC ADHD (all types) 63% Conduct / Oppositional Defiant Disorders 7% Reaction Attachment Disorders 5% Developmental Disorders 4% PDD Spectrum and other Child Psychosis 3% Total with behavioral or mental health diagnosis 93%

40. Outcomes Research Key Components of Intervention Model • Multidisciplinary Team • Enhanced care coordination. • Initial on-site psychiatric assessments, if indicated by intake procedures; • Telehealth/telepsych patient follow-ups; • Telehealth consultations to primary care and other service providers; • Educational events targeting service providers; • Best practice/care guidelines; • Systemic data collection regarding patient/family outcomes and service delivery processes; and • A community advisory board and consumer participation

41. Enhanced Care Coordination Care Plan development Arrangement of Service Delivery Alignment of advocacy across systems Collaboration with family and physicians Crisis intervention plan Follow-up with family and team

42. CANS DATA Degree of Clinical Change (percent) at Discharge for Children who Received CBHP vs. Usual Care Enhanced Program • Dimensions Key Components (1-8) Usual Care (N=25)   (N=34)  Problems* 4% -30%  Mental health* 3% -23%  Substance use* 22% -56%  Risk Behaviors 10% -4%  Functioning* 24% -18%  Caregiver capacity* 11% -7%  Strengths 9% -9%   *significant difference between groups (p<.05) 

43. CANS DATA • Children who received CBHP services were more severe from children who received usual care across several factors including: • Being more often abused (68% v. 8%) • Had used psychiatric inpatient care (24% v. 0%) This increasing identification of children with complex behavioral health needs significantly affected the potential degree of clinical change at discharge. As a result, the CBHP was the most effective model in improving both the functional and strengths/supports dimensions in CANS-MH scores.

44. CANS DATA • CANS-MH score results from the CBHP data is comparable to a recent comprehensive review of level of care needs across the New York state system of mental health utilizing the CANS instrument. • Data suggests that IEPC is similar to the intensity of services provided by the Intensive Case Management levels of care in New York.

45. Findings • A multidisciplinary team approach was very effective • Care coordination and follow-up of services was important to patient outcomes • Appropriate triage at intake yielded greater efficiency and more effective results to patients • Tele-health is an extremely valuable tool in providing services to underserved areas of the state • Clinical guidelines enhance care

46. Findings • There is great variability among regional centers in many areas which makes quality assurance difficult to achieve • The role and methods of triage has to be standardized and more training needs to be provided • Increased cost efficiency can be gained through standardized methods of triage, appropriate use of team, standardization of forms and dictation methods and gaining reimbursement for services by non-physician providers • Highest level of unmet need was identified as availability of child psychiatry

47. Conclusions • A standardized approach is needed at all centers which would include: • Comprehensive triage and follow-up plan • Availability of a multidisciplinary team at each regional center • Utilization of standardized history forms and clinical tools - Vanderbilt; CHSC Med Hx; Beh Hx; Social Hx: and School Hx forms • Standardized dictation methods into the PEDS centralized transcription and issuance of reports

48. CHSC Challenges and Barriers Inadequate Resources (Long-waiting lists) Minimal services available Emergency and Crisis Intervention Wrap-around Services Social Marketing and Outreach

49. Evolution of Service Model Oversight Committee Discussions between CHSC, DHS, SAMHSA Development of Proposal SAMHSA System of Care

50. Children’s Mental Health System of Care Early Identification Primary Care Schools Juvenile Justice Child Welfare/ DHS Community Mental Health Agencies Families Family/Youth Advocacy Orgs