Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health...

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

Susan StrombergChild, Adolescent, and Family Branch, SAMHSA

Jeffrey Lobas, MDChild Health Specialty Clinics

Gary LippeDept. of Human Services, NE Iowa

Comprehensive Community Mental Health Services for Children and Their Families(Systems of Care)

Susan Stromberg

October 16, 2007

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

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.

Systems of Care

Systems of Care Program Framework 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

System of Care Model

CHILDAND

FAMILY

MENTALHEALTH

SERVICES

EDUCATIONAL SERVICES

HEALTH SERVICES

SUBSTANCEABUSE

SERVICES

VOCATIONAL SERVICES

RECREATIONAL SERVICES

OPERATIONAL SERVICES SOCIAL

SERVICES

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!!+

System of Care Core Values

Community based

Child and family focused (family driven and youth guided)

Culturally and linguistically competent

System of Care Guiding Principles

Comprehensive array of services

Individualized care

Least restrictive setting

Family and youth involvement

Service integration

System of Care Guiding Principles

Care coordination Early identification and early

childhood intervention Smooth transitions Rights protection and

advocacy Nondiscrimination

System of Care Concept is…

A framework and guide, not a prescription

Flexible and creative

Adaptive to family and community needs

Consistent in philosophy

Systems of Care

Systems of Care Resilience, Leadership &

Transformation

Leadership

Transformation

Resilience

What is involved? Rethinking traditional

approaches

Strengths-based

Family driven & youth guided

Embracing culture

Who is involved? Youth

Adults

Families

Providers

Communities

Fulfilling Potential

Eastern Kentucky

North Carolina (10 counties)

California 5 (Santa Cruz,San Mateo, Riverside Ventura, &

Solano Counties)

Vermont 1 (statewide)

Lyons, Riverside, & Proviso, IL

Bismarck, Fargo, & Minot, ND

Northern Arapaho Tribe, WY

Sault Ste. Marie Tribe, MI

Rhode Island 2 (statewide)

Hillsborough County, FL

Charleston, SC

King County, WA

Clark County, WA

Clackamas County, OR

Vermont 2 (statewide)

Passamaquoddy Tribe, ME

Rhode Island 1 (statewide)

Maine (4 counties)

Edgecombe, Nash, & Pitt Counties, NC

Alexandria, VA

Baltimore, MD

South Philadelphia, PA

Mott Haven, NY

Detroit, MI

Northwoods Alliance, WIMilwaukee, WI

Navajo Nation

Sacred Child Project, ND

San Diego County, CA

Napa & Sonoma Counties, CA

Lane County, OR

Santa Barbara County, CA

Greenwood, SC

West Palm Beach, FL

Contra Costa County, CA

Birmingham, AL

North Carolina (11 counties)

Oglalla Sioux Tribe, SD

Lancaster County, NEWillmar, MN

Pima County, AZ

Marion County, IN

Charleston, WV

Montgomery County, MD

Delaware (statewide)

Burlington County, NJWestchester County, NY

Worcester, MANew Hampshire (3 regions)

Gwinnett & Rockdale Counties, GA

System-of-Care Communities of the Comprehensive Community Mental Health Services for Children and Their Families Program

United Indian Health Service, CA

Nebraska (22 counties)

San Francisco, CA

Clark County, NV

Rural Frontier, UT

Denver, CO

Las Cruces, NM

Wichita, KS

Parsons, KS

Travis County, TX

Sacramento County, CAGlenn County, CA

Colorado (4 counties)El Paso County, TX

Oklahoma

Ft. Worth, TX

Choctaw Nation, OK

St. Charles County, MOMissouri

Broward County, FL

Connecticut (statewide)

Washington, DC

New York, NY

Lake County, INIllinois (Chicago area)

Idaho

Wai'anae & Leeward, HI

Fairbanks, AK

Yukon Kuskokwim Delta Region, AK

Guam

Puerto Rico

Oakland, CA

Monterey County, CA

Four Counties, OR

Allegheny County, PA

Southern Consortium& Stark County, OH

Cuyahoga County, OH

Jackson, MSSt. Louis, MO

Nashville, TNLouisiana (5 parishes)

3 counties & Catawba Nation, SC

9-1-93 42-1-94 79-1-94 9

11-1-94 29-1-97 9

10-1-98 13 11-1-98 1

Date Number

Funded Communities

9-30-99 205-1-00 17-1-00 1

10-1-02 189-30-03 79-30-04 4

Date Number

Erie County, NY

Albany County, NY

Montana & Crow Nation

Kentucky(8 counties)

Systems of Care as a Transformation Strategy

• Customer focused

• Family driven

• Bridging Systems

Vision & Beliefs + Actions x (CQI)2

FamilyInvolvement

Moving from family involvement to family driven

Fully embracing youth involvement

Opening the data setEstablishing key benchmarks

Sustainability - defining how systems of care contribute

Integrating technical assistance activities

Moving from concept to reality. Tools & strategies

YouthInvolvement

TechnicalAssistance

Research

System of CareTransformation

CulturalCompetence

National Wraparound Initiative

Setting standards

Developing materials that are user-friendly

Embracing CQI and the Benchmarking Initiative

Continuous Quality Improvement

National T.A.Community ProgramAdministrators

ImprovementContinuous

Quality

Strategies to ImproveCultural Context

Program Performance

CQI Feedback

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%

Source and Item(s)

Enrollment and Demographic Information Form (EDIF): Item 14

Definition Percentage of cases where the caregiver participated in developing the child’s service plan.

Time period Intake into services

Calculation Number responding yes to edif14a or edif14c/# responses to edif14a and edif14c

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

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.

Beginnings

Youth MOVE

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/

Transformation Resources

Got a question about a family-driven, youth-guided system of care?

Start here

www.systemsofcare.samhsa.gov

Work togetherThere is strength in numbers…

System of Care: Partnership between SAMHSA, DHS,

and CHSC Jeffrey Lobas, MD, EdD.

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

Direct Services

Enabling Services

Population Based Services

Infrastructure Building

Title V Children with Special Health Care NeedsChild Health Specialty Clinics (CHSC)

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.

Creston

Council Bluffs

Carroll

Sioux City

Ft. Dodge

Spencer

Mason City

Oelwein

Ottumwa Burlington

Davenport

Iowa City

DubuqueWaterloo

Child Health Specialty Clinics

Regional Centers Satellite Centers Central Office

Sioux Center

Shenandoah

Des Moines

Elkader

Chariton

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

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

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

Focus Groups Structured Interviews with Families and

Community Leaders Outcome Research Flow and Time Studies Satisfaction Surveys

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

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%

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

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

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)

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.

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.

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

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

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

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

Oversight Committee Discussions between CHSC, DHS, SAMHSA Development of Proposal SAMHSA System of Care

Early

Identification

Children’s Mental Health System of Care

Primary Care

Schools

Mental HealthAgencies

JuvenileJustice

Child Welfare/DHS

Community

Families

Family/YouthAdvocacy Orgs

Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families


Evaluation, Assessment and Diagnosis Treatment and Care PlanImplementation

and Coordination

Monitor and

Follow-Up

Community Circle of Care


Multidisciplinary Team

Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up



Outreach/Lighthouse

Multidisciplinary TeamNavigator Team Navigator Team

Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up



Outreach/Lighthouse

Evaluation

and Dx

Rx and and Care

Plan

Family Team

Meeting

Care Coordination

(Process)

Navigator Team

Intake/

Triage

Monitor and

Feedback

Multidisciplinary Team Navigator Team

Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up



Subspecialty and Primary Care

Outreach/Lighthouse

Evaluation

and Dx

Rx Care Plan

Family Team

Meeting

Care Coordination

(Process)

Navigator Team

Intake/

Triage

Monitor and

Feedback


Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up




Community Based Wraparound Services

Outreach/Lighthouse

Evaluation

and Dx

Rx and Care Plan

Family Team

Meeting

Care Coordination

(Process)

Navigator Team

Intake/

Triage

Monitor and

Feedback


Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up





Emergency and Crisis Management

Outreach/Lighthouse

Evaluation

and Dx

Rx and Care Plan

Family Team

Meeting

Care Coordination

(Process)

Navigator’s Team

Intake/

Triage

Monitor and

Feedback

Multidisciplinary Team Navigator’s Team

Early

Identification


Primary Care

Schools


JuvenileJustice

Child Welfare/DHS

Community

Families



and Coordination

Monitor and

Follow-Up





Emergency and Crisis Management

Quality Assurance and Evaluation

Outreach/Lighthouse

Evaluation

and Dx

Treatment and Care

Plan

Family Team

Meeting

(Local)

Care Coordination

(Process)

Navigator Team

Intake/

Triage

Monitor and

Feedback


Partnership, Collaboration, Integration

DHSIowa Department of Human

Services


Systems of Care Work

ACCESS

Navigation

COORDINATION

INDIVIDUALIZED SUPPORTS

Systems of Care Professionals and Families

Share Common Goals

• We want children and youth to be in safe and stable homes

• We want to assist families to meet their children’s needs

• We seek family preservation or reunification if the child has been removed

Meeting the mental health needs of children, youth, and families is critical to achieving these goals

What Works?

• When children and youth with serious mental health needs receive coordinated services, their functioning substantially improves at school, at home, and in their community.

*Data Trends #104, September 2004, University of South Florida

A System of Care Is…A community partnership among families,

youth, schools, and public and private organizations which provide coordinated

mental health services. Our partners include:

• Families• Education• Provider Agencies• Mental health and substance

abuse professionals

• Juvenile justice• Primary health care• Faith community• Other community

organizations• Child welfare

• Family-driven and youth-guided• Researched and evidenced based• Supports Individualized for each family• Wrap around services provided• Culturally and linguistically competent• Community-based

A System of Care Is…Guided by Core Values

Benefit: Homes Are Stable

• The percentage of children and youth who lived in multiple settings decreased by 11 percent over 12 months.

Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005

• Caregiver strain is reduced in many families.

• More than a quarter of families had higher functioning after 30 months; more than half remained stable.

Source: CMHS National Evaluation: Aggregate Data Profile Report, 2005

Benefit: Families Are Stronger

• Caregiver job, vocational, and educational skills improve.

• Incomes increase.• Families have more time and support.

Sources: CMHS National Evaluation: Updates from the National Evaluation, Services Evaluation Committee Meeting, 2004CMHS National Evaluation: Aggregate Data Profile Report, 2004

Benefit: Families Have More Resources


A care coordination, wrap around

system of care


• Decisions about services are made based on what the family needs; funding is secured through the care coordinator which eliminates time and effort for the family.

• Services are identified and service gaps are filled whenever possible.

Outcome: Improved Access to Needed Services

• Decisions about services are family driven.

• Parent voice is integral to the developing system and to system change at the local and state level

• Families have access to other caregivers who have experience parenting a child with mental health and behavioral challenges.

Outcome: Empowered Caregivers

• Child welfare, health care, education, and mental health professionals work closely together.

• Mental health services are introduced in homes by system of care representatives including parents who have caregiver experience with a child who has mental health and behavioral challenges.

• Professionals who work in the system of care are offered technical assistance to better understand and serve their clients in a family centered approach.

• Needed child and family services are more accessible.

Outcome: Coordinated Services

• Early mental health intervention helps children, youth, and families stay together.

• Early mental health intervention reduces the length of time for out-of-home placement.

Outcome: Decreased Out-of-Home Placements

• Supports based on family needs• Wrap around services• Services developed in response to needs

Outcome: Individualized services and supports for each family

What Our Partnership Could Accomplish

• Coordinated, community-based services that support families in need

• Collaborative, individualized plans of action for families in their local community

• A community support structure that is accessible and family-focused

AMCHP Association of Maternal & Child Health Programs

Mental Health: Perspective of State Title V

AMCHP Association of Maternal & Child Health ProgramsTitle V Performance MeasuresSummary Numbers 200

12006

% Change

# of States with>1 perf. Measure relevant to mental health

24 36 50%

Total perf. Measures relevant to mental health across States/Territories

30 57 90%

# States/Territories with>1 priority need relevant to mental health

30 49 63%

Total # priority needs relevant to mental health across States/Territories

39 101 159%

AMCHP Association of Maternal & Child Health Programs AMCHP’s Role• AMCHP’s 2005-2009 strategic plan identified

emotional behavioral health as a priority focus area

• Develop Key Partnerships- Public Health, Mental Health Systems, Private Sector

• AMCHP in partnership working for policy and legislative reforms

• 2006 - AMCHP convened a series of meetings with NASHP, SAMHSA, MCHB to produce “roadmap”

• Developing common set of principles

AMCHP Association of Maternal & Child Health Programs Key Partners• Maternal and Child Health Bureau• Substance Abuse and Mental

Health Services Administration• National Academy of State Health

Policy• Georgetown Child Development

Center• Family Voices• Federation of Families

AMCHP Association of Maternal & Child Health ProgramsA Common Set of Principles• A continuum of services relating to

mental health;• Strengthening the interface between

public health and mental health, including prevention

• Increasing protective factors and risk reduction.

• Mental Health and Primary Care (Medical Home)

AMCHP Association of Maternal & Child Health ProgramsCurrent Activities

• Developing A Public Health Approach to Mental Health

• Collecting and Disseminating Best Practice Models

• Development of Monograph– Conceptual Framework for PH

approach– Continuum of Services– Common language

AMCHP Association of Maternal & Child Health ProgramsNext Step: Engagement• Strategies to Engage Stakeholders

formally and informally– Stakeholder Meeting– Focus Groups– Interviews– Document Review– Surveys– Presentations

AMCHP Association of Maternal & Child Health ProgramsChallenges for Leadership• Dialogue between cultures• Trust and understanding• Value

Susan Stromberg Child, Adolescent, and Family Branch, SAMHSA Jeffrey Lobas, MD Child Health...

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