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 ServicesSubstance Abuse and Mental Health Services Administration

“I think you should be more explicit here in Step Two.”

Secret Formula for Transformation

Child, Adolescent Service System Program (CASSP) – 1984 –

Comprehensive Community Mental Health Services Program for Children and Their Families

– 1993 –

Circles of Care– 1998 –

Beginnings ~Beginnings ~

Fiscal Year (FY) 2005 budget

$106,000,000

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, CANapa & Sonoma Counties, CAWai‘anae & Leeward, HILyons, Riverside, & Proviso, ILSedgwick County, KSSoutheastern KansasMaine (4 counties)Baltimore, MDNavajo NationLas Cruces, NMMott Haven, NYEdgecombe, Nash, & Pitt Counties, NCBismarck, Fargo, & Minot, NDSouthern Consortium & Stark County, OHLane County, ORSouth Philadelphia, PARhode Island 1 (statewide)Charleston, SCAlexandria, VAVermont 1 (statewide)Milwaukee, WI

Phase II (1997–2004)Birmingham, ALSan Diego County, CAHillsborough County, FLEastern KentuckyPassamaquoddy Tribe, MEDetroit, MISault Ste. Marie Tribe, MISt. Charles County, MOLancaster County, NENebraska (22 counties)Clark County, NVNorth Carolina (11 counties)Sacred Child Project, NDClackamas County, ORAllegheny County 1, PARhode Island 2 (statewide)Travis County, TXRural Frontier, UTVermont 2 (statewide)Clark County, WAKing County, WAWisconsin (6 counties)Northern Arapaho Tribe, WY

Phase III (1999–2006)Yukon Kuskokwim Delta Region, AKPima County, AZContra Costa County, CAUnited Indian Health Service, CADenver area, CODelaware (statewide)West Palm Beach, FLGwinnett & Rockdale Counties, GALake County, INMarion County, INMontgomery County, MDWorcester, MAWillmar, MNHinds County, MSNew Hampshire (3 regions)Burlington County, NJWestchester County, NYNorth Carolina (11 counties)Greenwood, SCOglalla Sioux Tribe, SDNashville, TNCharleston, WV

Phase IV (2002–2010)Fairbanks Native Association, AK

Glenn County, CAMonterey, CA

Sacramento County, CASan Francisco, CA

Urban Trails, Oakland, CAColorado (4 counties)

Connecticut (statewide)Washington, DC

Broward County, FLGuamIdaho

Chicago, ILNorthern Kentucky

Southeastern LouisianaSouthwest Missouri

St. Louis, MOMontana & Crow Nation

Albany County, NYErie County, NY

New York, NYCuyahoga County, OH

Choctaw Nation, OKOklahoma (5 counties)

Mid-Columbia Region (4 counties), ORPuerto Rico

South Carolina (3 counties & Catawba Nation)

El Paso County, TXFt. Worth, TX

Phase V (2005–2011)Mississippi River Delta area, AR

Butte County, CACalifornia Rural Indian Health Board,

Inc., CALos Angeles County, CA

Placer County, CASoutheastern Connecticut

Sarasota County, FLHonolulu, HI

McHenry County, ILAugusta area, ME

Worcester County, MAIngham County, MI

Kalamazoo County, MIMinnesota (4 counties)

Blackfeet Tribe, MTMonroe County, NY

Mecklenburg County, NCMultnomah County, ORAllegheny County 2, PA

Beaver County, PARhode Island 3 (statewide)

Yankton Sioux Tribe, SDMaury County, TNHarris County, TX

Wyoming (statewide)

~ 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.”

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

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

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

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.

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.

Youth Guided means that youthtake the lead in…

Educating all professionals and adults who work with young people on the importance of engaging and empowering youth.

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/

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.

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

Clinical Excellence

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

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)

3.6

1.8

0.0

1.0

2.0

3.0

4.0

Time

Me

an

# o

f d

ay

s

Intake 12 months

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

0.5

0.3

0.0

0.5

1.0

Time

Me

an

# o

f a

rre

sts

in

pa

st

6 m

o. Intake 12 months

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

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 ParticipantFunded 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.

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

Changes in Juvenile Justice Involvement Rates over Time

9.5%

66.8%

13.7%

46.5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Jefferson Montgomery

Per

cen

t

Intake 18 months

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.

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!

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.

How

How

can are

we

we

improve? doing?

Family-driven

Youth-guided

Cultural &

linguistic

competence

Evidence-

based / Clinical

excellence

Continuous

quality

improvement

Transformation Score Card

From Ordinary…

To Extraordinary…

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

Turn a

bad hair

day into

a new

style…

Remember, Rededicate, Rejoice & Transform