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Taking Action to Transform Childrens Mental Health

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Title: Taking Action to Transform Childrens Mental Health


1
Taking Action to Transform Childrens Mental
Health
  • Larke Nahme Huang, Ph.D.
  • American Institutes for Research
  • Presentation for
  • Childrens Mental Health Voice of Florida
  • Statewide Summit
  • January 10-11, 2006

2
Overview
  • Where we are selected findings in childrens
    mental health
  • How can we transform mental health care for
    children, youth and their families?
  • Whats happening around the country?
  • Creating and sustaining momentum for
    transformation

3
Where we are
4
Selected National Findings A Public Health
Crisis in Mental Health
  • 20 adults/children have a mental health problem
  • ½ have a serious emotional disorder
  • 13 of preschoolers have emotional/behavioral
    disorder
  • 20 million suffer from serious disabling mental
    illness
  • Suicide 30,000 a year 80/day
  • 40 had contact with primary care provider
    within the last month
  • Adolescents 15-19y/o 3rd leading cause of
    death 17-19 think about killing themselves
    5-8 make attempt only 1/3 get treatment
  • YET,
  • Only half of individuals with serious mental
    illness get treatment, services or supports

5
Childrens Use of Mental Health Services
Number of Youth Admitted for Mental Health
Service in the US.
Cases of Mental Health Service Use per 100,000 US
Youth Population
1,318,722
86.3
1,897
69.7
707,854
1,118
1986
1997
1997
1986
Inpatient Outpatient MH Clinic Services
Only Dept. HHS, Rutgers Univ., Annie Casey
Foundation, 2002
6
Selected Findings for Youth
  • Of children with serious emotional/behavioral
    disorders 50 drop-out of high school (compared
    to 30 of students with other disabilities) (U.S.
    Dept of Education, 2001)
  • Youth entering Juvenile Justice 66-75 have
    serious emotional problems (Coalition on Juvenile
    Justice Teplin, 2002)
  • 1/3 children in mental health system have a
    co-occurring disorder (age 11 age 17-18 SA)
    (Kessler)
  • (SAMHSA, 2005)

7
Selected Findings for Youth
  • 500,000 children in foster care estimates up to
    40-80 have emotional/behavioral and/or substance
    abuse problem
  • 44
  • highest of
  • of Latino youth in foster care, 57 (The AFCARS Report  Preliminary FY 2001
    Estimates as of March 2003.  Washington, D.C.,
    DHHS, 2003.  ( latest federal statistics  on
    foster care supplied by the states for the
    Adoption and Foster Care Analysis and Reporting
    System Zero to Three)

8
Disparities for Children of Diverse Racial and
Ethnic Groups
  • Black and Latino kids identified/referred at same
    rates as general population, but less likely to
    receive specialty mental health or meds
    (Kelleher, 2000)
  • African American and Latino children have highest
    rates of unmet need (Sturm, 2000)
  • Asian American and Latino female teens have
    highest rates of depression (Commonwealth Fund,
    1997)
  • 1 of 5 Latina teens makes a suicide attempt
    (CDCP, 2005)
  • Minority children tend to receive mental health
    services through juvenile justice and child
    welfare systems more often than through schools
    or mental health setting (Alegria, 2000)
  • In child welfare, minority youth have poorer
    outcomes, fewer services, less likely to have
    plans for family contact and more likely to be in
    out-of-home placements (Courtney et al, 1996).

9
How can we transform mental health care?
10
Transformative Concepts
  • New Freedom Commission
  • Resiliency and Recovery
  • Family-Driven Care
  • Using What Works
  • Harnessing Technology
  • Public health framework
  • promotion,
  • prevention,
  • early identification,
  • intervention,
  • aftercare
  • Builds on Systems of Care Values/Principles
    Customized to Local/State Community
  • strengths-based, individualized,
  • family-driven, youth-guided, culturally
    competent,
  • community-based, coordinated services and
    supports across agencies

11
1. Resiliency and Recovery
  • Work toward goal of resiliency/recovery
  • Identify and build on strengths of youth and
    family
  • Outcomes are different, including optimism,
    quality of life as legitimate outcomes
  • Strengthening protective factors, e.g., family
    community assets

12
2. Family-Driven Care
  • Families have a voice
  • choosing supports, services, and providers
  • setting goals
  • designing and implementing programs
  • monitoring outcomes
  • determining the effectiveness of all efforts to
    promote the mental health and well being of
    children and youth

13
How Do We Operationalize Family-Driven?
  • Families and Youth
  • Have accurate, understandable, and complete
    information necessary to make choices
  • Share decision-making and responsibility for
    outcomes with providers.
  • Are organized to collectively use their knowledge
    and skills as a force for systems transformation.
  • Engage in peer support activities to reduce
    isolation, gather and disseminate accurate
    information, and strengthen the family voice.
  • Attitude shift professionals as partners

SAMHSA Focus Groups Blau, Osher 2005
14
How Can We Make It Work?
  • Providers
  • Embrace the concept of sharing decision-making
    authority and responsibility.
  • Providers take the initiative to change practice
    from provider-driven to family-driven.
  • Administrators and Staff
  • Share power, resources, authority,
    responsibility, and control with families and
    youth.
  • Administrators allocate staff, training, support
    and resources to make family-driven practice work

15
How Can We Make It Work?
  • Communities
  • Change efforts focus on removing barriers and
    discrimination created by stigma.
  • Values shift from blaming to strengthening
    families
  • Everyone who connects with children, youth, and
    families continually advance their cultural and
    linguistic responsiveness as the population
    served changes.

16
How Can We Make It Work?
  • Policies
  • Family-run organizations receive resources and
    funds to support and sustain the infrastructure
    that is essential to insure an independent family
    voice in their communities, states, tribes,
    territories, and the nation.
  • Meetings and service provision happen in
    culturally and linguistically competent
    environments where family and youth voices are
    heard and valued, everyone is respected and
    trusted, and it is safe for everyone to speak
    honestly.
  • Whole family approach to care
  • Response to changing demographics
    family-driven care for all families?

17

How Can We Make It Work?
DSS
DJS
PS
MH
CH F
I A
L MI
D LY
R. Crowel, 2005
18
How Can We Make It Work?
H/MH
Legal
CHILD FAMILY
ED/ VOC
Case Mgmt
CW
Rec
19
How Can We Make It Work?
  • MEDICAID
  • Medicaid Inpatient
  • Medicaid Outpatient
  • Medicaid Rehab. Svcs.
  • Medicaid EPSDT
  • MENTAL HEALTH
  • MH General Revenue
  • MH Medicaid Match
  • MH Block Grant
  • EDUCATION
  • ED General Revenue
  • ED Medicaid Match
  • Student Services
  • SUBSTANCE ABUSE
  • SA General Revenue
  • SA Medicaid Match
  • SA Block Grant
  • CHILD WELFARE
  • CW General Revenue
  • CW Medicaid Match
  • IV-E
  • IV-B
  • Adoption and Safe Families Act
  • OTHER
  • TANF
  • Childrens Medical Services
  • Mental Retardation/Developmental Disabilities
  • Title XXI
  • Local Funds
  • JUVENILE JUSTICE
  • JJ General Revenue
  • JJ Medicaid Match
  • JJ Federal Grants

S. Pires, 2002
20
How Can We Make It Work?
CHILD WELFARE
JUVENILE JUSTICE
EDUCATION
MENTAL HEALTH
Blended, Braided, Flexible Child Focused vs.
System Focused
Care Coordination
Provider Network
Child and Family
Plan of Care
21
3. Using What Works
  • Identifying and implementing practices that work
    (evidence-based, best practices)
  • Examine array of existing programs/services,
    discard practices that are not effective
  • Build in accountability and CQI data feedback
    loops beyond monitoring
  • Families want what works and family choice

22
Using What Works
  • The effectiveness of services, no matter what
    they are, may hinge less on the particular type
    of service than on how, when, and why families or
    caregivers are engaged in the delivery of
    care...it is becoming increasingly clear that
    family engagement is a key component not only of
    participation in care but also in the effective
    implementation of it. (Burns, Hoagwood,
    Mrazek)
  • Evidence based practices are part of the answer
  • Promising and best practices need to be in the
    mix
  • Balanced by strong engagement between families
    providers
  • And a goal of resiliency and recovery- reaching
    potential

23
Useful Websites for Evidence-Based and Promising
Practices
  • National Registry of Evidence Based Programs and
    Practices (NREPP)
  • http//www.delprograms.samhsa.gov/template_cf.cfm
    ?pagemodel_list
  • Office of Juvenile Justice Delinquency Prevention
    Model Programs Guide
  • http//www.dsgonline.com/mpg2.5/mpg_index.htm
  • Georgetown University National Technical
    Assistance Center
  • http//www.gucchd.georgetown.edu/programs/ta_cent
    er/topics/evaluationevidencebasedpractice.htm
  • National Wraparound Initiative
    http//www.rtc.pdx.edu/nwi
  • National Implementation Research Network
  • http//www.nirn.fmhi.usf.edu
  • Center for Evidence Based Practice  Young
    Children With Challenging Behavior
    http//challengingbehavior.fmhi.usf.edu/fixsen-eta
    l-may03.html
  • State of Hawaii ttp//www.hawaii.gov/health/menta
    l-health/camhd/library/pdf/ebs/ebs016.pdf

24
4. Harnessing Technology
  • Delivery of care e.g., telehealth,
    tele-trainings, etc.
  • Decision-support
  • Providers Interagency Decision-Support
    Coordinated information technology infrastructure
    to enable sharing of data
  • Family Decision-Support Information collection,
    organization and dissemination to support
    family-driven care
  • www.networkofcare.org

25
Is there evidence that transformation will
improve youth, program and system outcomes?
26
Comparative Cost Data
  • Community-based Services vs
  • Institutional Costs
  • (approx. average annual per child cost)
  • Kansas 12,900 vs. 25,600
  • Vermont 23,344 vs. 52,988
  • New York 40,000 vs. 77,429
  • (2001 data)

27
Wraparound Milwaukee
  • Outcomes
  • Reduced juvenile delinquency
  • Higher school attendance
  • Better clinical outcomes
  • Lower use of hospitalization
  • Reduced costs of care
  • Program costs 4,350/month vs. 7,000 per month
    per child for residential treatment or juvenile
    detention
  • Replications Madison, WI Indianapolis, State
    of New Jersey, etc.

B. Kamradt 2002
28
Boston Childrens Hospital Community Health
Partnerships
  • Partnership with Schools
  • Low income African American/Hispanic, poor
    performing schools
  • School Guidance Counselor- school-wide
    prevention/early intervention programs starting
    in 6th grade
  • Outcomes 3 years, all 7th graders pass English
    MCAS exam
  • In top 52 schools for closing achievement gap
    between white and minority students

  • Beardslee, 2006

29
Whats happening around the country?Key
mental health an issue beyond the specialty
mental health system
30
Leverage NFC Report for State-Level Reform
  • Different strategies
  • focus on specific goal areas or general concept
    of transformation and recovery
  • www.nasmhpd.org for state implementation
    activities
  • Major State reform efforts
  • Childrens Substance Abuse and Mental Health
    State Infrastructure Grants (7)
  • State Infrastructure Grants (7)

31
State Reform Efforts New Mexico
  • Interagency Behavioral Health Purchasing
    Collaborative- formed by Governor
  • Legislation statewide system of behavioral
    health care emphasize prevention, early
    intervention, resiliency, recovery,
    rehabilitation
  • 17 agencies- comprehensive BH plan
  • Inventory all expenditures
  • Commitment to system of care values
  • Single delivery system with shared vision and
    goal Straight from NFC
  • Uniform billing codes and definitions
  • Emphasis on evidence-based practices

32
State Reform Efforts New Mexico
  • Contracting with 1 Statewide Entity (carries full
    risk)
  • Contract with providers
  • Braided flexible funding single billing process
  • UR/UM
  • Assuring Care Coordination
  • Consumer/Family relations
  • Behavioral Health Planning Council
  • 51 families and consumers
  • Local Systems of Care

33
State Reform Efforts Kansas
  • Kansas Transformation Work Groups
  • Governor-supported Driven by advocates and
    Consumer and Family Organizations
  • State-wide work groups focusing on 6 goals of NFC

34
State Reform Efforts Illinois
  • Illinois Childrens Mental Health Act
  • Legislation created Childrens Mental Health
    Partnership
  • 25 member cross agency, advocates and legislators
  • Re-organize childrens mh services
  • Mandate To develop Childrens MH Plan June
    2005 cross agencies, budgets, prevention and
    education component
  • Make childrens mental health a priority

35
Creating and Sustaining Momentum for
Transformation
36
Components of TransformationFormer Surgeon
General, Dr. Julius Richmond
37
Creating An Action Plan for Transformation
  • Transformation requires three essential elements
  • a new and continuously expanding knowledge base
  • a social strategy to accomplish change,
  • sustained public and political will

38
Sustaining Momentum
  • Process (who signs up when the meetings
    over?)
  • Ongoing commitment to collaboration
  • To principles and a shared vision
  • Ongoing funding and resources
  • Political will
  • Driven by
  • Knowledge of what works
  • Demonstrable benefits
  • Strategic alliances and support
  • Focused by
  • Systematic planning and action

39
Whats really required for transformation?
  • Proof its the right thing to do
  • Data
  • Political outcomes
  • Clinical and Quality of Life outcomes
  • Economic outcomes
  • Progressively deeper collaboration
  • Economic buy-in (match issues, reprioritizing
    funding)
  • Policy, procedure, relationship values changes
  • Experiences the benefits of collaboration

40
Whats really required for transformation?
  • Progressively stronger engagement of
    families/advocacy organizations
  • Design implementation
  • Evaluation
  • Training/Social Marketing
  • Advocacy

41
Transformation is Messy

"The truth is that change is inherently messy. It
is always complicated. It invariably involves a
massive array of sharply conflicting demands.
Despite the best-laid plans, things never happen
in exactly the right orderand in fact, few
things rarely turn out exactly right the first
time around real change is intensely personal
and enormously political.
- David Nadler, from Champions of Change
42
Achieving the PromiseUse the New Freedom
Commission report to.
  • Help the community (local, state, nationally)
    understand what they should want
  • Why a child with behavioral health needs who
    graduates, is employable, and has a future is a
    good outcome for the child, the community and the
    country.

43
Frame Understandable Messages.
  • Communities, legislatures, governors will not
    always understand why systems of care, or
    evidence-based practices, or recovery and
    resiliency or childrens self-esteem are good
    things.
  • They will understand why children who are not
    incarcerated, who do not drive drunk, who
    graduate, and who have higher incomes as adults
    is a good thing.

44
Use transformation to focus on childrens lives
in their communities, not their lives in our
systems
45
WE SHALL HAVE ALL OF ETERNITY IN WHICH TO REST.
NOW, LET US WORK FOR THEIR SAKE AND OURS
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