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Report of the Childrens Workgroup Florida Commission on Mental Health and Substance Abuse

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Title: Report of the Childrens Workgroup Florida Commission on Mental Health and Substance Abuse


1
Report of the Childrens WorkgroupFlorida
Commission on Mental Health and Substance Abuse
  • Co-ChairsHonorable Jeri Cohen, MiamiJohn
    Haines, Ed.D., TallahasseeCommission
    MembersPatricia Holmes, M.S.Representative
    Sandra MurmanLaura SchuckBob SharpePhyllis
    Sloyer, MPAStaffBob FriedmanMary Ann
    KershawDebora Simmons

2
Methods Used By Workgroup
  • Meetings
  • Five Meetings Held in Conjunction with Commission
    Meetings
  • One Special All-Day Meeting Held on Financing
  • Material Reviewed
  • Testimony to Overall Commission
  • Presentations to Workgroup (14 presentations were
    made by invitation)
  • Florida Statutes, Reports, and Other Documents
  • Reports and Documents from Other States,
    Professional Organizations, and Federal Level
  • Individual Discussions
  • Consultant on Financing

3
Findings Prevalence Incidence
  • Mental Health
  • 10 with serious emotional disturbances
  • 20 with diagnosable disorder

4
Substance Abuse
  • (from Florida Youth Substance Abuse Survey, 2000)
  • Use Within Past 30 Days
  • High School Students
  • 43.4 alcohol
  • 18.3 marijuana
  • Middle School Students
  • 20.4 alcohol
  • 5.1 marijuana

5
Special Populations
  • Foster Care 75 with mental health and/or
    substance abuse problems
  • Juvenile Justice about 100,000 Florida youths 10
    to 17 (7 of total population) are referred for
    delinquency each year 60 have emotional
    problems, 36 have serious substance abuse
    problems, and 20 have a serious mental disorder
  • Substance Abuse 50 of adults in substance abuse
    system have children
  • Child Protection 80 of children in child
    protection system have parents with mental health
    and/or substance abuse problem.

6
Preschool Children
  • 9 in two to five year age range with serious
    mental health problems
  • Increased attention to parent-child relationships
    during infancy
  • Greatly under-served population

7
Co-occurrence of Mental Health and Substance
Abuse Problems
  • Of youngsters treated for substance abuse
    disorders, 80 to 85 also have a mental health
    disorder
  • Of youngsters with co-occurring disorders, in
    83.5 of the cases the mental health disorder was
    first, in 3.7 they occurred at same time, and in
    12.8 of the cases, the substance abuse disorder
    was first (from National Comorbidity Study)
  • Yet, there is a lack of integrated treatment, or
    even consistent cross-system training

8
Long-Term Consequences Need for Preventive
Efforts I
  • Early onset psychiatric disorders have been
    associated with subsequent truncated educational
    attainment, higher risk of teenage childbearing,
    higher risk of early marriage, lower probability
    of late marriage, and lower family income
  • R. Kessler, based on National Comorbidity Study
  • Early onset disorders tend to be more severe and
    disabling than later onset disorders
  • R. Kessler

9
Long-Term Consequences Need for Preventive
Efforts II
  • Report to the Commission by Alan Leshner,
    Director, National Institute on Drug Abuse
  • If we can prevent the use of illegal substances
    before an individual reaches young adulthood,
    then the likelihood of an adult substance abuse
    disorder is slight

10
Resources I
  • Many public agencies with important role in
    childrens mental health and substance abuse, and
    numerous funding streams
  • Inadequate resources
  • Fragmentation in planning, funding, and service
    delivery
  • Lack of accountability at the system level
  • High level of unmet need (DCF-supported MH/SA
    system presently serves about 23 of children in
    need of MH services and 14 of children in need
    of SA services).

11
Behavioral Health Funding Streams for
Children Families in the Public Sector
  • 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
  • OTHER
  • TANF
  • Childrens MedicalServices
  • Mental Retardation/Developmental Disabilities
  • Title XXI
  • Local Funds
  • CHILD WELFARE
  • CW General Revenue
  • CW Medicaid Match
  • IV-E
  • IV-B
  • Adoption and Safe Families Act
  • JUVENILE JUSTICE
  • JJ General Revenue
  • JJ Medicaid Match
  • JJ Federal Grants

12
Resources II
  • Absence of insurance (either public or private)
    constitutes significant barrier to access to
    treatment, and to choice of provider.

13
Resources III
  • Considerable concern about reimbursement rates
    for services under Medicaid. Special concern
    expressed about Behavioral Health Overlay
    Services (BHOS).

14
Resources IV
  • In 1990s, Florida has shifted to greater reliance
    upon Medicaid funding and less on general revenue
    funding. However, it does not appear that Florida
    is fully realizing the potential of Medicaid yet.
    In particular, match from public school systems
    and local government agencies may have potential
    for significantly leveraging funds, and use of
    IMD waiver to include residential substance abuse
    services may also help.

15
Childrens Budget
16
Childrens Substance Abuse Federal Funding
17
Systems of Care I
  • General consensus that integrated,
    community-based systems of care represent
    approach to be taken in serving children with
    severe behavioral health challenges.
  • For example, the Surgeon Generals Report on
    Mental Health indicates that, the multiple
    problems associated with a serious emotional
    disturbance in children and adolescents are best
    addressed with a systems approach in which
    multiple service sectors work in an organized,
    collaborative way.

18
Systems of Care II
  • The best treatment programs provide a
    combination of therapies and other services to
    meet the needs of the individual patient from
    Principles of Drug Addiction Treatment A
    Research-Based Guide, National Institute on Drug
    Abuse.

19
Systems of Care III
  • Within both mental health and substance abuse
    systems, Florida has strong statutes that call
    for the establishment of such systems
  • However, resources to assist communities in
    developing such systems has not accompanied the
    statutes, and while Florida has a number of
    communities with promising efforts, much more
    work is needed to develop and evaluate
    collaborative systems.

20
Case Management with Flexible Funds
  • Consistent support for the recommendation of Dr.
    Martin Cohen to the Commission that, in serving
    individuals with complex problems, it is
    essential to develop a single point of
    responsibility and accountability for each
    consumers care give that person the authority
    to get the consumer what they need when they need
    it.
  • Some excellent examples of this in Florida but
    additional work to develop effective systems of
    case management with flexible funds (often called
    wraparound) is needed in order to develop
    systems of care that provide individualized care.

21
Specialty Mental Health System
22
Provider Network
  • Acknowledged to be a key to an effective system
    of care
  • While there are many excellent providers (both
    organizationally and individually) in Florida,
    concern was expressed about the general need to
    add more providers to the network, and to
    strengthen the capacity of existing providers to
    offer high quality individualized care.

23
Prevention
  • Consensus is that strong prevention efforts are a
    key to long-term progress
  • While there have been considerable resources
    invested in prevention, particularly in the
    substance abuse, juvenile justice, and child
    protection systems, there is not a
    well-coordinated, comprehensive, integrated
    prevention effort with multi-system planning.

24
Fiscal Incentives
  • A major part of an effective system is the use of
    fiscal incentives to promote system goals and
    objectives. Concerns were raised about the manner
    in which such incentives are currently used in
    the system.

25
Information and Referral
  • Need for strong information and referral services
    was strongly identified, particularly by parents
    who are not sure where to turn when they first
    suspect that help is needed
  • Florida has launched a collaborative mental
    health-substance abuse effort to provide
    information and referral services
  • This was started without any additional
    resources.

26
Screening
  • Absence of routine screening procedures to detect
    special social and emotional needs of children
    within systems such as primary health care, child
    care, and education
  • These are the systems that have the opportunity
    to identify children at a point in time when
    intervention can be more cost-effective.

27
de facto Mental Health/Substance Abuse System
All Children
Family
Neighborhood
Prevention
UniversalServices
Primary Healthcare
Child Care
School
Developmental Disabilities
SpecialHealthcare
JuvenileJustice
SpecialEducation
Shelters
ChildWelfare
de facto Mental Health/Substance Abuse System
Mental Health Substance Abuse
Specialty Mental Health/Substance Abuse System
28
Families
  • Families are becoming increasingly more involved
    both at the system and service planning level.
    However, there is a long way to go to adequately
    involve families, and particularly to incorporate
    family choice into the service system.

29
Diversity
  • Census data indicate that the population in
    Florida is becoming increasingly diverse. Yet
    there is a general absence of attention to racial
    and ethnic diversity in planning and delivering
    services.

30
Local Infrastructure and Capacity
  • It is acknowledged that effective service
    delivery requires an adequate infrastructure and
    capacity at local and state level. However, a
    consistent concern was expressed about a
    perceived declining capacity at the local level
    to plan and manage the system both because the
    system is becoming increasingly more complex, and
    number of staff at the local level is not growing
    to keep up with the need.

31
Accountability
  • Florida has been one of the most proactive states
    in developing an outcome-based accountability
    system. However, present system needs to be
    re-examined to determine if proper measures are
    being used, and to develop procedures to put the
    information that is gathered to use to strengthen
    the system and improve care.

32
Information Systems
  • Effective system management requires strong
    information systems. Yet, concerns were expressed
    that existing systems currently fail to provide
    the data needed for system management and
    monitoring, and for collaboration between
    agencies.

33
Vision for the System
  • Based on discussions within the Workgroup,
    presentations to the overall Commission, review
    of state statutes, and lessons learned from
    presenters to the Workgroup and articles about
    characteristics of effective systems.

34
Vision for the System
  • Designed to be able to provide individualized,
    and family-centered services within communities
  • integrated at the service delivery level so that
    comprehensive services can be provided
  • integrated at the policy/system level so that
    resources are accessible at the practice level in
    the manner that they are needed without
    categorical barriers
  • accountable for quality of care at the practice
    level, and accountable for overall system
    performance

35
Vision for the System
  • with strong family involvement at all levels
  • responsive to needs of diverse communities and
    populations of children and families
  • with emphasis on promotion of health and
    well-being and prevention of problems, as well as
    treatment
  • with wide range of home and community-based
    options for children and families

36
Vision for the System
  • with coordination and collaboration in planning,
    funding, and service delivery between systems,
    especially mental health, substance abuse,
    dependency, delinquency, education, physical
    health, and child care
  • with case managers/service coordinators who work
    closely with children with the most complex needs
    and their families to provide support to them and
    to ensure that the needed services are provided

37
Vision for the System
  • with a community that is educated about the needs
    of children and families, with the result that
    stigma is reduced and barriers to entry into care
    are reduced
  • with all families having access to needed mental
    health and substance abuse services
  • with families having reasonable choice about
    providers and services
  • with information systems that provide the type of
    data needed to effectively manage and continually
    improve a complex system

38
Vision for the System
  • with a focus on strengths of children and
    families as well as problems
  • with a strong developmental perspective,
    providing appropriate promotion, prevention, and
    treatment services across the developmental cycle
    for children, beginning with the youngest of
    children and including children making a
    transition into adulthood
  • with a large and diverse provider network.

39
Recommendations
  • What Do We Need to Do to Reduce the Discrepancy
    Between our Findings and our Vision?

40
Recommendations
  • At the practice level, Florida should ensure that
    there is a strong case management system in place
    with flexible funds and reasonable caseload
    sizes, and a well-prepared provider network so
    that children with the most complex needs and
    their families can receive individualized and
    comprehensive services

41
Recommendations
  • At the policy/system level, ensure that the
    structure provides the resources for coordinated,
    individualized care. This includes moving to
    blended or pooled funding, to the use of lead
    agencies and administrative service organizations
    (in large communities) to share responsibility
    for system development, and service delivery
    (including the case management function), and to
    promote accountability

42
Recommendations
  • Ensure joint planning among program, policy and
    funding agencies responsible for mental health
    and substance abuse services, the child welfare
    system, the juvenile justice system and the
    school system

43
Recommendations
  • Develop a greater multi-systemic emphasis on
    promotion of well-being and prevention, and a
    stronger focus on the needs of young children.
    There should be an ongoing multi-system effort to
    develop appropriate health promotion, prevention,
    and early intervention activities

44
Recommendations
  • Continue to support community-level planning and
    system management. This should include developing
    the local capacity and leadership through such
    mechanisms as strengthening use of information
    systems, expanding opportunities for technical
    assistance, and ensuring adequate staff to
    innovate as well as plan and manage complex
    systems

45
Recommendations
  • Seek new state, federal, and local funding to
    respond to high level of unmet need, and to bring
    about needed system change explore ways to
    expand federal funding, such as use of local
    match for Medicaid, expansion of the Medicaid
    program in the schools, and the support of the
    IMD waiver for residential substance abuse
    services explore ways to use existing funds more
    effectively through collaboration, pooled
    funding, and proper use of fiscal incentives.
    Also, review reimbursement rates for services
    provided under Medicaid

46
Recommendations
  • Build on the philosophy included in Chapters 394
    and 397, and particularly included in the
    establishment of pilot system integration
    programs in four districts for childrens mental
    health, and in two districts for childrens
    substance abuse. The state should provide funding
    for implementation of the approach expressed in
    Chapters 394 and 397, thereby not only addressing
    inadequate resources but also creating fiscal
    incentives to develop collaborative,
    community-based systems of care that provide
    individualized, family-centered services

47
Recommendations
  • Provide needed funding for strong information and
    referral systems, and establish communications
    campaign to educate general public about nature
    of behavioral health issues in children, and how
    to access services

48
Recommendations
  • Increase the involvement of parents of children
    with behavioral health problems in state and
    local policy and planning

49
Recommendations
  • Ensure that systems are responsive to the needs
    of children and families from diverse racial and
    ethnic groups

50
Recommendations
  • Recognize the importance of the de facto
    behavioral health system, institute consistent
    screening procedures for behavioral health
    problems with the de facto system, and develop a
    training and communications campaign specifically
    targeted at de facto system

51
Recommendations
  • Ensure that all children have either public or
    private insurance coverage for behavioral health
    services, and that the benefit provides for an
    appropriate range of services

52
Recommendations
  • Create mechanisms for independent study and
    evaluation of promising innovations around the
    state so that communities around the state can
    benefit from the innovations. These studies
    should examine new system of care developments,
    changes in financing and contracting, specialized
    courts, expanded involvement of families, and new
    types of collaborations.
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