Developing a Community-Based Mental Health System for Children and Adolescents in Maine: Service Use, Cost, and Policy Directions

1
Developing a Community-Based Mental Health System
for Children and Adolescents in Maine Service
Use, Cost, and Policy Directions

• James T. Yoe, Ph.D.
• Robert DuBrow
• Maine Department of Health and Human Services
• Office of Quality Improvement Services
• 2008 SAMHSA/CMS Invitational Conference on
  Medicaid and Mental Health
• Services/ Substance Abuse Treatment
• Baltimore, Maryland
• September 25 26, 2008

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Maine DHHS Childrens Behavioral Health Services
Guiding Principles

• 1. Services based on the familys and childs
  strengths.
• 2. Families are full participants in all
  aspects of planning and delivery of services
• 3. Children have access to a comprehensive
  array of services that meet the childs physical,
  emotional, educational and social needs.
• 4. Children receive individualized services
  guided by an individualized service plan (ISP).
• 5. Children receive services in the least
  restrictive, most normative environment that is
  clinically possible.
• 6. Children receive integrated services with
  linkages between agencies.
• 7. Early identification and intervention for
  children with emotional problems should be
  promoted.
• 8. Children are ensured smooth transitions to
  adult service systems, as they reach maturity
• 9. The rights of children should be protected
  and effective advocacy efforts for emotionally
  disturbed children and youth be promoted.
• 10. Children receive services without regard to
  race, religion, national origin, sex, physical
  disability or other characteristics and services
  should be sensitive and responsive to cultural
  differences.

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Childrens Behavioral Health ServicesTarget
Populations

• Children with Emotional and/or Behavioral
  Disorders
• Children with Developmental Disabilities or
  Severe
• Developmental Delays
• Children with Mental Retardation or Autism

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Childrens Behavioral Health ServicesMedicaid
(MaineCare) Core Services

• Emergency/Crisis Resolution Services (Sec. 65
  AC)
• Targeted Case Management (13.12)
• Outpatient Services (Sec. 65F K
• Outpatient Psychotherapeutic
  Assessment and Treatment 65 F
• Outpatient Medication Assessment and
  treatment 65 K 
• In Home Treatment Services
• Home Based Mental Health Services -
  37
• Child and Family Behavioral Health
  Treatment Service 65 MN
• Assertive Community Teams (ACT) 65 J
• Day Treatment Services
• Childrens Habilitation Services (Sec. 24 ) 
• Out of Home Residential Treatment Services PNMI
  (Sec. 97)
• Inpatient Psychiatric Hospital Treatment (Sec.
  45)
• Hospital Inpatient treatment
  (Community Hospital Psychiatric Units
  Psychiatric Inpatient Hospitals)

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Childrens Behavioral Health Services Facts on
Child MaineCare Members Diagnosed with Mental
Health/Substance Abuse Challenges

• Total Number of Children (Birth to 21 years)
  eligible for full Medicaid (MaineCare) Benefits
  (any time during the year) SFY 2007 148,350 -
  SFY 2008 147,901
• One quarter of eligible children had at least one
  paid medical claim where a mental health or
  substance abuse diagnosis was present in 2007
  (23.4 - 34,736) and 2008 (24.8 - 36,641)
• 24.9 of males and 21.9 of female eligibles
  received a MH/SA diagnosis on a claim.
• School-age Children and older youth were more
  likely to be diagnosed with a MH/SA conditions.

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Childrens Behavioral Health ServicesStudy
Purpose

• Develop methodology to accurately identify and
  extract MaineCare Paid Claims for children and
  youth diagnosed with a MH/SA challenges and
  specifically members that used one or more of the
  identified Core Childrens Mental Health
  Services.
• This analysis specifically focuses on the
  characteristics of children and youth recipients
  of ME- DHHS Childrens Behavioral Health Services
  and examines MaineCare (Medicaid) service use
  patterns and expenditures over a two-year study
  period.

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Childrens Behavioral Health Services Study
Design

• All data was obtained from the MaineCare Paid
  Claims Data System over a 2 year period SFY 2007
  (7/1/2006 to 6/30/2007) and SFY 2008 (7/1/2007 to
  6/30/2008) (Paid Claims extracted based on
  service dates)
• Initial extract identified claims for children
  and youth birth thru 21 years who had a mental
  health or substance abuse diagnosis. Selection
  was refined using specific CBHS procedures and,
  for hospital services, a combination of provider
  type, provider specialty and MH/SA diagnosis.
• Primary diagnosis was determined for each child
  by assigning each member to one MH/SA diagnostic
  category, based on category that appeared most
  frequently on claims during the study years.
• MH/SA conditions identified using ICD-9 codes
  291 thru 314.99 and 316. Excludes Mental
  Retardation (315 315.99)
• Mental Health pharmacy claims were not included
  in study.

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Childrens Behavioral Health Services Child and
Youth Characteristics
N (unduplicated children 2007 2008) 30,271
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Childrens Behavioral Health Services Child
Youth Characteristics
N (unduplicated children 2007 2008) 30,271
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Childrens Behavioral Health Services Child
Youth Characteristics
N (unduplicated children 2007 2008) 30,271
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Childrens Behavioral Health Services The
Service Array and Utilization
N (undup. 2007) 21,520 N (undup. 2008) 22,712
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Childrens Behavioral Health Services The Costs
FY 2007 CBHS Expenditures 240,497,244
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Childrens Behavioral Health Services The Costs

Service Expenditures By Service Category FY 2008
Total Expenditures (FY2008) 216,650,343
Service expenditures in 2008 may
under-represent actual expenditures for the year
since claim payments continue to be processed
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Childrens Behavioral Health Services The Costs
Service expenditures in 2008 may under-represent
actual expenditures for the year since claim
payments continue to be processed.
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Childrens Behavioral Health Services
Expenditures By Mental Health Service Category
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Childrens Behavioral Health ServicesSummary of
Results

• 30,271 children received a core MaineCare MH
  service over the 2 year study period 21,520 in
  FY2007 22,712 in FY 2008 accounting for 14.5
  of eligible children in 2007
• Most children (77) were between the ages of 6
  and 18 years with more males represented in the
  younger age groups.
• Most common diagnoses were stress/adjustment
  (24), Neurotic/Other (23) and ADHD related
  (19)
• Male service users were significantly more likely
  to receive conduct related, other psychotic, and
  ADHD related diagnoses while females were more
  likely to receive stress adjustment,
  neurotic-depressive, major mood and substance
  abuse diagnoses.
• Service Expenditures for children diagnosed with
  MH/SA abuse conditions who receive MH Services
  represented 37.3 of total Child MaineCare
  expenditures in FY 2007.
• Inpatient Psychiatric Hospital and Out-of-Home
  Residential Treatment accounted for 60 of the
  overall MH expenditures in FY2007 representing
  13 of child service users.

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Childrens Behavioral Health ServicesSummary of
Results - Continued

• Most frequently used services in 2007 and 2008
  included Outpatient-Clinical Services ( 53,
  54), Targeted Case Management (33,31)
  Hospital -Related Outpatient Treatment (36) and
  Medication Assessment Tx (21,20)
• Child and youth diagnosed with Major Mood
  Disorders and Other Psychotic Disorders had the
  highest annual service expenditures.

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Childrens Behavioral Health Services Policy and
Service System Initiatives

• Contract established with Administrative Services
  Organization for MaineCare Behavioral Health
  Services operational since December 2007
• Focus on identification, dissemination and use of
  Evidence-based Practices (EBPs) and measurement
  of outcomes in childrens behavioral health
  programs
• Initiation of Child Steps, an evidence-based
  mental health research project in 3 Maine clinics
  to evaluate the effectiveness of manualized
  clinical interventions and use of family
  partners for children 8-14 years.
• Development and implementation of a
  Trauma-Informed System of Care (THRIVE
  Initiative) and implementation System of Care
  Principles state-wide.
• Target resources to Increase the use of
  effective, intensive community-based treatments
  and reduce the use of high-cost, out-of-home
  treatment.
• Work to enhance service system coordination and
  collaboration and develop a single, fully
  integrated childrens behavioral health system.
• Mental Health screening of all children who have
  contact with Child Welfare
• Enhance the role of families and youth at all
  levels of CBHS program operations, including
  Policy Development, Quality Improvement
  Activities and Training.

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Childrens Behavioral Health Services
Evaluation Next Steps

• Conduct study of the demographic and clinical
  characteristics of children and youth users of
  inpatient psychiatric treatment and out-of-home
  residential treatment services and variation in
  service use across geographic areas.
• Examine utilization and cost of behavioral health
  pharmacy data in child and youth recipients of
  Childrens Behavioral Health Services.
• Evaluate MaineCare primary health care service
  use and costs for CBH service users compared to
  MaineCare children without mental health
  challenges.

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Acknowledgements The leadership of the Maine
Department of Health and Human Services Brenda
Harvey, DHHS Commissioner Geoffrey Green,
Deputy Commissioner Joan Smyrski, Doug Patrick,
Office of Child Family Services Childrens
Behavioral Health Services, Elsie Freeman,
Andrew Hardy, Kimberly Cook, Office of Quality
Improvement Services
Jay.yoe_at_maine.gov