Challenging Behaviors in Challenging Times: How We Can Best Serve Children through Multi-Agency Collaboration

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Challenging Behaviors in Challenging TimesHow
We Can Best Serve Children through Multi-Agency
Collaboration

• UNDERSTANDING OUR SYSTEMS
• William Arroyo, M.D.
• Regional Medical Director, Los Angeles County
  Department of Mental Health
• December 7, 2010

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MISSION

• Enriching lives through partnership designed to
  strengthen the communitys capacity to support
  recovery and resiliency

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New Strategic Plan (6-10-10)Goals

• Enhance the quality and capacity of mental health
  services and supports in partnership within
  available resources
• Eliminate disparities especially those due to
  race, ethnicity and culture
• Enhance the communitys emotional and social
  well-being
• with a workforce capable of meeting the needs of
  our diverse communities
• Maximize fiscal strength
• Use of research and technological advancements

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DMH Nos. At A Glance

• No. of outpatient clients 209,386 (FY 08-09)
• No. of inpatients 15,879 (FY 08-09)
• Avg. daily no. of clients in adult justice
  programs 2300
• No. clients served in juvenile justice programs
  15,954 (FY 08-09)
• No. of clients with Public Guardian 2800
• No. of calls received by ACCESS 283,098
• Crisis field evaluations 19,000 served
• 4 Urgent Care Centers (24 hr) 11,000 served

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At A Glance - 2

• 47 directly-operated programs
• 130 contracted agencies
• 112 potential new contractor agencies
• 89 pharmacies
• 27 fee-for-service hospitals
• 3 indigent hospitals
• 338 fee-for-service individuals
• 4 contracts/MOUs with veterans organizations
• Budget of 1.58 billion (gross appropriation) (FY
  09-10)

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New Treatment Strategies

• Short term
• Focused (especially around crisis, trauma,
  depression)
• Evidence based
• Expansion of community based approaches
• Expansion of in-home strategies
• Expansion of crisis resolution approaches
• Integration with primary care

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Main Sources of Childrens MH Funding

• Realignment
• Medi-Cal Managed Care
• EPSDT (a Medi-Cal program) includes Therapeutic
  Behavioral Services, Day Treatment, Day Rehab,
  Outpatient
• Healthy Families basic SED MH benefit
• AB 3632
• Mental Health Services Act FSPs and PEI
• Specialized Foster Care
• Family Preservation

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EPSDT (Medical Necessity Criteria)

• Below age 21
• Mental disorder results in at least one of
  following (1) significant deterioration
  in key domain (2) probability of significant
  deterioration in key domain or
• (3) a probability of not progressing
  developmentally

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Medical Necessity Criteria - 2

• Condition is not responsive to general medical
  interventions
• (Outpatient) Intervention would
• (1) significantly diminish impairment
• (2) prevent significant deterioration in
  key
• domain or
• (3) allow child to progress
  developmentally
  
• Meets the criteria of one of the following Dx

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ELIGIBLE DIAGNOSES

• Pervasive Developmental Disorders (including
  Aspergers D and excluding Autistic D)
• Disruptive Behavior D
• Feeding/Eating D of Infancy and Early Childhood
• Elimination D
• Schizophrenia/Psychoses

• Mood D
• Anxiety D
• Somatoform D
• Factitious D
• Dissociative D
• Paraphilias
• Gender Identity D
• Eating D

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ELIGIBLE DIAGNOSES -2

• Impulse Control D
• Adjustment D
• Personality D, exc. Antisocial Personality
  Disorder

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Mental Health Services Act

• Proposition 63a California voters ballot
  initiativepassed in 2004
• Based on recovery/wellness
• Stakeholder involvement
• Focus on unserved and underserved
• 1 tax on personal income in excess of 1 million
  intended to expand mental health services
• 5 components
• Community Services and Supports, Workforce
  Education and Training, Capital/Technology,
  Prevention/Early Intervention, Innovation

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Outcomes Increase

• Likelihood of having a safe place to live
• Having meaningful use of time (e.g., school,
  work, training).
• Having supportive relationships with family,
  friends, and neighbors.

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Outcomes Reduction of

• Suicide
• Incarceration
• School failure and dropout
• Unemployment
• Prolonged suffering
• Homelessness
• Removal of children from their homes

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FULL SERVICE PARTNERSHIPS

• The FSP program is for children ages 0-15 or TAY
  ages 16 24 and their families who would benefit
  from a program designed to address the total
  needs of a family whose child or youth is
  experiencing significant emotional, psychological
  or behavioral problems that are interfering with
  their wellbeing.
• FSP programs are capable of providing a wide
  array of services beyond the scope of traditional
  clinic-based outpatient mental health services.
  Those participating in a FSP program will have
  the support of a service provider 24 hours a day,
  7 days a week.

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Childrens Programs (0-15)

• Full Service Partnership - (high end
• children)
• Priority populations
• (1) children removed or at risk of
• removal from their families,
• (2) children experiencing extreme
  behaviors at school (3) children involved
  with Probation and families affected by substance
  abuse

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Transition Age Youth Programs (16-24)

• Full Service Partnerships (high end youth)
• Priority Populations (1) youth with
  substance abuse disorders, (2) youth who are
  homeless or at risk of becoming homeless,
  (3) youth are emancipating from DCFS
  Probation, (4) or youth leaving long term
  institutional care, experiencing first psychotic
  break

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FULL SERVICE PARTNERSHIP SERVICES (0-15, TAY)

• 24/7 clinic/field-based/in-home that include
  multi-discipinary teams for crisis intervention
  assess
• Culturally competent
• Individualized
• Social/recreational/faith-based
• Engagement with ethnic minorities through
  schools/primary care clinics/shelters
• Wraparound
• Trauma specific services
• Community re-entry services (juvenile halls
  camps)

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FSP Services (0-15, TAY) (contd)

• Transportation
• Interagency collaboration
• Respite Care
• Probation halls/camps
• GLBT specific
• MH Services Supports for caregivers/parents,
  including crisis family services
• Temporary/permanent supportive housing
• Co-Occurring Disorders Services
• Drop-in Center Services (TAY)

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FSP TAY only

• Peer partners
• Support for independent living
• Basic living skills
• Integrated MH with law enforcement agencies

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Requirement of Full Service Partnership (LACDMH)

• Programs may not discriminate against individuals
  with a mental illness who have co-occurring
  disorders, including individuals with physical
  health problems, developmental delays, low
  literacy issues, substance abuse issues, or other
  issues.  Rather, providers must demonstrate the
  ability to collaborate with other Departments or
  entities (e.g., Regional Center, DHS) in order to
  ensure clients access the services most
  appropriate for their needs and to which they are
  entitled.

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MHSA Prevention and Early Intervention (PEI)
Priority Populations

• Underserved Cultural Populations
• Individuals Experiencing Onset of Serious
  Psychiatric Illness
• Children/Youth in Stressed Families
• Trauma-Exposed Individuals
• Children/Youth at Risk for School Failure
• Children/Youth at Risk of Juvenile Justice
  Involvement

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Priority Child/Youth Population (indigents)
multi-dimensional definition

• Severe emotional/behavioral crisis
• In or at risk for out of home placement
• Certain diagnostic categories
• Severe functional impairment

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OPERATIONAL AGREEMENT BETWEEN L.A. CO. and
REGIONAL CENTERS (2005)

• Chief Administrative Officer
• Department of Mental Health
• Probation Department
• Department of Children and Family Services
• Seven Regional Centers (in L.A. County)

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AGREEMENT

• State regulations indicate that regional center
  funds shall not be used to supplant the budget of
  any agency which has a legal responsibility to
  serve all members of the general public and is
  receiving public funds for providing those
  services
• Agreement is to meet the needs of persons with
  developmental disabilities who are also mentally
  ill

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GOALS OF AGREEMENT (pertaining to LACRCs and
LACDMH)

• Increase leadership, communication
• To optimize utilization of agency resources
• To decrease costs and minimize fiscal risk
• To ensure continuity of services
• Improve quality outcomes
• Strive toward highest client functioningin least
  restrict setting
• Timely resolution of conflicts

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AGREEMENT - OUTPATIENT

• LACDMH and LACRCs will develop and
  implementgeneral plan for crisis
  interventionshall include after-hours emergency
  response systems, interagency notification
  guidelines and f/u
• If psychiatric care is warranted, both will
  develop procedure for a client based on the
  presenting dx and medical necessity, as defined
  by State regulations. Once the client no longer
  requires MH treatment, the client is referred to
  LACRC for f/u

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AGREEMENT - INPATIENT

• RC clients admitted to psychiatric inpatient
  facilities due to a mental disorder will be the
  responsibility of LACDMH. LACDMH will provide
  psychiatric treatment until there is no further
  medical necessity for acute inpatient care.
  Discharge shall occur when medical necessity
  criteria are no longer met. If placement by RC
  is delayed, the client is placed on
  administrative days for which RCs are
  responsible beginning on the 5th administrative
  day.

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CA CODE OF REGULATIONSTitle 9, Chpt 11, Section
1830.205

• Los Angeles County DMH will meet the needs of
  Regional Center clients/consumers who meet
  medical necessity criteria as in CA code
• Persons eligible for developmental disability
  services referred to LACDMH for mental health
  services will receive an evaluation and
  assessment to determine the extent of their need
  for services. LACDMH will provide appropriate
  mental health services

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Critical Challenges Issues

• Funding for indigent care
• Emergency response capacity given ER overcrowding
  limited long-term care options
• Katie A. lawsuit (children in foster care)
• Implementation of MHSA components of PEI, WET and
  Innovations
• Needs of youth in juvenile justice system, i.e.
  halls camps
• AB 3632 funding
• Healthcare reform
• Workforce issues

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Resources

• Los Angeles County DMH website with MHSA info.,
  list of mental health agencies, other MH links
• http//dmh.lacounty.gov
• Los Angeles County DMH Medi-Cal Network Providers
  (Psychiatrists and Psychologists)
• http//dmh.lacounty.gov/cms1_054947.pdf
• Los Angeles Network of Care provides an online
  service directory, i.e. addiction, disability
  insurance, housing, emergency shelter (by zip
  code)
• http//losangeles.networkofcare.org/mh/home/
• Los Angeles County Guide to Medi-Cal MH Services
• http//dmh.lacounty.gov/cms1_046410.pdf
• Healthy Families
• http//www.healthyfamilies.ca.gov/hfhome.asp
• CA State DMH
• www.dmh.ca.gov

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Resources (contd)

• CA Mental Health Planning Councils Master Plan
• http//www.dmh.ca.gov/MHPC/masterplan.asp
• Characteristics of the uninsured
• http//covertheuninsured.org/media/research/brffs.
  pdf
• Report from the Presidents New Freedom
  Commission on Mental Health
• http//www.mentalhealthcommission.gov/reports/repo
  rts.htm
• Healthy People 2010 report Mental Health
  Section
• http//www.healthypeople.gov/Document/pdf/Volume2/
  18Mental.pdf
• California Little Hoover Commission Report On
  Mental Health, Being There Making a Commitment
  to Mental Health Nov. 2000
• http//www.lhc.ca.gov/lhcdir/report157.html