Office of Mental Health and Substance Abuse Services Children - PowerPoint PPT Presentation


Title: Office of Mental Health and Substance Abuse Services Children


1
Office of Mental Health and Substance Abuse
ServicesChildrens Advisory Committee
Residential treatment facility research and
data overview
  • October 17, 2008

Andy Keller, Boulder Peter Selby, Seattle
2
Current residential capacity in Pennsylvania
  • 3,038 in-state accredited residential treatment
    facility (RTF) beds as of September 1, 2008
    (versus 3,223 in October of 2007)
  • 1,309 non-accredited RTF beds
  • Non-Medicaid beds
  • Youth development centers 4 facilities, 696 beds
  • Secure care 9 facilities, 267 beds
  • Secure residential 4 facilities, 98 beds
  • Juvenile detention centers (JDCs) 22 facilities
    with 870 beds
  • What does it mean that 1,700 youth per year from
    other states use Pennsylvania RTF facilities?

3
What kind of transformation is needed?
  • Goals related to RTF for transforming the
    behavioral health system for youth
  • Reduce reliance on RTFs
  • This will require enhancement of community
    capacity
  • This will require a reduction in RTF capacity
  • Intensify and improve the quality of the
    treatment in RTFs.
  • This will require improved quality standards for
    RTF care across the board standards that are
    enforced
  • This will require development of specialized RTF
    capacity for key groups trauma, young women,
    youth with aggressive behavior, co-occurring
    substance use and mental health needs
  • Bring youth back to their communities from out of
    state, as well as from distant out of community
    placements
  • Make family involvement a fundamental component
    of RTF services

4
Can the strategy be statewide, regional or
county-level?
  • It must be county-level because local systems of
    care vary widely in their needs, available
    services, and strategies
  • It must be regional because smaller counties will
    need to share some specialized capacity
  • It must be statewide because the funding and
    standards to drive the transformation require
    that scope
  • Bottom line It must be an integrated strategy
    encompassing all three levels

5
Example one Residential treatment facility
service use patterns vary at the county level
  • 2005 2006 patterns of RTF service by Child in
    Substitute Care (CISC) / non-CISC are stable at
    multi-county level
  • But there are major differences at the
    county-level

6
Example two Diagnoses of residential treatment
facility users also vary by county
  • Same pattern of CISC/non-CISC diagnoses is seen
    at each level of analysis
  • But there are major differences in proportion at
    county-level

Primary diagnosis CISC versus non-CISC
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Statewide
HealthChoices
Expansion
Allegheny
Philadelphia
Conduct disorder (CISC)
Conduct disorder (Non-CISC)
Mood disorder (CISC)
Mood disorder (Non-CISC)
ADHD (CISC)
ADHD (Non-CISC)
Adjustment disorder (CISC)
Adjustment disorder (Non-CISC)
7
Will require new rate structure
  • Evolution of rate structure over time
  • Historically, there had been cost-based methods
    to develop rates
  • With the statewide implementation of managed
    care, there has been less focus on cost-based
    reimbursement with rates more subject to
    negotiation
  • Current rates are low, creating pressure to limit
    quality of care and sell capacity to other states
    at higher prices
  • There is now a need to develop cost-based
    methodologies for targeted new RTF modalities and
    partner with providers and behavioral health
    managed care organizations (BHMCOs) to implement
    them

8
Infrastructure for new rate structure
  • New RTF regulations include a review of the
    fee-for-service (FFS) rate setting
  • New FFS rate structure can serve as a benchmark
    for BHMCO rate setting
  • BHMCOs have historically used FFS rates as a
    reference point for their rates
  • The new structure should include
  • A base rate for all accredited RTF care
  • Differential rates to be paid in addition to the
    base rate for each of the areas of specialization
    prioritized by OMHSAS
  • Development of a process to engage RTF providers
    in transformation efforts, including inclusion of
    performance incentives

9
Essential to define the need for residential
treatment facility capacity at the county and
regional levels
  • Important to carry out needs assessment to
    determine appropriate capacity for basic and
    specialized RTF services
  • Will require a collaborative process involving
    the Department of Public Welfare (DPW), Office of
    Children, Youth and Families (OCYF), OMHSAS,
    counties, BHMCOs, families, and key stakeholders
    in each county
  • Determine each countys need for RTF capacity in
    each area of specialization identified by the
    service array subgroup
  • Transformation will require reductions in current
    RTF capacity and more RTF specialization
  • Without reductions, beds will continue to be
    filled even if community options are expanded
  • Increased costs to deliver enhanced RTF care and
    expanded community services will require offsets

10
Need to set standards to enhanced continuum of RTF
  • Standards would be developed for the following
    areas of specialization
  • Specialized residential programming
  • Gender-responsive services
  • Secure RTF
  • Other specialized programs, including treatment
    for co-occurring mental health (MH)/developmental
    disability, autism spectrum, co-occurring
    MH/substance abuse
  • Placement options that vary by intensity and
    focus
  • Extended sub-acute stabilization and evaluation
  • Family-based RTF (30 60 days, fewer beds)
  • Longer-term intensive and restrictive RTF
  • Small group homes in community (non-RTF)

11
Examples of success from other states
  • In many ways, Pennsylvania must be a leader on
    this initiative
  • No other state that we know of has the amount of
    existing RTF capacity that OMHSAS has
  • No other large state has fully implemented a
    similar statewide strategy
  • That being said, we can learn from the
    experiences of other states and RTF providers

12
Examples of success from other states
  • Oregon cut its RTF use in half through policy
    changes and changes to the RTF referral process
  • Without any new funding, the State, in
    partnership with stakeholders, significantly
    enhanced capacity to track resources and outcomes
  • Oregon also targeted improved services at the
    local level, using evidence-based practices
  • State administrative rules were rewritten to make
    sure all clinical procedural codes needed were in
    place and care coordinators were accessible in
    each community
  • The State used policymaking and purchasing to
    leverage changes focused on increasing family
    voice across all levels
  • Success was seen in changes in the role of family
    members, the location of services and type of
    services provided

13
Examples of success from other states
  • New York is in the early stages of a transition
    driven by their Office of Child and Family
    Services that will
  • Establish criteria to access services that
    include standardized assessment tools (Child and
    Adolescent Needs Strengths), integrated use of
    evidence-based practice, and requirements to
    expand community-based services
  • Commit 620,000 per year to the operation of a
    statewide evidence-based dissemination center
    that has already trained over 400 clinicians in
    trauma-focused cognitive behavioral therapy

14
Examples of success from other states
  • Individual RTF providers have successfully
    transitioned from large institutional models to
    family-based group home, therapeutic foster care,
    mobile crisis and stabilization services and
    wraparound-based community approaches
  • Two programs in California
  • Hathaway-Sycamores Child and Family Services
  • EMQ Children and Family Services
  • The Drenk Center in New Jersey

15
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Title: Office of Mental Health and Substance Abuse Services Children


1
Office of Mental Health and Substance Abuse
ServicesChildrens Advisory Committee
Residential treatment facility research and
data overview
  • October 17, 2008

Andy Keller, Boulder Peter Selby, Seattle
2
Current residential capacity in Pennsylvania
  • 3,038 in-state accredited residential treatment
    facility (RTF) beds as of September 1, 2008
    (versus 3,223 in October of 2007)
  • 1,309 non-accredited RTF beds
  • Non-Medicaid beds
  • Youth development centers 4 facilities, 696 beds
  • Secure care 9 facilities, 267 beds
  • Secure residential 4 facilities, 98 beds
  • Juvenile detention centers (JDCs) 22 facilities
    with 870 beds
  • What does it mean that 1,700 youth per year from
    other states use Pennsylvania RTF facilities?

3
What kind of transformation is needed?
  • Goals related to RTF for transforming the
    behavioral health system for youth
  • Reduce reliance on RTFs
  • This will require enhancement of community
    capacity
  • This will require a reduction in RTF capacity
  • Intensify and improve the quality of the
    treatment in RTFs.
  • This will require improved quality standards for
    RTF care across the board standards that are
    enforced
  • This will require development of specialized RTF
    capacity for key groups trauma, young women,
    youth with aggressive behavior, co-occurring
    substance use and mental health needs
  • Bring youth back to their communities from out of
    state, as well as from distant out of community
    placements
  • Make family involvement a fundamental component
    of RTF services

4
Can the strategy be statewide, regional or
county-level?
  • It must be county-level because local systems of
    care vary widely in their needs, available
    services, and strategies
  • It must be regional because smaller counties will
    need to share some specialized capacity
  • It must be statewide because the funding and
    standards to drive the transformation require
    that scope
  • Bottom line It must be an integrated strategy
    encompassing all three levels

5
Example one Residential treatment facility
service use patterns vary at the county level
  • 2005 2006 patterns of RTF service by Child in
    Substitute Care (CISC) / non-CISC are stable at
    multi-county level
  • But there are major differences at the
    county-level

6
Example two Diagnoses of residential treatment
facility users also vary by county
  • Same pattern of CISC/non-CISC diagnoses is seen
    at each level of analysis
  • But there are major differences in proportion at
    county-level

Primary diagnosis CISC versus non-CISC
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Statewide
HealthChoices
Expansion
Allegheny
Philadelphia
Conduct disorder (CISC)
Conduct disorder (Non-CISC)
Mood disorder (CISC)
Mood disorder (Non-CISC)
ADHD (CISC)
ADHD (Non-CISC)
Adjustment disorder (CISC)
Adjustment disorder (Non-CISC)
7
Will require new rate structure
  • Evolution of rate structure over time
  • Historically, there had been cost-based methods
    to develop rates
  • With the statewide implementation of managed
    care, there has been less focus on cost-based
    reimbursement with rates more subject to
    negotiation
  • Current rates are low, creating pressure to limit
    quality of care and sell capacity to other states
    at higher prices
  • There is now a need to develop cost-based
    methodologies for targeted new RTF modalities and
    partner with providers and behavioral health
    managed care organizations (BHMCOs) to implement
    them

8
Infrastructure for new rate structure
  • New RTF regulations include a review of the
    fee-for-service (FFS) rate setting
  • New FFS rate structure can serve as a benchmark
    for BHMCO rate setting
  • BHMCOs have historically used FFS rates as a
    reference point for their rates
  • The new structure should include
  • A base rate for all accredited RTF care
  • Differential rates to be paid in addition to the
    base rate for each of the areas of specialization
    prioritized by OMHSAS
  • Development of a process to engage RTF providers
    in transformation efforts, including inclusion of
    performance incentives

9
Essential to define the need for residential
treatment facility capacity at the county and
regional levels
  • Important to carry out needs assessment to
    determine appropriate capacity for basic and
    specialized RTF services
  • Will require a collaborative process involving
    the Department of Public Welfare (DPW), Office of
    Children, Youth and Families (OCYF), OMHSAS,
    counties, BHMCOs, families, and key stakeholders
    in each county
  • Determine each countys need for RTF capacity in
    each area of specialization identified by the
    service array subgroup
  • Transformation will require reductions in current
    RTF capacity and more RTF specialization
  • Without reductions, beds will continue to be
    filled even if community options are expanded
  • Increased costs to deliver enhanced RTF care and
    expanded community services will require offsets

10
Need to set standards to enhanced continuum of RTF
  • Standards would be developed for the following
    areas of specialization
  • Specialized residential programming
  • Gender-responsive services
  • Secure RTF
  • Other specialized programs, including treatment
    for co-occurring mental health (MH)/developmental
    disability, autism spectrum, co-occurring
    MH/substance abuse
  • Placement options that vary by intensity and
    focus
  • Extended sub-acute stabilization and evaluation
  • Family-based RTF (30 60 days, fewer beds)
  • Longer-term intensive and restrictive RTF
  • Small group homes in community (non-RTF)

11
Examples of success from other states
  • In many ways, Pennsylvania must be a leader on
    this initiative
  • No other state that we know of has the amount of
    existing RTF capacity that OMHSAS has
  • No other large state has fully implemented a
    similar statewide strategy
  • That being said, we can learn from the
    experiences of other states and RTF providers

12
Examples of success from other states
  • Oregon cut its RTF use in half through policy
    changes and changes to the RTF referral process
  • Without any new funding, the State, in
    partnership with stakeholders, significantly
    enhanced capacity to track resources and outcomes
  • Oregon also targeted improved services at the
    local level, using evidence-based practices
  • State administrative rules were rewritten to make
    sure all clinical procedural codes needed were in
    place and care coordinators were accessible in
    each community
  • The State used policymaking and purchasing to
    leverage changes focused on increasing family
    voice across all levels
  • Success was seen in changes in the role of family
    members, the location of services and type of
    services provided

13
Examples of success from other states
  • New York is in the early stages of a transition
    driven by their Office of Child and Family
    Services that will
  • Establish criteria to access services that
    include standardized assessment tools (Child and
    Adolescent Needs Strengths), integrated use of
    evidence-based practice, and requirements to
    expand community-based services
  • Commit 620,000 per year to the operation of a
    statewide evidence-based dissemination center
    that has already trained over 400 clinicians in
    trauma-focused cognitive behavioral therapy

14
Examples of success from other states
  • Individual RTF providers have successfully
    transitioned from large institutional models to
    family-based group home, therapeutic foster care,
    mobile crisis and stabilization services and
    wraparound-based community approaches
  • Two programs in California
  • Hathaway-Sycamores Child and Family Services
  • EMQ Children and Family Services
  • The Drenk Center in New Jersey

15
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