Behavioral Health Services for Children & Families

Transcription

1 Behavioral Health Services for Children & Families A Framework for Planning, Management and Evaluation Connecticut Department of Children and Families Bureau of Behavioral and Health and Medicine September

2 Table of Contents Table of Contents Pg. 2 Executive Summary Pg Section I - Introduction Pg Section II Summary of Foundational Sources Pg. 14 Section III - Common Framework Pg Section IV - Overview - Progress, Challenges, & Recommendations Pg Section V Service Capacity and Access Pg Section VI - Service Effectiveness and Quality Pg Section VII - Stakeholder Involvement in Planning and Oversight Pg Section VIII - Management of Systems and Services Pg Section IX - Cultural Competence Pg Section X - Public Awareness and Policy Pg Section XI - Funding and Revenue Maximization Pg Section XII - Summary & Conclusion Pg. 101 Appendix A - Review & Summary of Foundational Sources Pg Appendix B - Outline of Common Framework Pg Appendix C - Listing of Proposed Action Steps Pg

3 Executive Summary This White Paper traces developments in the behavioral health system for children and families in Connecticut over the past eight years with a particular focus on the progress made, challenges that remain and a blueprint for continuing improvement over the next five years and beyond. It is intended as a living document that will be modified and adapted to incorporate new perspectives, knowledge, and best practice. Within DCF, the Bureau of Behavioral Health and Medicine is vested with the primary responsibility to plan, administer and evaluate a comprehensive, integrated statewide system of behavioral health services, substance abuse services, medical services, and related supports for various groups of children, adolescents and their families. 1 Between 2000 and 2003 a trio of seminal reports were generated that, in sum, called for an overhaul and reorganization of the children's behavioral health system, both in Connecticut and across the nation. These reports include: Delivering and Financing Behavioral Health Services in Connecticut (Child Health & Development Institute, 2000) Report of the Governor's Blue Ribbon Commission on Mental Health (Governor's Blue Ribbon Commission on Mental Health, 2000) Achieving the Promise: Transforming Mental Health Care in America (Report of the President's New Freedom Commission on Mental Health, 2003) More recently, DCF developed an Agency Strategic Plan to guide agency practice for the 5 year period beginning July 1, 2008 and ending June 30, This integrated plan includes goals and activities for each of the Department s mandates including Child Welfare, Behavioral Health, Juvenile Justice, and Prevention. The three reports referenced above, several others produced around the same time (e.g. The Surgeon General's Report, 1999 and Geballe, 2000) and the Agency's Strategic Plan are fairly consistent in their recognition of the key challenges facing the behavioral health service system for children in Connecticut. Analysis of the reports referenced above reveals a set of goals and benchmarks against which Connecticut's Behavioral Health Service System for Children and Families can be evaluated. Within this common framework, this paper documents progress made, challenges remaining and action steps for the future. 1 This paper focuses on behavioral health care and does not include a full and comprehensive review of the Department's efforts, plans and accomplishments regarding the delivery of medical care to the children in the care and custody of the Department. However, selected medical programs and projects are reviewed towards the goal of a more integrated and holistic healthcare system. 3

4 Common Framework The Common Framework, adapted from the foundational sources, is an organized way of describing what a well functioning behavioral health system looks like and will be utilized throughout the paper to document accomplishments, identify challenges, and develop action steps. The framework is composed of 7 components of system functioning. Service Capacity, Access and The Service Array: In an ideal system, service capacity matches need, services can be easily accessed, and the service array matches the diversity of client needs. Service Effectiveness and Quality: To achieve maximum success, only the most effective services are funded and delivered and the system possesses the necessary infrastructure to evaluate and maintain a high quality of care. Stakeholder Involvement in Planning and Oversight: To be truly responsive to the needs of the population served, behavioral health systems must develop effective means of including consumers, youth, family members, and other key stakeholders in the planning, development, delivery, and oversight of behavioral health services. Management of Systems and Services: An effective behavioral health service system organizes, manages and coordinates care to promote improved service, ease of use, and cost-effectiveness. Management strategies include coordinating and integrating various child serving systems, policy development, care management practices, contracting mechanisms, and effective use of information and technology. Cultural Competence: The Behavioral Health Service System must insure effectiveness for all of the children and families that it serves. The system must be knowledgeable of, informed by, and responsive to the variety of demographic, ethnic and cultural groups in need of care. Education and training, workforce development, and practice modifications are necessary to effectively engage and care for all cultural groups. Public Awareness and Policy: An effective service system educates the public about behavioral health care and addresses policies that are discriminatory against those with a behavioral health disorder. A major barrier to the effectiveness of behavioral health services is the lack of general public awareness that emotional and psychiatric problems are medical conditions, that there is no shame in seeking care, that disorders can be effectively treated, and that a productive life in the community is available to all with the proper services and supports. Funding and Revenue Maximization: A well functioning system maximizes all available sources of revenue and blends or braids funding streams to enhance the service array and improve access to care. The behavioral health service system is funded by a patchwork quilt of state, federal, and local programs, private insurance, philanthropic organizations, school districts, individuals, families, and others. Children and families are well served when funding sources are aligned to maximize available resources, ease access to care, and promote best practice. 4

5 Progress Made DCF and its community partners have demonstrated significant progress in all areas outlined within the common framework described above. Examples include: Service Capacity and Access - Selected Accomplishments: o There has been tremendous growth in community based services including Care Coordination, Emergency Mobile Psychiatric Service, Extended Day Treatment, Intensive In-Home Services, Therapeutic Group Homes and other community based services o Enhanced Care Clinics have been established to expand timely access to outpatient care o DCF and the Department of Social Services have collaborated through the Connecticut Behavioral Health Partnership to significantly expand Medicaid enrollment and the delivery of community based behavioral health services. o Utilization of high end institutional care, including inpatient and residential care, has been substantially reduced Service Effectiveness and Quality - Selected Accomplishments: o The Department has overseen the expansion of Evidence Based Treatment including 9 Intensive In-home Models of Care o DCF has expanded implementation of trauma specific screening and treatment including Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and Dialectical Behavior Therapy (DBT). o Through involvement in the Connecticut Workforce Collaborative on Behavioral Health the department has supported multiple initiatives to improve the behavioral health workforce o The Department has collaborated with academic centers on research to support practice improvement o DCF has significantly expanded its utilization of quality improvement processes, data, and outcome assessment methodologies to improve care. o Prevention and Early Intervention initiatives have been expanded Stakeholder Involvement in Planning and Oversight - Selected Accomplishments: o DCF has adopted and expanded the use of family centered service models o Training in family centered practice has been provided within local systems of care, DCF offices and the wider community o The Department has supported Parent Training and leadership initiatives to prepare and support stakeholder involvement at all levels o Expanded use of Peer Supports through the CTBHP o Continued support of youth, consumer, and family advisory bodies Management of Systems and Services - Selected Accomplishments: o Positions, policies, and programs have been established to improve integration across mandates o DSS and DCF established the CTBHP and carved out behavioral health within Medicaid 5

6 o o o The Department has utilized the CTBHP to facilitate improved access to BH services for children and families served in the child welfare system and voluntary services program. Clinical Case Conference utilization has been expanded to better integrate child welfare and behavioral health practice The Department has developed shared service networks to remove some categorical barriers to access to care Cultural Competence - Selected Accomplishments: o Improved Cultural Competence has been promoted through the Department's personnel practices o The Department has invested in the development of the DCF Office of Multicultural Affairs o Multiple Cultural Competence training initiatives have been conducted o The Department has supported True Colors, Quinceanara, Black History, and other Culturally Specific Projects o DCF has improved its use of data to support culturally competent care o Mental Health Block Grant funds have been utilized to support cultural competence initiatives Public Awareness - Selected Accomplishments: o DCF has participated and supported anti-discrimination campaigns: o DCF supports several suicide prevention and education programs o Through, policy, programs, and practice DCF has promoted a Recovery & Resilience oriented system of care o DCF provides education on various behavioral health topics to staff, providers, and the public o The Department has supported of grassroots advocacy on behalf of children with serious emotional disturbance and their families Funding and Revenue Maximization - Selected Accomplishments: o The Department has helped to increase Enrollment in Husky Plans o DCF and DSS have partnered to shift selected services from grant funding to Fee-for-Service reimbursement under the CTBHP o Through the CTBHP, DCF and DSS have blended DCF grant funds and Medicaid to better serve children and families o The department has engaged in shared contracting with partner agencies (DMHAS & Judicial) to blend service networks o In conjunction with DSS, the department has been working to better align Medicaid with evidence based and best practice Challenges & Action Steps Despite the significant progress that is documented above and in more detail throughout this paper, it is important that this progress is understood in the context of the overall magnitude of the problem. Between 7% and 9% of children and youth in the United States meet the criteria for serious emotional disturbance (SED) indicating the presence of a psychiatric disorder that seriously interferes with functioning in the home, school, and/or community. Most recent estimates are that up to 20% of children and youth have some form of psychiatric 6

7 disturbance and upwards of 70% with a disorder do not receive treatment appropriate treatment. In Connecticut, this translates to an estimated 60,000 to 76,000 children and youth with SED and up to 100,000 additional youth with some form of psychiatric disturbance requiring specialty care. It is also well documented that rates of psychiatric disorder in children and adolescents are even higher within disadvantaged groups including children in poverty and those involved with the child protective or juvenile justice systems. Despite having one of the highest state per capita incomes in the country, Connecticut cities continue to have some of the highest child poverty rates in the nation. Effective intervention for children with behavioral health needs is critically important, especially when considering that recent epidemiological studies estimate that half of all adults will meet the criteria for a psychiatric disorder at some point in their life (Kessler et al, 1994). In addition, half of all behavioral health disorders in adults originated during childhood (Kessler et al, 1994). DCF and its partners have made tremendous progress in improving the Behavioral Health System for children and families in Connecticut but in the context of the tremendous need described above, many challenges remain. A selection of the most significant challenges and the action steps required to address them are noted below: Service Capacity and Access: o Challenge: Service capacity remains below reasonable estimates of need: Action Step: Conduct a needs assessment to determine needs for service across the state and the development of priorities for service expansion/reallocation. o Challenge: Service capacity across geographic areas is not equitably distributed in proportion to need: Action Step: Utilize geo-mapping technology to determine geographic patterns of need current service availability and develop priorities for service expansion/reallocation. o Challenge: The dissemination of trauma specific services has not been sufficient to insure that all children requiring care can access effective trauma treatment: Action Step: Continue to fund/support dissemination of evidence based trauma treatment through projects such as the TF-CBT Learning Collaborative and DBT initiative. o Challenge: Overstay and unnecessary utilization of inpatient, emergency room, and residential care continues despite improvements Action Steps: Expand community based treatment options to reduce overstay and re-align residential utilization and residential program design with specific needs identified through data and case review of stuck children. Service Effectiveness and Quality: o Challenge: Children s Behavioral Health lacks an integrated system of comprehensive screening and assessment, an infrastructure for reporting and analysis, and processes to promote the use of data in daily practice. Action Step: Design an integrated system of screening and assessment that includes an infrastructure for the dissemination of data to key users and integration of data reports into daily practice. 7

8 o o o o o Challenge: Earlier intervention has been proven to be highly effective in terms of human and economic cost but continues to be underutilized. Action Step: It is sound policy to support parents as their child's first and most important social/emotional relationship. The department will develop an early intervention plan that will identify priorities, select the most effective evidence based programs and strategies, and work either to re-allocate existing resources and/or seek new sources of support to expand early intervention programming. Challenge: In order for parents to support their children, both parents and children must be physically and emotional healthy. Action Step: Develop a medical home model to improve access to medical care. Challenge: Connecticut's first forays into evidence based practice focused on intensive community based treatments that could divert youth from residential care. Although this focus was strategic and appropriate, it has resulted in less availability of EBPs in less intensive outpatient settings and more intensive residential and hospital level care. There is a need to have EBPs readily available at all levels of care in the continuum of services. Action Step: Identify those EBPs best suited for implementation in inpatient, residential, intermediate, and outpatient services and develop strategies for promoting their implementation and sustainability across levels of care. Challenge: State and private non-profit agencies offer few employment opportunities for consumers/family members. Action Step: Promote methods of increasing consumer/family member opportunities for employment within the behavioral health system. This is widely regarded as a means to both support productive lives in the community and improve the quality of care. Challenge: The Department has yet to progress to a level where all or most program improvement and resource allocation decisions are informed by quality improvement data and processes. Although many programs now include a quality improvement component, many do not and the level of QI is not uniform across programs. Action Step: Develop a plan to insure that a rigorous quality improvement program is in place for all existing behavioral health programs by 2013 and that all newly procured programs include an adequate QI process. Stakeholder Involvement in Care and System Planning and Oversight: o Challenge: Very few opportunities exist within the children's behavioral health service system for involvement of individuals with lived experience with mental illness or being the family member of an individual with mental illness. Action Step: Expand the role of individuals with lived experience throughout the behavioral service system but particularly on the staff of service providers and state agencies that provide care. These roles should include paid employment opportunities. o Challenge: Use of the Engaging Families evidence-based family engagement model is limited to application with EDT programs and these practices are not widespread. Action Step: Expand the engaging families or similar initiatives to outpatient services and residential care. 8

9 o Challenge: Too few Consumers, Youth, and Families (CYF) are available to fulfill membership and leadership responsibilities involving System Oversight. Action Step: Conduct an inventory of CYF currently participating in membership and leadership roles and establish goals for recruitment and retention of CYF within the Connecticut Workforce Collaborative on Mental Health. Management of Systems and Services: o Challenge: Further integration of Child Welfare and Behavioral Health is needed. Issues include: overlapping mandates without overlapping jurisdiction; need for cross training; and lack of structures to support joint decision-making. Action Step: Explore BH and CPS integration at the area office level, support the cross training of BH and CPS staff, and develop methods, such as formal local service system reviews that support joint decision making and establishment of priorities for program development. o Challenge: Most Behavioral Health services that are delivered to children and families in the child welfare system were not specifically designed for this specialty population. Action Step: Identify a set of evidence based Behavioral Health Services that are optimally matched to the needs of the specific child welfare population. Develop a plan to pilot and then expand access to these services throughout child welfare. o Challenge: Young adults often do not respond well to the services and supports designed for the adult population and the array of services designed specifically to address their needs is insufficient in both quantity and breadth. Action Step: DCF and DMHAS will collaborate to develop an expanded array of services for the young adult population. DMHAS, who will ultimately own the service array, should take the lead with consultation and assistance from DCF. o Challenge: Despite improved consultation to Emergency Departments and the development of additional resources for diversion, unnecessary utilization of hospital emergency departments by children in behavioral health crisis continues to increase while utilization of alternative community based options such as Emergency Mobile Psychiatric Services is flat. Action Step: Improve Utilization and management of EMPS and provide incentives for EMPS/ED collaboration to reduce the number of youth seeking behavioral health services at EDs and increase diversion from inpatient care following an ED visit. Cultural Competence:. o Challenge: Despite considerable efforts, the Department remains challenged in its work to support the diverse needs of staff and clients regardless of their race, religion, color, national origin, gender, disability, sexual orientation, gender identity or expression, age, socio-economic status, or language. At present the Department lacks a comprehensive and integrated plan to assess, measure and promote cultural competence within the agency and with its contracted providers Action Step: Develop an annual plan for the promotion of culturally competent behavioral health practice. Action Step: Utilize a defined measure of culturally competent service delivery and systematically monitor the performance of the Department 9

10 and its contracted providers. Establish strategies and goals to reduce disproportionate minority contact and other negative outcomes indentified through the assessment process. Action Step: Amend the Scope of Service for all contracts to assure that contract language requires tangible evidence of the delivery of genderspecific and culturally competent services. Public Awareness: o Challenge: DCF spends a very small portion of its overall budget on raising public awareness and education. Many children and families lack knowledge of behavioral health disorders and/or avoid help due to discrimination and stigma. Many in the general public and in the child serving system lack sufficient understanding of MH disorders to be of assistance. Action Step: Develop strategies for identifying existing print and video educational resources and disseminating throughout the department and community. Action Step: Work with all state and local family advocacy organizations to identify opportunities for community education on Behavioral Health with a focus on local community activities. Action Step: Develop an education and public awareness plan to include at least one major community awareness project. Action Step: Work with the SDE to expand training in signs and symptoms of suicidality to all school districts throughout the state. Work with the Governor's Youth Suicide Task Force and other groups to promote. Funding and Revenue Maximization: o Challenge: The Department has taken significant steps to maximize the revenue available for the delivery of behavioral health services and used various methods to align funding sources to improve access to care and support best practices. However, there are further steps to be taken in the areas of the conversion of grants to FFS, reducing categorical barriers to access, increased utilization of joint contracting mechanisms, and further removal of regulatory barriers to evidence based and best practices. Action Step: Identify other opportunities for conversion from grant to FFS balanced with methods of limiting program growth to control costs. Action Step: Create a listing of all BH services funded across multiple systems and indicate where categorical eligibility criteria apply. Use this data to develop strategies to reduce categorical limits on access to care. Action Step: Use the catalogue of services described above to identify opportunities for shared contracting. Action Step: Pursue full implementation of the Medicaid Rehabilitation Option for children and work with DMHAS, DSS, DPH, and the DCF Licensing Division to insure that current and future licensing regulation does not provide an impediment to the delivery and reimbursement of evidence based and best practices. 10

11 I. Introduction The Department of Children and Families (DCF), established under Section 17a-3 of the Connecticut General Statutes, is one of the nation s few comprehensive, consolidated agencies serving children and their families. As described in the Report of the Governor's Blue Ribbon Commission on Mental Health (2000), "Connecticut was the first state in the nation to legislate the structure for a consolidated agency for services for children and their families. The move to integrate children's service within a single agency rather than scatter them across separate agencies was based on several premises: The mental health needs of children were too often overlooked or given too little attention within the system for adults. The developmental needs of children require a specialized set of interventions that are distinct from those that are effective for adults. There is considerable overlap in the populations of children and adolescents who have experienced abuse or neglect, those who have significant emotional disabilities and those who have been involved in the juvenile justice system. The wide range of services needed by children and their families can best be met in an agency that works in partnerships with families and the community agencies which address the needs of children, including schools, advocacy groups, and private providers of care for children." The enabling legislation established in 1974 directs DCF to provide a spectrum of behavioral health services, child protection and family services, juvenile justice services, substance abuse-related services, education services specifically acting in the capacity of a school district for committed children, and prevention services. Further, DCF is mandated to license, monitor and evaluate certain services provided by private and community providers including outpatient psychiatric clinics for children, extended day treatment services, foster homes and group homes. These legislative mandates reflect Connecticut s historical belief that the wide range of services necessary to meet the needs of children and their families can best be realized through an integrated approach that draws upon family, community and state resources. Within DCF, the Bureau of Behavioral Health and Medicine is vested with the primary responsibility to plan, administer and evaluate a comprehensive, integrated statewide system of behavioral health services, substance abuse services, medical services, and related supports for various groups of children, adolescents and their families. 2 Children and families can access state-operated or state/community funded services directly or through referrals from various sources. The goals are to (1) foster resiliency 2 This paper focuses on behavioral health care and does not include a full and comprehensive review of the Department's efforts, plans and accomplishments regarding the delivery of medical care to the children in the care and custody of the Department. However, selected medical programs and projects are reviewed towards the goal of a more integrated and holistic healthcare system. 11

12 to enable the child to function successfully at home, at school and in the community, (2) to improve family functioning and (3) support permanency for children. The family is considered a partner in all aspects of the planning, treatment, and discharge processes. To achieve this goal, DCF works with families, other caregivers, and the broader stakeholder community to ensure the availability of an array of clinically effective services for Connecticut children or adolescents with serious emotional, behavioral and/or substance abuse disorders. DCF also provides specialized behavioral health and medical services for those involved with the child protection and/or juvenile justice systems, particularly for those youth with Serious Emotional Disturbance (SED) who are at placement risk, and for those youth with special mental health or developmental needs who are transitioning out of DCF s service system. Despite this effort to consolidate children's services within a single state agency, it has been noted (Geballe, 2000) that many other agencies and systems provide, fund and/or coordinate behavioral health services for children. These other entities include The Department of Social Services, The Department of Public Health, The Judicial Branch Court Support Services Division, The Department of Corrections (16 & 17 Year Olds), The Department of Developmental Services, The State Department of Education and local school districts, and other public and private service systems. This reality, and the continuing challenge to better integrate the Department's multiple mandates has, at times, resulted in a perception of the behavioral health system for children and families as under-performing due to system fragmentation and competition for resources between agencies and mandates. Between 2000 and 2003 a trio of seminal reports were generated that, in sum, called for an overhaul and reorganization of the children's behavioral health system, both in Connecticut and across the nation. These reports include: Delivering and Financing Behavioral Health Services in Connecticut (Child Health & Development Institute, 2000) Report of the Governor's Blue Ribbon Commission on Mental Health (Governor's Blue Ribbon Commission on Mental Health, 2000) Achieving the Promise: Transforming Mental Health Care in America (Report of the President's New Freedom Commission on Mental Health, 2003) In the ensuing years and through a combination of legislative action, advocacy efforts, agency partnerships, federally funded projects, program developments, management strategies, policy changes, and other initiatives, Connecticut has been making steady progress in addressing the issues and challenges confronting the children's behavioral health system. More recently, DCF developed a strategic plan to guide agency practice for the 5 year period beginning July 1, 2008 and ending June 30, This integrated plan includes goals and activities for each of the Department's mandates including Child Welfare, Behavioral Health & Medicine, Juvenile Justice, and Prevention. Of the 48 discrete 12

13 activities outlined in the plan, 5 pertain specifically to behavioral health & medicine with the remaining activities focused on child welfare, juvenile justice, and prevention related activities. This report traces developments in the Connecticut behavioral health system over the past eight years with a particular focus on the progress made, challenges that remain and a blueprint for continuing improvement over the next five years and beyond. It is intended as a living document that will be modified and adapted to incorporate new perspectives, knowledge, and best practices. 13

14 II. Summary of Foundational Sources The three foundational reports, along with several others produced around the same time (e.g. The Surgeon General's Report, 1999 and Geballe, 2000) and elements of the Agency's Strategic Plan are fairly consistent in their recognition of key challenges facing the behavioral health service system in general, and in some cases the particular behavioral health system for children in Connecticut. Some core recommendations are shared across sources such as the need for meaningful family and consumer involvement in all aspects of planning, oversight, and care, as well as the need for better integration and coordination of care, particularly across systems (e.g. behavioral health and juvenile justice) and service sectors (e.g. residential and community based care). In addition to the elements they have in common, each report and perspective includes unique elements not addressed in the other reports. The CHDI report is unique in its focus on the carve-out of behavioral health from physical health and the specificity of recommendations pertaining to administrative and management structures (e.g. ASO, lead service agencies, etc.). The Blue Ribbon Commission Report is unique in its focus upon youth transitioning between systems and its emphasis on prevention. The President's New Freedom Report is distinctive in its emphasis upon more effective use of technology, addressing discrimination based on mental illness, and healthcare disparities in the mental health system. Finally, the DCF Strategic Plan is unique in its focus on the reduction of restraint and seclusion, the accreditation of DCF operated congregate care facilities, and the identification of intersections with the child welfare system. Considering the elements they share in common and their unique contributions to our understanding of the behavioral health service system for children and families, these four reports provide the basis for a comprehensive framework for planning, designing, and evaluating behavioral health services. The remainder of the report will utilize this framework to document the progress that has occurred in Connecticut over the last 8 years, the challenges that remain, and action steps for the future. A detailed review and analysis of the seminal reports is included as Appendix A. 14

15 III. Common Framework The Behavioral Health Service system is complex and multi-faceted. Any effort to assess the status of the system, identify gaps in care, or establish goals for the future must consider the various components of the system. A review of the issues addressed in the foundational reports reveals seven core aspects of behavioral health service delivery and system management including: 1. Service Capacity, Access and the Service Array: Children and families need to easily access the type of service they need at the time they need it. Preferably, services are accessible and provided in the community in the least restrictive setting necessary. The overall capacity of the service system in comparison to need, the variety and type of services within the array (e.g. respite care, behavioral supports, family treatment, medication, etc.) and the allocation of resources across levels of care (e.g. from standard outpatient treatment through extended day treatment to residential and inpatient care) all impact access and the sufficiency of the service system. 2. Service Effectiveness and Quality: Children and families need services that are effective and match their needs and preferences. There are many strategies and approaches to insuring the delivery of quality care. These include the provision of effective screening and assessment, the promotion of evidence based and best practices, the development and support of a competent workforce, the use of technology to support practice, and the use of data and programs of quality improvement. 3. Stakeholder Involvement: The system must be driven and informed by multiple stakeholders, particularly the children and families that receive care. Stakeholder involvement needs to be meaningful and occur at all levels of planning, design, oversight, delivery, and evaluation of behavioral health services. 4. Management of Services and Systems: The coordination of care across providers and service systems is critically important to the overall success of the system. The effectiveness and efficiency of the rules and processes regarding how services are accessed, utilization is managed, and adjustments are made to better meet child and family needs can be as important to the success of the system as the quality of the services themselves. In addition, coordination of services across child welfare, juvenile justice, adult and children s behavioral health, developmental, and healthcare service systems is critical to prevent fragmentation and to promote more efficient and integrated service delivery. 5. Cultural Competence: The Behavioral Health Service System must insure effectiveness for all of the children and families that it serves. The system must be knowledgeable of, informed by, and responsive to the variety of ethnic and cultural groups in need of care. Education and training, workforce development, 15

16 and practice modifications are necessary to effectively engage and care for all cultural groups. 6. Public Awareness: A major barrier to the effectiveness of behavioral health services is the lack of general public awareness that emotional and psychiatric problems are medical conditions, that there is no shame in seeking care, and that problems can be effectively treated. Discrimination against individuals or families based on the presence of a psychiatric disorder, or discrimination in policies that govern insurance reimbursement, can be more harmful than the condition itself. An effective service system educates the public about behavioral health care and addresses policies that are discriminatory against those with a behavioral health disorder. 7. Funding and Revenue Maximization: The behavioral health service system is funded by a patchwork quilt of state, federal, and local programs, private insurance, philanthropic organizations, school districts, individuals, families, and others. When funding sources are aligned to maximize available resources and ease access to care, children and families are well served. When funding is not well aligned the child and family can be presented with a dizzying array of rules and procedures that create barriers to access and discontinuities in care. A well functioning system maximizes all available sources of revenue and blends or braids funding streams to enhance the service array and improve access to care. Within each of the seven categories outlined above there are various components and sub-categories. For example, within the section on Service Capacity and Access, resource allocation is an important subcategory. Resource allocation concerns the analysis and adjustment of the relative allocation of resources within the array of services including outpatient and community based services versus residential or institutional care, clinical services versus adjunct or supportive services, or other service parameters. Similarly, within the section on Funding and Revenue Maximization, efforts to structure the State's Medicaid Plan to better fund evidence based practices is itself multi-faceted and complex. It should also be noted that the seven categories of the Common Framework are somewhat arbitrary and in fact, may overlap in several areas. For example, efforts to expand the service array often involve revenue maximization. Similarly, the cultural competence of the service system can be significantly improved by the inclusion of a diverse group of stakeholders that mirror the population being served on critical factors such as age, gender, race, and ethnicity. The following sections will track the seven categories of the Common Framework and identify (a) one or more indicators of a well functioning system, (b) evidence of progress, (c) remaining challenges and (d) action steps for each subcategory. The outline for the Common Framework is provided as Appendix B. 16

17 IV. Overview - Progress, Challenges, & Recommendations Beginning in 2000 and proceeding through the present, DCF, in partnership with other stakeholders in children s behavioral health, including family organizations, the Governor, the Office of Policy and Management, the Connecticut State Legislature, the Department of Social Services, the Department of Mental Health and Addiction Services, the Department of Developmental Services, the Court Support Services Division of the Judicial Branch, advocacy organizations, provider groups, researchers, academics and others, has been engaging in a systematic effort to address the issues and implement many of the recommendations contained in the aforementioned foundational reports. Organized within the Common Framework outlined above, the multiple initiatives, projects, programs, and tasks represent a comprehensive and systematic effort towards system improvement. While many challenges remain and many problems persist, the number and magnitude of accomplishments represent true progress towards the goal of a transformed system. Despite the significant progress that has been made, it is important to consider this in the context of the overall magnitude of the problem. Between 7% and 9% of children and youth in the United States meet the criteria for serious emotional disturbance (SED) indicating the presence of a psychiatric disorder that seriously interferes with functioning in the home, school, and/or community. Most recent estimates are that up to 20% of children and youth have some form of psychiatric disturbance and upwards of 70% do not receive treatment for their disorder 3. In Connecticut, this translates to an estimated 60,000 to 76,000 children and youth with SED and up to 100,000 additional youth with some form of psychiatric disturbance requiring specialty care. It is also well documented that rates of psychiatric disorder in children and adolescents are even higher within disadvantaged groups including children in poverty and those involved with the child protective service or juvenile justice systems. Despite having one of the highest state per capita incomes in the country, Connecticut cities continue to have some of the highest child poverty rates in the nation. Effective intervention for children with behavioral health needs is critically important, especially when considering that recent epidemiological studies estimate that half of all adults will meet the criteria for a psychiatric disorder at some point in their life. In addition, half of all behavioral health disorders in adults originated during childhood 4. In addition, children and youth in the child welfare and juvenile justice systems are at significantly higher risk for traumatic experience and related psychiatric 3 Costello, E Jane Ph.D.; Egger, Helen M.D.; Angold, Adrian M.R.C.Psych. 10-Year Research Update Review: The Epidemiology of Child and Adolescent Psychiatric Disorders: I. Methods and Public Health Burden. Journal of the American Academy of Child & Adolescent Psychiatry. 44(10): , October Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States Results From the National Comorbidity Survey Ronald C. Kessler, PhD; Katherine A. McGonagle, PhD; Shanyang Zhao, PhD; Christopher B. Nelson, MPH; Michael Hughes, PhD; Suzann Eshleman, MA; Hans-Ulrich Wittchen, PhD; Kenneth S. Kendler, MD Arch Gen Psychiatry. 1994;51(1):

18 disorders. Up to 70% of children in the child welfare system have experienced significant trauma which often contributes to a cascade of psychiatric (depression, anxiety, & behavioral disorders, etc.), social (delinquency, crime, poor educational adjustment, etc.), and medical problems (health risk behaviors, heart disease, diabetes, etc.) 5 Research has clearly demonstrated that early intervention is far superior to waiting until problems are entrenched, educational opportunities have been lost, and lives are set off on the wrong track. Similar to every other state in the nation, Connecticut has far more children with behavioral health needs than the combined public and private systems have the capacity to serve. Correcting this monumental gap between what is available and what is needed, will require a significant infusion of new resources as well as improved effectiveness and efficient management of existing services. In addition, behavioral health problems are exacerbated by the many stresses that face our most vulnerable families including poverty, lack of educational and vocational opportunities, crime, violence, lack of healthcare, lack of safe/affordable housing, and other social problems. For many of the families in greatest need, the only chance for success lies in a multimodal approach that addresses basic needs while offering therapeutic treatment and supports. The following sections of this paper will review each of the seven (7) components of the framework. 5 Edwards, Valerie J., Holden, George W., Felitti, Vincent J., Anda, Robert F. Relationship Between Multiple Forms of Childhood Maltreatment and Adult Mental Health in Community Respondents: Results From the Adverse Childhood Experiences Study Am J Psychiatry :

19 V. Service Capacity and Access Increasing Capacity Increasing Capacity - Indicator: When the overall capacity of the service system approaches the ability to serve all the children and families that can be reliably estimated to require care, service capacity can be characterized as adequate. However, even if overall capacity is adequate, geographic sub-areas may continue to be under-resourced and particular subpopulations (e.g. Spanish speaking families) may be underserved. Increasing Capacity - Progress: Between 2000 and 2008 the Capacity of the community service system has expanded significantly to better serve the children and youth of Connecticut. Through a combination of DCF & CSSD grant funding, the availability of evidence based and intensive outpatient services in Connecticut has expanded dramatically resulting in one of the most comprehensive service arrays in the nation. In addition, the CTBHP has developed the Enhanced Care Clinic Program to increase the service capacity and access to care for outpatient clinics across the state. DCF's development of over 50 Level II Therapeutic Group homes created the opportunity for hundreds of children with complex needs to receive intensive services and attend school in the community. Specific examples of service expansion are described below: Care Coordination: A community based service where paraprofessional staff members provide care management services and access to flexible funding to families of children with serious emotional disturbance. Target Population: Children with serious emotional disturbance at risk for or returning from out of home care and engaged in 2 or more services requiring coordination of care. Capacity: In the department expanded care coordination capacity from 16 to 60 care coordinators to serve children and families with serious emotional disturbance. The current care coordination program has the capacity to serve approximately 1400 families per year. Outcomes: In 2004, an evaluation completed by the Child Health and Development Institute (CHDI) found that the children and youth being served in the care coordination program met target population criteria, the program "had considerable success in securing services" to meet family needs, parents and youth highly valued the program, and the program adequately reflected system of care principles as indicated by the Wraparound Fidelity Index. 19

20 MST: Multi-Systemic Therapy (MST) is one of the most well researched and effective evidence based programs in the world. MST provides intensive services in the home and community to youth and their families. Target Population: Youth with serious behavioral disorders and their families. Capacity: In 1998 the first MST team in CT was funded as an aftercare program for JJ youth discharged from residential care. Since 1998 the program has been growing steadily through the addition of MST teams by both DCF and CSSD, and the development of in-state capacity to provide quality assurance, fidelity management, consultation and support to providers. DCF added additional teams in 2000 and In 2003 & 2004, the department introduced two MST programs for specialty populations; MST- Building Stronger Families designed for children and families involved with the child welfare system, and MST-Problem Sexual Behavior which provides follow-up care to youth discharged from residential care and on parole for problem sexual behaviors. In 2006, DCF funded 2 additional MST teams to serve Bridgeport and the Manchester/Hartford areas. Between 1999 and 2008, DCF Funding of MST has grown from $400,000 to $4,556,403. DCF funded MST has the capacity to serve over a thousand families each year. In 2008 there were 27 MST teams funded by both DCF and CSSD. Outcomes: An evaluation of MST implementation in Connecticut conducted by the Connecticut Center for Effective Practice (CCEP) in found that the Connecticut teams were having rates of success comparable to those reported in the literature for implementation of MST with fidelity. According to the study " the majority of children and youth who completed MST were living at home, attending school, and had not been arrested since the beginning of the program." In addition, the study tracked the post treatment recidivism of MST recipients and found that they were 15%-20% less likely to recidivate compared to comparable youth receiving comparable care. Although this may seem like a relatively small improvement the report notes that previous analyses suggest that "even a small reduction in recidivism (anywhere from 7%-10%) would be sufficient to pay for all of the juvenile justice services currently being offered by the state." MDFT: Multi-Dimensional Family Therapy is an intensive family and evidence-based treatment for children and youth based on the principles of strategic and structural family therapy. Target Population: Children with serious behavioral problems and substance abuse and their families. Capacity: In April, 2002, CT got its 1 st MDFT team when it launched the Hartford Youth Project as a part of the federal initiative called the "System of Care for Youth." MDFT was one of the services provided to the substance abusing youth served by this project. In 2003, 4 additional MDFT teams were 20

21 funded to serve substance abusing youth & their families in 4 DCF area offices. In 2004, DCF established in-state capacity to provide MDFT consultation & training for regular MDFT teams to occur by a provider in CT. In 2005 & 2006, the equivalent of four additional teams were added to the service system, both jointly funded by DCF & CSSD. These programs provide MDFT to families of girls discharging from the CSSD brief respite programs in Waterbury & New Haven. In 2006, 5 providers were funded to provide MDFT - Family Substance Abuse Treatment Services (FSATS). Funding for MDFT has grown from $440,000 in 2004 to $2,177,621 in The 14 teams serve 350 families annually. Outcomes: Recent program improvements include the integration of the Global Assessment of Individual Needs (GAIN) nationally recognized standardized assessment process into MDFT practice, and training in and delivery of a group curriculum for adolescents focusing on preventing sexually transmitted disease and HIV. Similar to the implementation of MST, Connecticut has been successful in implementing MDFT with fidelity to the evidence-based model and is achieving comparable outcomes to those documented through randomized controlled trials and that are superior to residential care and/or "treatment as usual." IICAPS: Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) is designed to address the behavioral health needs of children/adolescents and their families. Target Population: Children experiencing emotional, behavioral, and/or psychiatric difficulties at risk of requiring out-of-home clinical care (psychiatric hospitalization or residential treatment), or returning home from out-of-home care, and their families. Capacity: Developed at Yale Child Study Center, DCF funded an expansion of IICAPS throughout Connecticut beginning in Initially funded by state grants, IICAPS transitioned to fee-for-service under the Connecticut Behavioral Health Partnership in During SFY08, DCF collaborated with CSSD and DSS to expand statewide access to IICAPS for youth involved with juvenile probation. Currently there are 14 provider agencies delivering IICAPS services, with some agencies operating more than one IICAPS site. The number of cases served during each of the last three fiscal years is presented below. SFY06 SFY07 SFY Outcomes: From the most recent QA report on IICAPS, "year-to-date data indicate a 36.8% decrease in psychiatric inpatient admissions, 32.4% decrease in ED visits, and an 42.9% decrease in residential treatment 21