Outcomes of Systems of Care

1. Outcomes of Systems of Care Shannon Robshaw, MSW Senior Advisor for System Design and Implementation The Technical Assistance Network for Children’s Behavioral Health The Institute for Innovation and Implementation University of Maryland, School of Social Work December 6, 2018

2. 13-20% of children and adolescents have a diagnosable mental, emotional, or behavioral disorder, and this costs the public $247 billion annually. • 50% of adult mental illness occurs by age 14; 75% by age 24 • 1 in 10 children in the US suffer from a serious emotional disturbance (SED) • In 2015, suicide was the third leading cause of death among youth ages 10-14 and the second leading cause of death between ages 15-34.

3. “…mental health problems in youth are likely to become one of the main public health challenges of the twenty-first century.” - WHO

4. Mental Health Disorders are the MOST Expensive Conditions in Childhood • While children who receive mental health services are less than 10%of the overall Medicaid child population, they account for 38% of all Medicaid child expenditures (Pires, Grimes, Allen, Gilmer, & Mahadevan, 2013). • The highest expenditures for all types of insurance and conditions (including physical conditions) among children 0 – 17 were for the treatment of mental disorders: Costing $13.8 billion in 2011 (AHRQ, 2015).

6. Children Using Behavioral Health Care in Medicaid with Top 10% Highest Expenditures • Have mean expenditures of $46,959 • BH expense: $36,646 • PH expense: $10,314 Expense is driven by use of behavioral health, not physical health care Pires, S., Gilmer, T., McLean, J. and Allen, K. 2018. Faces of Medicaid Series: Examining Children’s Behavioral Health Service Use and Expenditures:, 2005-2011. Center for Health Care Strategies: Hamilton, NJ. Available at: https://www.chcs.org/resource/faces-medicaid-examining-childrens-behavioral-health-service-utilization-expenditures/

7. Social Determinants of Health Wraparound focuses across life domains, including social determinants of health

8. Children and Youth with Serious Behavioral Health Conditions Are A Distinct Population from Adults with Serious and Persistent Mental Illness Have different mental health diagnoses (ADHD, Conduct Disorders, Anxiety; not so much Schizophrenia, Psychosis, Bipolar as in adults), and diagnoses change often. Do not have the same high rates of co-morbid physical health conditions. Coordination with other children’s systems (CW, JJ, schools) and among behavioral health providers, as well as family issues, consumes most of care coordinator’s time, not coordination with primary care, though primary care coordination also important. Are multi-system involved – two-thirds typically are involved with CW and/or JJ systems and 60% may be in special education – systems governed by legal mandates. To improve cost and quality of care, focus must be on child and family/caregiver(s) – takes time – implies lower care coordination ratios and higher rates. Pires, S. March 2013 Customizing Health Homes for Children with Serious Behavioral Health Challenges. Human Service Collaborative. Washington, D.C.

9. Definition of a System of Care • broad, flexible array of effective services and supports for a defined population • organized into a coordinated network, integrates care planning and management across multiple levels • culturally and linguistically competent • meaningful partnerships with families and youth at service delivery, management, and policy levels • supportive policy and management infrastructure, • data-driven. Pires, S. (2010). Building systems of care: A primer, 2nd Edition. Washington, D.C.: Human Service Collaborative for Georgetown University National Technical Assistance Center for Children’s Mental Health.

10. CMS/SAMHSA May 2013 Joint Information Bulletin https://www.medicaid.gov/federal-policy-guidance/downloads/cib-05-07-2013.pdf

11. National evaluation of Children’s Mental Health Initiative (CMHI) • SAMHSA-funded initiative • 106 sites initially funded from 2002 to 2010 • More than 134,000 children and youth have received services • Data collected between October 2003 and December 2014 on outcomes of children and youth receiving SOC services

12. Demographics of Study Participants, Grantees Initially Funded 2002–2010 (n = 15,669)

13. Most Common Diagnoses of Children Served by Grantees Initially Funded 2002–2010 Diagnoses based on DSM–IV criteria. *Because children may have more than one diagnosis, percentages for diagnoses may sum to more than 100%.

14. The National Evaluation’s ROI Study • Youth served in systems of care are less likely to receive psychiatric inpatient services. From the 6 months prior to intake to the 12-month follow up, the average cost per child served for inpatient services decreased by 42%. • Youth in systems of care are less likely to be arrested, resulting in a55% reduction in average per-youth arrest-related costs.

15. Enrollment in a SOC resulted insignificantly improved clinical outcomes Improvement in behavioral & emotional symptoms Fewer internalizing and externalizing symptoms Improvements in levels of clinical impairment Fewer suicidal thoughts & attempts

16. Clinical Outcomes As measured by the Child Behavior Checklist (CBCL), upon entering services, 76.1% of children and youth had significantly elevated levels of symptoms. This number fell to 53.8% in 6 months after beginning services, and further to 48.7% after 12 months. • Internalizing symptoms: The number of children and youth who had significantly elevated levels of internalizing symptoms such as depression and anxiety was 61.0% at entry into services, but fell to 51.7% after 6 months and 47.4% after 12 months. • Externalizing symptoms: For externalizing symptoms, such as aggression and rule-breaking, the proportion of children and youth who had significantly elevated symptoms fell from 74.7% at intake to 64.6% after 6 months and further to 60.3% after 12 months.

17. Clinical Outcomes • Clinical impairment: Upon entering services, 76.8% were rated as showing significantly high levels of impairment on the Columbia Impairment Scale (CIS). This was reduced to 67.5% after 6 months and 63.8% after 12 months of services. • Suicidal thoughts: Upon entering services, 28.4 % of children and youth experienced suicidal thoughts in the previous 6 months. After receiving SOC services, this proportion fell to 19.5% after 6 months and 16.2% after 12 months. At entry into services, 8.5% of children and youth had made a suicide attempt in the previous 6 months. After 6 months receiving services, this rate fell to 4.8% after 6 months and 4.0% after 12 months.

18. After enrollment in a SOC, youth were • less likely to be arrested

19. Juvenile Justice Outcomes Delinquency Survey, Revised (DS-R) Intake through 24-month follow-up.

20. After enrollment in a SOC, children were treated in less restrictive levels of care

21. Least Restrictive Care Multi-System Services Contacts (MSSC) Intake through 24-month follow-up. * Inpatient Hospitalization: p < .05. All other trend lines: n.s.

22. Enrollment in a SOC resulted inimproved educational outcomes • Higher rates of educational achievement • Improved school attendance • Fewer suspensions & expulsions • Higher rates of educational achievement • Improved school attendance • Fewer suspensions & expulsions

23. Education OutcomesOutcomes • School Attendance: 53.8% improved after enrollment in SOC (intake to 24-month follow-up) (n = 394) • School Performance: 48.2% improved (n = 251) Based on Education Questionnaire, Revised (EQ-R

24. Systems of Care Work • Reduced behavioral & emotional problems • Improved functioning in school & in the community • Increased behavioral & emotional skills • Reduced suicidal ideation & attempts • Reduced substance use problems • Improved ability to build relationships

25. Cost savings are realized • Fewer out-of-home placements/diversion from higher levels of care • Fewer ER visits • Better school-related outcomes • Fewer arrests • Greater capacity for caregivers to work

26. Data Sources • National evaluation of the CMHI that funded over 250 local SOCs since its start in 1993 with 6-year SOC development grants • Evaluation of the Medicaid Psychiatric Treatment Facility Psychiatric Residential Treatment Facilities (PRTF) Waiver Demonstration • Published literature • State and communities that have conducted their own analyses

27. Common Characteristics of the SOCs • Serve population of children and youth with serious and complex disorders; priority on risk of out‐of‐home placement • Array of home‐ and community‐based treatment services and supports • Individualized, wraparound approach • Intensive care management at low ratios • Goal of diversion and/or return of children and youth from inpatient and residential treatment settings • Evidence of positive clinical and functional outcomes • Some may not use the term “SOC” but approach reflects SOC characteristics

28. System of Care Outcomes • Federal Children’s Mental Health Initiative (CMHI) launched in 1993 to fund communities, tribes, and territories to implement the system of care (SOC) approach • National evaluation of the CMHI found • Positive outcomes for children and families • Improvements in systems and services • Better investment of limited resources • Results have led to efforts to expand implementation of the approach so that more children and families benefit

29. Examples: National CMHI Evaluation

30. Examples: PRTF Evaluation

33. New Jersey Children’s System of Care ObjectivesTo Help Youth Succeed… At Home Successfully living with their families and reducing the need for out-of-home treatment settings. In School Successfully attending the least restrictive and most appropriate school setting close to home. In the Community Successfully participating In the community and becoming independent, productive and law-abiding citizens.

34. New Jersey Language Is Important Client Case Placement

35. New Jersey Low Intensity Services Out of Home Intensive In-Community • Wraparound – CMO • Behavioral Assistance • Intensive In-Community Out of Home Lower Intensity Services • Outpatient • Partial Care • After School Programs • Therapeutic Nursery Service Array Expansion to Reduce Use of Deep End Services Prior to Children’s System of Care Initiative Today

36. New Jersey Out of home treatment is an intervention, not the final destination! Out of Home Treatment in a SOC Key points to remember…. • Removing a child from their natural environment is a life altering decision • The pursuit of out of home treatment is a Child Family Team (CFT) decision that should be made with clear purpose AND expectations

37. New Jersey Building In State Capacity and Increasing Community Based Services

38. New Jersey • High Family Satisfaction • RTC length of stay decreased by 25% • Closure of state child psychiatric hospital and state operated RTC’s • Over 94% of youth accessing Mobile Response stay in current living situation • 250% Increase in families accessing Mobile Response since 2004 Youth involved with juvenile justice have access to System of Care services • NJ was maintaining 17 county juvenile detention centers. Today there are 11 • Decline in juvenile detention average daily population by 60% since 2004 • 6,000 less youth admitted to detention in NJ since 2004

39. Oklahoma • Oklahoma Systems of Care (OKSOC) began in 2 communities in 1999. • State and federal financing and the active sponsorship of the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) have helped OKSOC expand statewide to all 77 counties and increase the number of families and youths served. • OKSOC supports, maintains, and grows local systems of care communities by providing infrastructure, training and technical assistance, and staff professional development.

40. Oklahoma Specialty BH Services Community Support Housing Transportation Food Specialty Healthcare Linkage Assessment Linkage Assessment PCMH CHILDREN’S HEALTH HOME I N T E G R A T I O N Access to physician Consultation with HH EPSDT screening Immunization Referral to specialty care Child & Family SOC Team Schools Link Engage Advocate Support Wraparound Psychiatrist Medication Management Therapy Family Support Wellness Activitiess IDEA Transitions Education OJA Community Safety Placement Team Approach One Care Plan Support Transition to/from hospital care Team Approach One Care Plan Safety Placement(s) Permanency OKDHS

42. Wraparound Outcomes

43. Wraparound Outcomes

44. Wraparound Outcomes

45. Wraparound Outcomes

46. Louisiana • The Louisiana Coordinated System of Care (CSoC) began March 1, 2012 with the goals of: • Reducing state’s costs by leveraging Medicaid and other funding sources as well as increasing service effectiveness and reducing duplication across agencies • Reducing out-of-home placement for children currently in placement and future admissions of children and youth with significant behavioral health challenges and co-occurring disorders • Improving the overall outcomes of children and their caregivers

47. Louisiana Decreased utilization of costly restrictive settings • Only 4.7% of the children enrolled in CSoC spent any days in an inpatient hospital setting, with an average length of stay of only 6 days.  • 54.5% decrease in the use of the emergency room • 91% of the children discharged or dis-enrolled from the program are in a home and community based setting. Magellan 2018

48. Louisiana Significant improvements in overall functioning • Over the average length of enrollment (12 months), CSoC children demonstrated significant improvements in overall functioning. • 73% of the children discharged demonstrated improvements in clinical functioning • 91% of members reporting positive overall satisfaction with wraparound process • 87% of members reporting positive satisfaction with progress since starting CSoC Magellan, 2018

49. Does wraparound work?Evidence from Nine Published Controlled Studies is Positive *Included in 2009 meta-analysis (Suter & Bruns, 2009)

50. Outcomes of wraparound (9 controlled, published studies to date; Bruns & Suter, 2010) Better functioning and mental health outcomes Reduced recidivism and better juvenile justice outcomes Increased rate of case closure for child welfare involved youths Reduction in costs associated with residential placements