Shairi Turner MD, MPH Chief Medical Director September 25-26, 2007 Walter A. McNeil, Secretary

1. Improving Outcomes for Youth in the Juvenile Justice System Shairi Turner MD, MPH Chief Medical Director September 25-26, 2007 Walter A. McNeil, Secretary

2. The Office of Health Services • First established in 2005 • Role: To provide oversight for the delivery of medical, mental health, substance abuse and developmental disability services to the youth adjudicated delinquent. • Majority of services delivered by contracted providers.

3. The Office of Health Services Serves • Over 150,000 youth • 4 Major Program Areas • All of Headquarters • 55 State Clinical Staff

4. The Office of Health Services

5. Office of Health Services Responsibilities • Data Collection • Staff Training • Surveillance • Quality Assurance • Interagency Collaborations • Clinical Assistance • Policy and Rule Development • Contract Enhancement and Standardization • Legislative Support

6. A Profile: Who Are Our Youth? • Impoverished • Minorities • Males • Mentally Ill • Substance Abusers (Co-Occurring Disorders) • Medically complex and neglected • High Risk behaviors (STDs, Teen Pregnancies) • Developmentally Disabled • Disenfranchised families in crisis • Delinquent and Dependent

7. Primarily…… Non-violent minority males referred for misdemeanor offenses

8. Our Girls • One of three youth referred to the Department for delinquency is a girl. • 45% of those referred are African-American Girls • 21% of Detention admissions • Extensive trauma histories • 50-75% suffer from PTSD • Unique health needs

9. 3 Primary Issues:Medical Mental Health / Substance Abuse (Co-Occurring Disorders)Developmental Disabilities

10. Medical

11. I have 2 external pacemakers for my heart, one works and the other does not, I pull on them to get the staff worked up * * * I give myself extra insulin so I can eat more food Their words…

12. Overlying Concerns: • Complex conditions • Limited resources • Ensuring accountability with privatization • Systemic Barriers

13. Services Provided to Youth • Obstetrical Services (pre and post-natal) • Gynecological Services • Infant care • Emergency Services • Health Education • Intake Screenings • Physical Assessments • Sick Call Encounters • Immunizations • Medication Management • Acute and Chronic Disease Management

14. The Health Status of Incarcerated Youth Baseline Health • Asthma • Diabetes • Dermatologic Problems • Dental Caries • Hypertension • Obesity • Seizure Disorders • Traumatic Injuries • Orthopedic Injuries Greater Risk for • Sexually transmitted diseases • Hepatitis B and C • HIV/AIDs • Teen Pregnancy • TB exposure • Mental Illness • Substance Abuse

15. Complex Conditions • Cardiac Disorders • Cystic Fibrosis • Inflammatory Bowel Disease • Existing and New Cancers/Tumors • Sickle Cell Disease • Kidney Failure *A Medically Underserved Population*

16. Limited Resources • Insufficient physician and nursing services • Over-reliance on direct care staff • Diversion to State-operated programs • No specific funding for dental services *Inadequate treatment *

17. Ensuring Accountability • Medical Services Privatized • Monitoring through contracts • Laypeople overseeing medical providers • Limited technical assistance *Insufficient Oversight*

18. Systemic Barriers • Youth in any State-Operated Detention or Residential facilities OR any High/Maximum risk programs lose Medicaid Eligibility* • Youth who become ineligible are disenrolled not suspended from Medicaid** *Federal Regulations ** State Regulations *Continuity of care jeopardized*

19. Addressing: Complex Conditions Proposed Recommendations • Small programs with 24 hour nursing services and expanded physician coverage for medically complex youth. • Diversion of medically complex youth into community based treatment programs.

20. Addressing: Limited Resources Proposed Recommendations • Increased funding for medical and dental services. • State employed medical staff

21. Addressing: Accountability Proposed Recommendation State-employed Clinical staff to provide assistance, oversight and improved accountability.

22. Addressing: Systemic Barriers Proposed Recommendations: • Suspension of Medicaid instead of dis-enrollment. • Improved collaboration with the Department of Children and Families upon discharge.

23. Mental HealthandSubstance Abuse

24. My mother put cigarette butts out on my head when I was 2 years old. * * * I cannot tell you how many times my father raped me when I came home from school. * * * I started smoking marijuana with my parents at the age of 8. Their words…

25. Services Provided to Youth • Specialized Treatment Beds • Mental Health Overlay • Behavioral Health Overlay • Substance Abuse Overlay • Sex Offender Services • Intensive Mental Health • Comprehensive Mental Health • Re-Engineering underway • PACT Risk Needs Assessment • MST/FFT • Suicide Screenings • Psychological Assessments • Counseling • Crisis Intervention • Psychiatric Services • Medication Management

26. Overlying Concerns: • Complex conditions • Limited resources • Ensuring accountability with privatization • Systemic Barriers

27. Complex Conditions Our survey on DJJ youth in Need of Specialized Services • 49% of youth in DJJ programs had a diagnosed DSM-IV mental illness and an additional 14% demonstrated behaviors which suggested a mental health problem (63%) • 35% of the youth had a diagnosed DSM-IV substance-related disorder and an additional 30% demonstrated behaviors which suggested a substance abuse problem (65%) • 52% of the children reported for all substance-related disorders had a diagnosis of Substance Abuse AND 36% had a diagnosis of Poly-substance Dependence.

28. 50 Boys 40 Girls 30 Percent 20 10 0 MDD PTSD ConductD/O Diagnosis related to Physical Abuse Diagnosis relatedto Sexual Abuse Dual Diagnosis Mental Illness and GirlsDJJ Diagnosis by Gender

29. Limited Resources • Lack of Specialized Early Intervention Programs • Detention funded for crisis intervention not treatment • Long waits for specialty MH/SA beds • Residential Programs under-funded, not intended for complex mentally ill youth. • Comprehensive Mental Health beds in DJJ have a per diem nearly HALF of the state inpatient psychiatric per diems. *Inadequate treatment *

30. Ensuring Accountability • Mental Health, Substance Abuse and Psychiatric Services Privatized • Monitoring through contracts • Laypeople overseeing mental health and substance abuse providers. • Limited technical assistance *Insufficient Oversight*

31. Systemic Barriers • Lack of Mental Health Infrastructure in Florida. • Parents press charges vs. child to access mental health services in DJJ. • Limited access into Statewide Inpatient Psychiatric Placements (SIPPs) • Mental Health Issues interface with Zero Tolerance Policies.

32. Systemic Barriers • Lack of diversion (or less restrictive) alternatives in the community. • Limited Aftercare Services • Inadequate discharge planning • Medicaid Reform and Access

33. Addressing: Complex Conditions Proposed Recommendations • Culturally Competent Services • Evidence-Based studies utilize white youth • Comprehensive Gender Specific Programs • Effective girls programming not yet achieved • Trauma component critical • Equivalent services devoted to MH and SA needs.

34. Addressing:Limited Resources Proposed Recommendations • Reduction in demand for services by diversion of low risk youth to community based programs • Diversion of mentally ill/substance abusing youth to alternative community programs • Advancement of Risk-Needs tool to ensure proper placement and progress.

35. Addressing:Accountability Proposed Recommendation State-employed Clinical staff to provide assistance, oversight and improved accountability.

36. Addressing:Systemic Barriers Proposed Recommendations • Inter-agency and community collaboration to ensure appropriate: • Placement • Aftercare • Case management

37. Developmental Disabilities

38. Their Words… * * * What is a treatment goal and why is it keeping me from going home? * * * I am not stupid, I just cannot learn the way they are teaching me.

39. National Data • 70% of all juvenile delinquents have educational disabilities (LD or ED). • Youth are more than twice as likely to commit a delinquent offense as their non-disabled peers. • Youth with learning disabilities adjudicated at about twice the rate as non-disabled youth, and LD youth have greater recidivism rates.

40. Complex Conditions • Youth have developmental disabilities AND Mental health/substance abuse issues.

41. Limited Resources • Currently few beds to serve Developmentally Disabled youth. • Specialized training required for staff to interact with developmentally disabled AND mentally ill youth. • No specific funding for disability overlay services

42. Systemic Barriers • Incompetent to Proceed Process • Youth can spend up to 379 days in an ITP program and be found “Non-restorable”. • Private APD providers

43. Addressing:Developmental Disabilities Proposed Recommendations • Additional Resources to serve disabled youth • Multi-disciplinary workgroup to review ITP process

44. For these are all our children.We will all profit by, or pay for, whatever they become.- James Baldwin