EVIDENCE BASED PRACTICE INSTITUTE

1. SAFE-WA PARTNERS MEETING March 18, 2009 Tacoma, WA EVIDENCE BASED PRACTICE INSTITUTE Division of Public Behavioral Health and Justice Policy University of Washington

2. Outline • Children’s Mental Health Services • Children’s Mental Health in Washington State • House Bill 1088 • Evidence Based Practice Institute • Directions for the Future

3. Prevalence of Childhood Mental Health Disorders • By year 2020, WHO predicts childhood mental health disorders will rise proportionately by 50% internationally, becoming 1 of top 5 most common causes of morbidity, mortality, disability in children • In Washington State, ~19,000 youth are served each year by the foster care system • Youth in the foster care system experience high rates of MH problems • Less than ½ of youth in foster care receive MH services tailored to their unique needs

4. Use of EBTs: Strength of the Evidence • More than 1500 published clinical trials on outcomes of psychotherapies for youth • 6 meta-analyses of their effects • More than 300 published clinical trials on efficacy of psychotropic medications • Approximately 50 field trials of community-based services • Dozens of preventive intervention trials (34 effective interventions cited by Greenberg et al, 1999)

5. Use of EBTs: Disconnect between “Science” & “Service” • 80% of programs reviewed for inclusion in the Blueprints for Violence Prevention programs had no evaluation(Elliot, 1999) • 95% of school-based mental health programs reviewed had no evaluation(Rones & Hoagwood, 2000) • The most popular and widely-implemented programs have no evidence behind them, and some do harm(Elliot, 1999; Weisz, et al., 1995; 2001)

6. Status of Mental Health System and Evidence Based Treatments • President’s Commission reports public mental health system is “in a shambles” (President’s new Freedom Commission Report, 2004) • 90% of public mental health services do not deliver treatments programs or services that have empirical support (Elliot, 1999; Henggeler et al., 2003)

7. Validity of EBTs: Results of Studies with Minority Populations • Well-controlled studies looking at outcomes of mental health care for minorities are relatively rare • Studies of EBTs indicate that African American and Latino youth respond to interventions similarly to white youth • CBT for anxiety(Treadwell et al., 1995) • Parent training for disruptive disorders (Reid et al., 2001; Barrera et al., 2002) • Multisystemic Therapy for youth at risk of out-of-home placement due to delinquent behavior, substance use, or emotional disturbance(Borduin et al., 1995; Henggeler et al., 1992)

8. Developing an Evidence Based Culture • Washington State committed to promoting a more wide-spread culture supporting EBT’s • SB 5763 (2005) requires RSNs to develop criteria for implementing EBTs. • HB 1088 (2007) requires the access-to-care standards and the benefits packages for children's mental health services be revised, and that the system of care be based on defined elements and evaluated on outcome-based performance measures. • HB 1373 (2009) will improve mental health outcomes for children and the families who care for them by allowing early access to care before problems become too difficult and expensive to treat. • SB 5141 (2009) proposes funding of a pilot program to increase parental participation in evidence-based programs by providing incentives for parents already involved in rehabilitation of their children. • HR 2 State Children’s Health Insurance Program Reauthorization Act of 2009 (SCHIP) • Children’s Mental Health Initiative established a matrix of EBTs for use with youth with behavioral health disorders. • Braam Oversight Panel recommends implementing best practices for youth in the foster care system. • 2006 legislative proviso provided support for pilot implementation of EBTs in children’s mental health and child welfare. • MacArthur Models for Change Program • Reinvesting in Youth • Robert Wood Johnson Reclaiming Futures

9. Medication and MH TOTAL = 40,526 Children on psychiatric medication 56% received NO outpatient mental health care* 22,498 children 44% received outpatient mental health care 18,028 children Drug classes include: Antidepressant Antipsychotic Antianxiety Antimania ADHD (FY ’04)

10. Implementation Challenges • Clinical • Cultural adaptations • Change familiar practices/tension around manualized treatment • Systemic • Changing administrative processes • Workforce development • Salaries don’t support staff retention • Financial • Often takes new funding for start up • Mechanics of reimbursement

11. House Bill 1088 andthe Children’s Evidence Based Practice Institute

12. Overview of HB1088 • Legislature’s intentions • Elements of children’s mental health system • Outcome-based performance measures • Revised children’s mental health benefit package • Medication Management and care coordination • Improved access and coordination • Facilitating Medicaid Eligibility • Healthy Options • Evidence-Based Practice Institute • Goals • Responsibilities

13. HB1088: Support to substantially improve the delivery of children’s services through the development & implementation of a system that: • Values early identification, intervention, and prevention • Coordinates existing categorical children’s mental health programs and funding • Treats each child in the context of his/her family, and provides services and supports needed to maintain a child with his/her family and community • Integrates families into treatments through choice of treatment, participation in treatment, and provision of peer support • Focuses on resiliency and recovery • Relies to a greater extent on evidence-based practices • Is sensitive to the unique cultural circumstances of children and color and children in families whose primary language is not English • Integrates educational support services that address students’ diverse learning styles • Blends categorical funding to offer more service and support options to each child

14. Elements of a children’s mental health system Legislative goals by 2012: • A continuum of services from early identification, intervention, and prevention through crisis intervention and inpatient treatment • Equity in access to services for similarly situated children • Developmentally appropriate, high quality, and culturally competent services available statewide • Treatment of each child in the context of his/her family and other person that are a source of support and stability in her/her life • A sufficient supply of qualified and culturally competent children’s mental health providers • Use of developmentally appropriate evidence-based and research-based practices • Integrated and flexible services to meet the needs of children who are at risk of out-of-home placement or involved with multiple child-serving systems

15. Effectiveness shall be determined through the use of outcome-based performance measures • The Evidence Based Practice Institute, in consultation with parents, caregivers, youth, and others, shall develop outcome-based performance measures such as: • Decreased emergency room hospitalization • Decreased psychiatric hospitalization • Decreased rates of chemical dependency • Lessening of symptoms • Decreased numbers of out of home placement and runaways • Decreased involvement with the juvenile justice system • Improved school attendance and performance with fewer suspensions/expulsions and improved rates of graduation and employment • Reductions in use of prescribed medication • Decreased use of mental health services upon reaching adulthood for mental disorders

16. Develop revised children’s mental health benefit package • Strong consideration given to: • Developmentally appropriate evidence-based and research-based practices • Family-based interventions • The use of natural and peer support • Community support services • Review of other states’ efforts • Recommend revisions to legislature by January 1, 2009

17. Improve Medication Management and care coordination • Develop and implement policies to improve prescribing practices • Improve quality of children’s mental health therapy • Improve communication and care coordination btw primary care and mental health providers • Prioritize care in the family home • Identify children with emotional/behavioral disturbances who may be at high risk due to a variety of reasons • Review and evaluate appropriateness of psychotropic medications given to children under 5 years of age • Track prescriptive practices with goal of reducing use of psychotropic medication

18. Convene a representative group of regional support networks, community mental health centers, and managed care health systems to: • Establish mechanisms and develop contract language that ensures increased coordination of and access to Medicaid mental health benefits available to children and families • Define performance standards that track access to and utilization of services • Set standards for reducing the number of children prescribed antipsychotic drugs and receive no outpatient mental health services with their medication • Submit report on progress and findings to legislature by January 1, 2009

19. Facilitating Medicaid Eligibility • When youth are released from confinement, their medical assistance coverage will be fully reinstated on the day of their release • The department shall establish procedures for coordination between department field offices, JRA institutions, and county juvenile courts that result in prompt reinstatement of eligibility for youth who are likely to be eligible for medical assistance services upon release • The department shall adopt standardized statewide screening and application practices and forms designed to facilitate the application of a confined youth who is likely to be eligible for a medical assistance program

20. Healthy Options • Expansion from 12 to 20 visits for a child per year for both managed care plans and fee for service plans • Expansion in providers to licensed mental health professionals

21. Evidence Based Practice Institute Goals • Improve implementation of evidence-based and research-based practices • Continue successful implementation of “Partnerships for Success” process for implementing EBPs • Develop a series of information sessions, literature and online resources for families • Participate in identification of outcome-based performance measures and partner in statewide effort to implement statewide outcomes monitoring and quality improvement processes • Serve as a stateside resource on child and adolescent evidence-based, research-based, promising, or consensus-based practices for children’s mental health treatment • Implement a pilot program to support primary care providers • Evaluate implementation and impact of wraparound pilot

22. Evidence Based Practice Institute Additional Responsibilities • The EPBI shall review and summarize current law with respect to inpatient and outpatient mental health treatment for minors • The review shall include current practices to determine the percentage of cases in which parents are engaged by treatment providers and the extent to which they are actively involved in the treatment of their minor children • The EPBI shall provide a report and recommendations to the appropriate legislative committees by December 1, 2008

24. Building strong collaborations Increasing community capacity Improving youth outcomes UW PBHJP, Nursing, Social Work, CHMC Sustained training and consultation in MH and Primary Care State resource Monitor outcomes and quality assurance Community empowerment and education Implementation of PfS model Youth receiving appropriate EBP services

25. Develop recommended revisions to the access to care standards for children.

26. RECOMMENDATIONS • Address limits to access to services posed by current Access to Care Standards (ACS) • Adopt the STI Mental Health Benefits Design report recommendation to shift utilization management from front end restrictions to proactive care management of the most intensive and costly services • Increase access to services for youth and families not covered by Medicaid or insurance • Support provider organizations to increase youth and family access to & engagement in services • Increase access to child psychiatrists by expanding the Partnership Access Line (PAL), a primary care consultation program, statewide • Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including: • Intensive models for youth at risk of/transitioning from out-of-home placement : • Multidimensional Treatment Foster Care (MTFC) • Family Integrated Transitions (FIT) • Functional Family Therapy (FFT) • Multisystemic Therapy (MST) • Project MATCH • Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including: • Evidence-based models for youth exposed to past trauma, such as • Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) • Implement EBPs that align with stakeholder priorities and systematically engage families in treatment, including: • Evidence-based models for youth with co-occurring mental health and substance abuse disorders • Multisystemic Therapy (MST) • Family Integrated Transitions (FIT) • Multidimensional Family Therapy (MDFT)

27. RECOMMENDATIONS, cont’d • Implement evidence-based models that target early signs of behavioral problems & assist parents in working with oppositional and defiant behaviors: • Parent-Child Interaction Therapy (PCIT) • Positive Parenting Program (Triple-P) • The Incredible Years • Implement prevention & early intervention programs with evidence for effectiveness that align with stakeholder priorities, such as: • Nurse-Family Partnership • Positive Parenting Program (Triple-P) • School-based prevention programs with evidence for effectiveness (e.g., Good Behavior Game, School Development Project) • Build infrastructure to support EBP implementation: • Support community and tribal decision-making & oversight of EBP implementation, using models we know work (Partnerships for Success) • Build infrastructure to support EBP implementation: • Ensure that reimbursement processes align with EBP implementation

28. Washington State’s Children’s Evidence Based Practice Institute Summary of current projects related to HB1088

29. Partnerships for Success • A community-based participatory approach for strategically identifying and implementing evidence-based prevention, early intervention and treatment programs for children and families. • PfS has five primary goals • Community mobilization • Reducing duplicative local and state efforts • Promoting fiscal responsibility • Ensuring use of evaluation and other data in making decisions, and • Consideration for sustainability • The above goals are achieved through manualized activities: • Strategic planning (e.g., needs and resource assessment, gaps analysis, identifying targeted impacts/populations, aligning these with EBPs) • Implementation • Evaluation • Sustainability

30. Partnerships for Success, cont’d • With funds from a 2006 legislative Proviso, PfS is currently being piloted in Thurston & Mason Counties. • To date, the Thurston-Mason Community Team has: • Undertaken a community strategic planning process and selected and implemented Multisystemic Therapy (MST) based on assessment of needs, resources, and prospects for sustainability • Utilized funds to engage the Skokomish Nation in a coordinated PfS process (in Mason County) • Begun investigating options for expanding services to include prevention/early intervention programming based on articulated goals • HB 1088 directs the Children’s EBP Institute to “Continue the successful implementation of the Partnerships for Success model by consulting with communities so they may select, implement, and continually evaluate the success of EBPs that are relevant to the needs of children, youth, and families in their community”

31. Fulfilling the Promise • A Paul G. Allen Foundation-funded initiative designed to better link youth in foster care to evidence-based practices (EBPs) in mental health. • The FtP model provides training and consultation to both child welfare caseworkers and clinicians • Caseworkers receive training and consultation in identifying mental health needs using existing data sources (e.g., CHET) and in making appropriate, targeted referrals for EBPs. • To increase local capacity to provide evidence-based approaches, local mental health providers will be trained and will receive consultation in EBPs for common mental health problems of youth in foster care. • A pilot of caseworker training and consultation is currently underway; a small randomized trial of both the caseworker and clinician components will begin in the spring of 2008.

32. Primary Care Provider Consultation • Proposed Primary Care Provider Consultation Plan will consist of two components: • Telephone consult program will be open to all providers in a region regardless of their ability to commit to training sessions

33. Models for Change • A MacArthur Foundation initiative to support juvenile justice reform currently involving four states (Pennsylvania, Illinois, Louisiana and Washington). • These four states are receiving a combined $10 million to support system reform in juvenile justice, broadly targeting truancy, disproportionate minority contact (DMC), mental health, screening and assessment and other key areas. • Two action networks, composed of experts in the field around the nation, are particularly focused on DMC and mental health treatment for juvenile offenders.

34. Models for Change, cont’d • In addition to participating in nationwide forums on mental health, PBHJP is specifically focusing on cultural competence in evidence-based practice for Latino youth who are justice-involved and their families. • Partnering with Benton/Franklin County to assess the needs of the Latino community through an intervention model closely following Partnerships for Success (PfS). • These activities will result in a toolkit the MacArthur Foundation can use to support the implementation of culturally competent EBPs in other areas of the country. • In addition to our work with Benton/Franklin County, we are collaborating with the National Council of La Raza to convene a roundtable with national experts and mental health providers to discuss implementing EBPs within the Latino community.

35. Wraparound Washington Pilot • HB 1088 provides for “implementation of a wraparound model of integrated children's mental health services delivery” in up to six regional support network regions in Washington state • Wraparound model sites shall serve children with serious emotional or behavioral disturbances who are at high risk of residential or correctional placement or psychiatric hospitalization

36. What is different in wraparound? Wraparound brings the systems together at the family level – Plans are designed and implemented by a team of people important to the family The plan is driven by and “owned” by the family and youth Strategies in the plan include supports and interventions across multiple life domains and settings (i.e., behavior support plans, school interventions, basic living supports, family supports, help from friends and relatives, etc) Plans include supports for adults, siblings, and family members as well as the “identified youth”

37. When wraparound is implemented as intended… High-quality teamwork and flexible funds leads to enhanced creativity, better plans, and better fit between family needs and services/supports This in turn leads to greater relevance for families, less dropout Strengths, needs, and culture discovery and planning process leads to more complete engagement of families As family works with a team to solve its own problems, develops family members’ self-efficacy Individualization and strengths focus enhances cultural competence, relevance, and acceptability Focus on setting goals and measuring outcomes leads to more frequent problem-solving and more effective plans

38. Evaluation of Wraparound Pilot Projects in Washington A project of the UW Children’s Mental Health Evidence Based Practices Institute

39. Evaluation Questions 1.What is the level of fidelity and quality of wraparound implementation? 2. What outcomes are experienced by individual youth and families, in the following areas: Youth behavior and functioning, Family support and resources, Caregiver strain, Maintenance in community settings, and School, community, and juvenile justice outcomes 3. What is the adequacy of community supports for implementing wraparound across the state initiative and for the three funded sites?

40. Wrap Washington Pilot Evaluation:Summary of Youth Served North Sound 18 entered pilot project; 1 dropped out = 15 total Intake data completed for N=17 Gray’s Harbor 11 entered project; 5 dropped out = 6 total Intake data completed for N=6 Cowlitz County 7 entered project; 1 dropped out Intake data completed for N=6

41. Some initial outcomes of wraparound pilots In the first seven months of the program, 30 youth at risk of placement out of the community (e.g., psychiatric hospital, residential treatment, group homes, juvenile detention) have been enrolled in the three pilot counties. Seventeen have been enrolled in Skagit, six in Grays Harbor, and seven in Cowlitz. As of February 10, 2009, 29 of the 30 (97%) enrolled youth have been maintained in community-based, home-like settings: homes of biological or adoptive parents (73%), homes of relatives or friends (20%), or foster care (7%). Only one (3%) of the 30 youths has, to date, been placed out of the community (brief stay in juvenile detention due to probation violation).

42. Some initial outcomes of wraparound pilots The avoidance of out of community placement is impressive considering that, according to intake data, in the six months prior to enrollment in the wraparound projects: 29% of enrolled youth had required inpatient hospitalization 17% had experienced some other type of out-of-community placement (e.g., juvenile detention) or had no place to stay 29% had been arrested 25% had been suspended or expelled from school 37% had run away from home 14% had attempted suicide.

43. Workforce Development • Provider training • University curriculum • Parent Empowerment Program

44. Future Directions Now is the time! • Expansion of Evidence Based Practice • Strong emphasis on family and youth empowerment • Cross System Collaboration

45. Important Websites • PBHJP: http://depts.washington.edu/pbhjp • EBPI: http://depts.washington.edu/ebpi • PAL: http://palforkids.org • Primary Care Principles for CMH: http://palforkids.org/docs/Care_Principles_081508.pdf

46. Division of Public Behavioral Health and Justice Policy School of Medicine University of Washington 2815 Eastlake Ave Ste 200 Seattle, WA 98102 (206) 685-2085