RWJ Project – City of Philadelphia

1. RWJ Project – City of Philadelphia The “Walk-Through”

2. The Focus of the Walk-Through • In February 2006, the Blue Ribbon Commission (BRC) on Children’s Behavioral Health was convened to develop a framework and set of recommendations to improve the ability to promote social and emotional wellness. • One of the many recommendations outlined by the BRC is to make every effort to move children and youth from distant and residential settings to community-based and home-based services.

3. The Focus of the Walk-Through • The focus of the walk-through was on the interagency meeting process initiated for children and youth transitioning from inpatient to residential treatment, from residential treatment to community-based services, or from out-of-state placement to in-state community-based services.

4. The Focus of the Walk-Through • Functions of the interagency team meeting: • A mechanism for child-driven, family-focused treatment. • A mechanism for individualization and positive envisioning. • A mechanism to integrate expertise with multi-system participation. • A mechanism to incorporate the management of medically necessary care and child welfare responsibilities into the child-centered, family-focused approach consistent with CASSP principles.

5. The Focus of the Walk-Through • Prerequisites for an effective interagency team meeting: • Cross-system familiarity: From the top-down and the bottom-up, with expansion of the middle. Knowledge of the roles and mandates of others. • Good will: A readiness to share time and expertise, consider the child's needs, and offer the benefit of the doubt to team members.

6. The Focus of the Walk-Through Prerequisites (continued): • Preparation: Creating a meeting context: recruiting participants; confirming participation; sending meeting notices; preparing the child and family. • Meeting protocol and methodology: Need for a specific protocol for the meeting so that everyone is oriented to the process and time is used effectively. Need for a designated team facilitator to ensure that essential processes-including envisioning-occur.

7. The Focus of the Walk-Through • Prerequisites (continued): • Follow-up implementation and monitoring: Designated person takes, then distributes, meeting notes; clarity regarding specific tasks of each participant following the meeting; establishing mechanism for information exchange; setting next meeting date.

8. The Walk-Through Scenario • Patrick is a 17 year old Caucasian male who was admitted to St. Gabriel’s Residential Level II in October of 2006. • Most recently, the treatment team recommended a move to RTF Level I in order to better address his behavioral health needs. • The CBH care manager assigned to this facility has been reviewing and authorizing care; however, since the recommendation has been made to move him to RTF Level I, a teaming is required. • The CBH Care Manager in family court is responsible for conducting the teaming.

9. Who Was Involved • Probation Officer • CBH Family Court Care Manager • Myself (Playing the Role of Mother) • Mother • Youth (via phone) • St. Gabriel’s Hall (via phone)

10. Where Did the Process Begin • I was notified by the PO on 3/1/07 that a teaming was going to be held on 3/8/07 at Family Court. • The CBH Family Court Care Manager also phoned me on 3/1/07 to make me aware of the meeting and to introduce herself to me. • During the actual meeting, the CBH Care Manager explained to me the purpose of the meeting prior to calling Patrick at the RTF Program.

11. Important Observations • Teaming was held after approval for RTF I was given. • I was informed that the packets were sent out to RTF Providers prior to us meeting. • I was informed that there may be a possibility that Patrick would go out-of-state since two programs had already accepted him. But they told me every effort would be made to keep him in-state and close to his family.

12. Important Observations • We spoke to Patrick via phone. The CBH Family Court Care Manager asked him a lot of questions about his behaviors, his clinical needs, his history of drug use. • Patrick was told that he was court-ordered to be in residential treatment and that he had no choice in that but could have a choice in the RTF provider. • I was asked by the CBH Director if he had any psychological testing since I mentioned he had difficulty in school and had educational support. • Patrick is currently at St. Gabe’s and is reviewed by a care manager different from the one who did the teaming.

13. Important Observations • The CBH Director had a good understanding of Patrick’s bipolar disorder unlike others who have been working with him. She agreed that he has a need for intensive psychiatric treatment, particularly in finding medication(s) that are more effective. • Even though Patrick is 17, I was still able to listen and share my concerns. I was able to provide information that was not included in the evaluation or CBH information. • The person making the RTF referrals was not there so I was not aware of the RTF programs to which Patrick was being referred.

14. What Was It Like To Be In The Role • As a RWJ Project Team Member, my role was to play the “mother”. Observations from that perspective are: • Not sure why a teaming was needed if a decision for RTF Level 1 was already decided. • Frustrating that my voice (voice of the “parent”) was not really heard throughout the course of his treatment and is now being heard at a “teaming”.

15. What Was It Like (continued) • Concerned that this aging out youth continues to need treatment but is court ordered to a program that is not able to address that need. • Frustrated with how many people are involved in his care from both systems (DHS and CBH) and not having someone understand his case from multiple perspectives. • Faced with an aging out youth who has very limited time to “get it right” or else he could end up in the adult criminal justice system.

16. Practice Changes • Families need to be more involved in the provision of information that can guide how a case is managed and treated. • There needs to be a change in how “care is managed” by CBH as well as by DHS/JJS in order to ensure that treatment approaches fit the clinical profile. • Discussion with judges to define ways to ensure that placement is based upon clinical needs and not on judicial order. Judicial order could prevent a client from receiving appropriate care if the provider chosen does not have the capability to treat.

17. System Changes • There needs to be a dedicated unit that can begin managing these cases by: • Reviewing both DHS records and DBH clinical records to completely identify all needs – clinical, child welfare, delinquency, etc. • Providers would be contacted to first interview the youth in person, and then teaming done with parties at DHS and DBH to review all information together. • This will set the tone for the appropriate course of treatment as well as identify the child welfare/delinquent requirements.

18. System Changes • New operational procedures will be defined to ensure collaboration and stronger care management between DBH and DHS. • Cases will be managed by youth not by provider to ensure continuity of care and effective planning. Criteria to be established for custody cases that have specialized clinical needs as a starting point. • All youth currently in RTF placement should be assessed in a holistic manner – functional, medical, life skills, psychological, educational – and then determine actual services and supports needed.