Developing a Community-Based Mental Health System for Children and Adolescents in Maine: Service Use, Cost, and Policy D

1. Developing a Community-Based Mental Health System for Children and Adolescents in Maine: Service Use, Cost, and Policy Directions James T. Yoe, Ph.D. Robert DuBrow Maine Department of Health and Human Services Office of Quality Improvement Services 2008 SAMHSA/CMS Invitational Conference on Medicaid and Mental Health Services/ Substance Abuse Treatment Baltimore, Maryland September 25 & 26, 2008

2. Maine DHHS Children’s Behavioral Health Services: Guiding Principles 1. Services based on the family’s and child’s strengths. 2. Familiesare full participants in all aspects of planning and delivery of services 3. Children have access to a comprehensive array of services that meet the child’s physical, emotional, educational and social needs. 4. Children receive individualized services guided by an individualized service plan (ISP). 5. Children receive services in the least restrictive, most normative environment that is clinically possible. 6. Children receive integratedservices with linkages between agencies. 7. Earlyidentification and intervention for children with emotional problems should be promoted. 8. Children are ensured smooth transitions to adult service systems, as they reach maturity 9. The rights of children should be protected and effective advocacy efforts for emotionally disturbed children and youth be promoted. 10. Children receive services withoutregard to race, religion, national origin, sex, physical disability or other characteristics and services should be sensitive and responsive to cultural differences.

3. Children’s Behavioral Health Services:Target Populations • Children with Emotional and/or Behavioral Disorders • Children with Developmental Disabilities or Severe Developmental Delays • Children with Mental Retardation or Autism

4. Children’s Behavioral Health Services:Medicaid (MaineCare) Core Services • Emergency/Crisis Resolution Services (Sec. 65 A&C) • Targeted Case Management (13.12) • Outpatient Services (Sec. 65F & K Outpatient Psychotherapeutic Assessment and Treatment 65 F Outpatient Medication Assessment and treatment 65 K • In Home Treatment Services Home Based Mental Health Services - 37 Child and Family Behavioral Health Treatment Service – 65 M&N Assertive Community Teams (ACT) 65 J • Day Treatment Services • Children’s Habilitation Services (Sec. 24 ) • Out of Home Residential Treatment Services – PNMI (Sec. 97) • Inpatient Psychiatric Hospital Treatment(Sec. 45) Hospital Inpatient treatment (Community Hospital Psychiatric Units & Psychiatric Inpatient Hospitals)

5. Children’s Behavioral Health Services: Facts on Child MaineCare Members Diagnosed with Mental Health/Substance Abuse Challenges • Total Number of Children (Birth to 21 years) eligible for full Medicaid (MaineCare) Benefits (any time during the year): SFY 2007 = 148,350 - SFY 2008 = 147,901 • One quarter of eligible children had at least one paid medical claim where a mental health or substance abuse diagnosis was present in 2007 (23.4% - 34,736) and 2008 (24.8% - 36,641) • 24.9% of males and 21.9% of female eligibles received a MH/SA diagnosis on a claim. • School-age Children and older youth were more likely to be diagnosed with a MH/SA conditions.

6. Children’s Behavioral Health Services:Study Purpose • Develop methodology to accurately identify and extract MaineCare Paid Claims for children and youth diagnosed with a MH/SA challenges and specifically members that used one or more of the identified Core Children’s Mental Health Services. • This analysis specifically focuses on the characteristics of children and youth recipients of ME- DHHS Children’s Behavioral Health Services and examines MaineCare (Medicaid) service use patterns and expenditures over a two-year study period.

7. Children’s Behavioral Health ServicesStudy Design • All data was obtained from the MaineCare Paid Claims Data System over a 2 year period: SFY 2007 (7/1/2006 to 6/30/2007) and SFY 2008 (7/1/2007 to 6/30/2008) – (Paid Claims extracted based on service dates) • Initial extract identified claims for children and youth birth thru 21 years who had a mental health or substance abuse diagnosis. Selection was refined using specific CBHS procedures and, for hospital services, a combination of provider type, provider specialty and MH/SA diagnosis. • Primary diagnosis was determined for each child by assigning each member to one MH/SA diagnostic category, based on category that appeared most frequently on claims during the study years. • MH/SA conditions identified using ICD-9 codes: 291 thru 314.99 and 316. Excludes Mental Retardation (315 – 315.99) • Mental Health pharmacy claims were not included in study.

8. Children’s Behavioral Health Services: Child and Youth Characteristics N (unduplicated children 2007 – 2008) = 30,271

9. Children’s Behavioral Health Services: Child & Youth Characteristics N (unduplicated children 2007 – 2008) = 30,271

10. Children’s Behavioral Health Services: Child & Youth Characteristics N (unduplicated children 2007 – 2008) = 30,271

11. Children’s Behavioral Health Services: The Service Array and Utilization N (undup. 2007) =21,520 N (undup. 2008) =22,712

12. Children’s Behavioral Health Services: The Costs FY 2007 CBHS Expenditures = $240,497,244

13. Children’s Behavioral Health Services: The Costs Service Expenditures By Service Category: FY 2008 Total Expenditures (FY2008) =$216,650,343 Service expenditures in 2008 may under-represent actual expenditures for the year since claim payments continue to be processed

14. Children’s Behavioral Health Services: The Costs Service expenditures in 2008 may under-represent actual expenditures for the year since claim payments continue to be processed.

15. Children’s Behavioral Health Services: Expenditures By Mental Health Service Category

16. Children’s Behavioral Health Services:Summary of Results • 30,271 children received a core MaineCare MH service over the 2 year study period – 21,520 in FY2007 & 22,712 in FY 2008 accounting for 14.5% of eligible children in 2007 • Most children (77%) were between the ages of 6 and 18 years with more males represented in the younger age groups. • Most common diagnoses were stress/adjustment (24%), Neurotic/Other (23%) and ADHD related (19%) • Male service users were significantly more likely to receive conduct related, other psychotic, and ADHD related diagnoses while females were more likely to receive stress & adjustment, neurotic-depressive, major mood and substance abuse diagnoses. • Service Expenditures for children diagnosed with MH/SA abuse conditions who receive MH Services represented 37.3% of total Child MaineCare expenditures in FY 2007. • Inpatient Psychiatric Hospital and Out-of-Home Residential Treatment accounted for 60% of the overall MH expenditures in FY2007 representing 13% of child service users.

17. Children’s Behavioral Health Services:Summary of Results - Continued • Most frequently used services in 2007 and 2008 included: Outpatient-Clinical Services ( 53%, 54%), Targeted Case Management (33%,31%); Hospital -Related Outpatient Treatment (36%) and Medication Assessment & Tx (21%,20%); • Child and youth diagnosed with Major Mood Disorders and Other Psychotic Disorders had the highest annual service expenditures.

18. Children’s Behavioral Health Services: Policy and Service System Initiatives • Contract established with Administrative Services Organization for MaineCare Behavioral Health Services – operational since December 2007; • Focus on identification, dissemination and use of Evidence-based Practices (EBP’s) and measurement of outcomes in children’s behavioral health programs; • Initiation of Child Steps, an evidence-based mental health research project in 3 Maine clinics to evaluate the effectiveness of manualized clinical interventions and use of “family partners” for children 8-14 years. • Development and implementation of a Trauma-Informed System of Care (THRIVE Initiative) and implementation System of Care Principles state-wide. • Target resources to Increase the use of effective, intensive community-based treatments and reduce the use of high-cost, out-of-home treatment. • Work to enhance service system coordination and collaboration and develop a single, fully integrated children’s behavioral health system. • Mental Health screening of all children who have contact with Child Welfare • Enhance the role of families and youth at all levels of CBHS program operations, including: Policy Development, Quality Improvement Activities and Training.

19. Children’s Behavioral Health Services: Evaluation Next Steps • Conduct study of the demographic and clinical characteristics of children and youth users of inpatient psychiatric treatment and out-of-home residential treatment services and variation in service use across geographic areas. • Examine utilization and cost of behavioral health pharmacy data in child and youth recipients of Children’s Behavioral Health Services. • Evaluate MaineCare primary health care service use and costs for CBH service users compared to MaineCare children without mental health challenges.

20. Acknowledgements: The leadership of the Maine Department of Health and Human Services: Brenda Harvey, DHHS Commissioner; Geoffrey Green, Deputy Commissioner; Joan Smyrski, Doug Patrick, Office of Child & Family Services – Children’s Behavioral Health Services, & Elsie Freeman, Andrew Hardy, Kimberly Cook, Office of Quality Improvement Services Jay.yoe@maine.gov