OMHSAS Children’s Policy Presentation

1. OMHSAS Children’s Policy Presentation Pennsylvania Council of Children, Youth and Family Services February 21, 2008

2. Three Presentations • Budget • Children’s Priorities • Youth and Family Teams/High Fidelity Wraparound

3. The Rendell Administration's Major Budget Initiatives • Implement the Protecting Our Progress economic stimulus plan • Reduce property taxes • Make needed investments in education • Implement Prescription for Pennsylvania • Achieve greater energy independence • Make Pennsylvania a strong economic competitor • Rebuild Pennsylvania’s infrastructure • Maintain the safety net • Move people off welfare into the labor force • Manage and reduce the growing prison population • Protect our environment

4. 2008-09 General Fund Expenditures The 2008-09 General Fund budget is $28.3 billion, an increase of $1.1 billion, or 4.2 percent,over 2007-08. Spending on Education, Medical Assistance, other Department of Public Welfare programs, Corrections and Debt Service comprises 88 percent of total General Fund expenditures. Total GF Expenditures: $28.3 Billion

5. Department of Public Welfare • No one currently receiving services will lose eligibility • Children will not experience any reduction in services • Pennsylvania will provide services for the growing number of individuals and families who require Medical Assistance

6. Investing in Child Development & Early Learning • Child Care Works Subsidized Child Care –expanded to serve an additional 2,600 children on a monthly basis to reach more than 235,000 children annually. • Keystone STARS– expanded to assure quality early learning experiences for more than 171,000 children. • Early Intervention– expanded to serve 3,000 additional children from birth through age five and to maintain existing services for 77,700 children • Nurse-Family Partnership–expanded to serve approximately 240 additional families to reach more than 4,200 families.

7. National leader in developing services for persons with autism Bureau of Autism Services created in 2007 • Developing practice model for children and families • Awarded respite mini-grants to over 1,000 families • Laid groundwork for Adult Community Autism Program (ACAP) • New for FY 2008-09 • $7.6 million for services for 400 adults in ACAP and new Autism Waiver, bringing the total to 600 • Intensive training to build provider and clinical capacity and establish Bio-behavioral Units • Support for Autism Parity bill

8. OMHSAS: Guiding Principles • The Mental Health and Substance Abuse Service system will provide quality services that: • Facilitate recovery and resiliency for adults and children • Are responsive to individuals’ unique strengths and needs throughout their lives • Focus on prevention and early intervention • Recognize, respect, and accommodate differences as they relate to culture/ethnicity/race, religion, gender identity and sexual orientation • Ensure individual human rights and eliminate discrimination and stigma • Are provided in a comprehensive array by unifying programs and funding building on natural and community supports unique to each individual and family • Are developed, monitored and evaluated in partnership with consumers, families and advocates • Represent true collaboration with other agencies & service systems

9. OMHSAS Objectives • Transform the children’s behavioral health system to a system that is family driven and youth guided. • Implementation of services and policy to support recovery and resiliency in the Adult Behavioral Health System • Assure that behavioral health services and supports recognize and accommodate the unique needs of older adults.

10. OMHSAS: FY 2008-09 Budget • Community MH Services • $1.011 B total state and federal funds, net increase of $7.577 M; state funds increase $10.937 M • No Cost of Living Adjustment • CHIPP funding of $11.515 M for the discharge of 166 individuals from the state hospitals • Transfer of $10.847 M from Medical Assistance for Structured Treatment Services • Elimination of funding line item for Psychiatric Training Services in Eastern PA

11. OMHSAS: FY 2008-09 Budget • Drug and Alcohol Services • FY 2008-09 Act 152 budget is $16.227 M • BHSI IGT funding of $12.107 M • BHSI funding is $45.300 M (MH: $20.130, D&A: $25.170) • No Cost of Living Adjustment • Sexual Responsibility and Treatment Program (Act 21) • Implemented in April 2004 on the grounds of Torrance State Hospital • Sixteen men are now being served • SRTP program operation was transferred to the Commonwealth and operated by Torrance State Hospital (July 1, 2006)

12. OMHSAS Children’s Priorities

13. Some Guiding Principles • Trauma informed culture should serve as the background for all services to children and adolescents • CASSP principles are assumed to be part of the children’s Objectives and Supporting Projects • Youth and Family Teams will lead to a transformation of the children’s behavioral health system.

14. Transformation • Transform the children’s behavioral health system to a system that is family driven and youth guided. • Establish an Institute to provide training, support and monitoring of Youth and Family Teams; • Develop mechanism for Medicaid payment of Youth and Family Team process; • Begin process of implementing Youth and Family Teams throughout the Commonwealth.

15. Children’s Supporting Projects and Actions • Create Home and Community Based Alternatives to Residential Treatment • Develop a “White Paper” addressing current environment, needs and recommendations for creating alternatives to the current residential treatment system • Change existing rules to permit small group homes and therapeutic housing • Enroll Multi Dimensional Treatment Foster Care as a Medicaid funded service • Maintain data base on RTF utilization

16. Children’s Supporting Projects and Actions • Partner with Education to support the development of effective school based supports and interventions • Have OMHSAS Children’s Advisory develop “White Paper” on school based behavioral health services • Engage youth to get their perspective on school based behavioral health services • Continue to build the relationship with DOE and collaborate on projects • Reduce admission to segregated programs

17. Children’s Supporting Projects and Actions • Create Behavioral Health competency to honor the strengths and address the unique individualized needs of children and adolescents: • In the child welfare system • In, or at risk of entering, the Juvenile Justice system • In the drug and alcohol system • With Fetal Alcohol Syndrome Disorder • That are Deaf or Hard of Hearing • With Traumatic Brain Injury • With Autism Spectrum Disorder or other Pervasive Developmental Disorder • With Physical Disabilities • And infants and young children

18. Children’s Supporting Projects and Actions • Develop strategies to address the needs of Transitional Youth • Support Youth involvement in the OMHSAS Advisory Council • Obtain Youth input in identifying needs, developing plans, implementing and monitoring service development for Transition Youth • Summarize OMHSAS Transition Pilot projects • Identify existing initiatives in other agencies • Work with OMHSAS housing plan

19. Children’s Supporting Projects and Actions • Develop a process for identifying and implementing evidence based practices; promising practices and culturally relevant practices • Utilize the SAMHSA National Registry of Evidence Based Practice, the NASMHPD Research Institute, the National Blue Print initiative and other sources to identify evidence based and promising practices • Document the expansion of Multi Systemic Therapy, Functional Family Therapy and other evidence based practices in current practice • Develop the Youth and Family Team process as the practice model for children’s behavioral health to support evidence based practice

20. Multisystemic Therapy Intensive In-Home Therapy Functional Family Therapy Wraparound Services Therapeutic Foster Care Family Support Parent Management Training Respite School Based Services Medication Guidelines Early Childhood Services Trauma- Focused Intervention Evidence Based Practices

21. ICSI • Community • 52 new Home and Community Based programs • Residential • 17 accredited, 43 PRTF sites, 1,394 beds • 15 Non-accredited, 79 residential sites, 1,246 beds • Total residential capacity to 3223 accredited and 1604 non-accredited beds

22. Positive Impacts • Inclusion of MultiSystemic Therapy and Functional Family Therapy as MA eligible services • Collaboration, including local team structures between BH, C&Y and JJ • Internal workgroup established to establish a framework for continuum of care and stakeholder process • Higher penetration in services for adjudicated youth in non residential settings • Cross Systems monitoring of residential services

23. Continuing Challenges • Timeliness of evaluations • Coordination of referrals • Local county relationships • Provider role • Quality of care

24. OMHSAS-OCYF Residential Initiative • Office of Children, Youth and Families (OCYF) and OMHSAS have convened joint PRTF work group • Retreat in October 2007 established joint work group • Goal to promote community alternatives to dramatically reduce use in three years and improve quality of remaining PRTF capacity • Continuum Work Group is developing report to begin dialogue with stakeholders

25. Quality Management Initiatives • Pay for Performance • Work group examining a measure for RTFs • Tentatively has selected family involvement • Efforts underway to define and develop indicators • RTF Outcome Pilot • Working with OCYF • Exploring a web based system using standard report mechanism • July 1, 2008

26. Youth and Family Teams Applying High Fidelity Wraparound

27. In Pennsylvania • We have a long history of collaboration and programs to support children and their families. • We do not have strong evidence of outcomes for our efforts. • We need to implement and support research proven approaches, such as… • High Fidelity Wraparound.

28. High Fidelity Wraparound • A process for supporting youth and families with complex behavioral health needs • Defined by National Wraparound Initiative • 10 principles • Four phases (engagement, plan development, implementation and transition) • Theory of Change: Needs, self efficacy, natural supports and an integrated plan

29. What Does the Research Say? High Fidelity Wraparound can produce significantly better outcomes for children and families with significant needs than traditional approaches: • Decreased restrictiveness of residential environments • Improved behavior and mental health symptoms • Improved school and early care outcomes • Decreased family and child safety issues and risk factors • Increased family engagement and satisfaction with services • Increased family resources to support their own children

30. Impact on CAFAS Scores after 6 Months

31. Impact on CAFAS Scores after 18 Months

32. Phases of wraparound Engagement and team preparation Plan development Implementation Transition Time

33. Phases of wraparound planning

34. The Team • Bring informal and formal resource together • Include family, friends, neighbors, service providers, spiritual leaders, others who want to help • Include service providers, who fill important roles • Unique to each family • Give everybody involved a chance to achieve consensus on what to do • Value family and community resources • Can help isolated families get needed support that lasts as long as it's needed

35. Training • Train and Hope does not work • About behavior and system change • Not satisfaction with training • Research on information provision and training • Factors that influence • Initial motivation and engagement • System and organizational support • Organizational climate and control • Methods of training

36. Need for Coaching • Newly-learned behavior is crude compared to performance by a master practitioner. • Newly-learned behavior is incomplete and will need to be shaped to be most functional in a service setting. • Newly-learned behavior is fragile and needs to be supported in the face of reactions from consumers and others in the service setting.

37. Fidelity Assessment / Improvement • Two leveled certification competency based certification process • Measures of compliance to the wraparound phases and activities • Measures of fidelity to the wraparound process • Use of the measures to guide ongoing professional development

38. Certification – Wraparound Practitioner Goal: to define the basic skill sets that must be demonstrated to be considered a competent entry level wraparound facilitator Requirements include: • Has received 3 hours of supervision/coaching per week • Has a professional development plan • Has demonstrated competency on wraparound process tools • Has demonstrated competency on each of nine practitioner tools

39. Action Plan • Community Education • Testing financing model in Allegheny County • Request for County MH/MR Programs to be Early Implementers

40. Community Context and Readiness • Engaging key stakeholders • Commitment to core wraparound components • Feasibility assessment • Staffing and supervision ratios / assignments • Policies, procedures and documentation processes • Implementation plan

41. Youth and Family Institute • Will provide training and certification • Will provide coaching • Will conduct on-going evaluation using the Wraparound Fidelity Index • Will continue to provide support for counties as they establish the Youth and Family Team process • Will provide information and education