The System of Care Approach:An Evidence-Based Practice for Improving Children’s Mental Health Outcomes

Beth A. Stroul, M.Ed.4th Annual DC SummitNow is the Time: Promoting and Implementing Evidence-Based Solutions for Mental Health October 8, 2014

What, Why, and How?

What are states and communities doing to improve outcomes and investments, why they’re doing it, and how they’re doing it……..

What?Expanding the system of care approach

Why?Evidence-based practice with documented positive outcomes

How? Developing and implementing strategies for wide-scale system change

Why Prioritize Children’s Mental Health 20% with diagnosable mental health condition

2-5% serious condition with functional impairment, one of most expensive populations across systems

New Medicaid data on 29 million children (Pires, et al)

› For children using behavioral health services, mean physical and behavioral health care expenditures $8,520/year – 5 times higher than Medicaid children in general ($1,729/year)

› Expenditures driven by behavioral health services used

Substantial resources still being invested in high-end, high-cost services across systems over and above Medicaid

High cost of doing nothing (Pires)

80%

15%

2 - 5%

More complex

needs

Less complex

needs

Intensive MHServices +Supports

Intermediate MH Services + Supports

Universal MH Promotion and Prevention

Universal Screening or for At-Risk Populations

Early Identification

Pires, 2006

Pyramid of Population of Children and Service Needs

Basic MH ServicesorNo MH Services

Why Prioritize Children’s Mental Health

Poor outcomes› School dropout› Substance use› Suicide› Poor vocational success› Correctional system involvement› Inability to live independently

High financial costs across state systems, high social costs to families and nation

SHOW ME THE OUTCOMES….SHOW ME THE MONEY!Bottom Line Questions

Are you getting the outcomes you want?Are you investing scarce resources wisely?

What?The System of Care

Approach

System of Care(SOC) Approach Framework and philosophy for children’s

mental health services

Shaped the work of states, communities, tribes, and territories – some elements in nearly all communities

Shaped national policy (Surgeon General’s Report, President’s New Freedom Commission Children’s Sub-Committee)

Used as framework for reform by partner child-serving and some adult systems

Broader application than for youth with serious mental health conditions (e.g., recovery-oriented SOCs for substance use conditions)

“A spectrum of effective, community-based services and supports for children and youth with or at risk for mental health or other challenges and their families, that is organized into a coordinated network, builds meaningful partnerships with families and youth, and addresses their cultural and linguistic needs, in order to help them to function better at home, in school, in the community, and throughout life.”

SOC Definition

Elements of Systems of Care

SER

VIC

E A

RR

AY

Specific evidence-informed interventions and culture-specific interventions can be included in each type of service

Home and Community-Based Treatment and Support Services

Assessment and evaluation Individualized “wraparound” service

planning Intensive care management Outpatient therapy – individual, family,

group Medication management Intensive home-based services Substance abuse intensive outpatient

services Mobile crisis response and stabilization Family peer support Youth peer support Respite services Therapeutic behavioral aide services Therapeutic mentoring

 

Behavior management skills training Youth and family education Mental health consultation Therapeutic nursery/preschool School-based behavioral health services Supported education and employment Supported housing Transportation

Out-of-Home Treatment Services Therapeutic foster care Therapeutic group home care Residential treatment services Inpatient hospital services Inpatient medical detoxification Crisis stabilization services

1. Family driven and youth guided

2. Community based

3. Culturally and linguistically competent

Core Values of theSOC Approach

1. Broad array of evidence-informed services and supports

2. Individualized services

3. Least restrictive, clinically appropriate setting

4. Families and youth as full partners at all levels

5. Cross-system collaboration at system level

6. Care management for coordination at services level

7. Services and supports for young children and their families

8. Services and supports for youth and young adults in transition to adulthood

9. Incorporate or link with mental health promotion, prevention, and early identification and intervention

10. Continuous accountability mechanisms

11. Rights protection and advocacy

12. Nondiscrimination

Guiding Principles

What the SOC Concept is Not

Not a “model” to be “replicated” like a manualized treatment

Not a single “program,” but a coordinated network of services across agencies

Not a “treatment or clinical intervention” that directly improves child and family outcomes without accompanying changes at the practice level to provide effective services and supports to achieve positive child and family outcomes

System Change + Practice Change = Improved Outcomes

What the SOC Concept Is Paradigm shift, vision, value base

Organizational framework for system reform

Not a prescription, but a guide with flexibility to implement in a way that fits each state, tribe, territory, community

Adapt the approach based on context (political, administrative, fiscal)

Multilevel intervention – Changes at state, local system, and practice levels

= AN APPROACH

“Sometimes the right path is not the easiest one.” Grandmother Willow, Pocahontas

“If you can dream it, you can do it.” Walt Disney

Why?Evidence of

Improved Outcomes and Investments

Evidence Base for SOCs

Federal Children’s Mental Health Initiative established by Congress in 1992 to fund communities, tribes, and territories to implement the SOC approach

National evaluation of the CMHI and other studies have found:

› Positive outcomes for children and families

› Improvements in systems and services

› Better investment of limited resources

Results have led to efforts to expand implementation of the approach so more children and families benefit

Stroul, Goldman, Pires, & Manteuffel, 2012

SOCs Improve the Lives of Children and Youth

Decrease behavioral and emotional problems (depression, anxiety, aggression)

Decrease suicide rates

Decrease substance use

Improve school attendance and grades

Decrease involvement with juvenile justice

Increase stability of living situations

Increase strengths

SOCs Improve the Lives of Families

Decrease caregiver strain

Increase capacity to handle their child’s challenging behavior

Improve problem-solving skills

Increase ability to work

Increase peer-to-peer support

Increase family education and supports

Improve the service experience of caregivers and youth

SOCs Improve Service Systems

Improve system management

Create interagency partnerships (structures, agreements, braided funding)

Result in systematic development and implementation of strategic plans to improve services

Improve requirements in contracts with MCOs, providers, regulations, Medicaid rules, standards, practice protocols

Improve accountability and use of data for quality improvement and decision making

SOCs Improve Services

Expand services to broad array of home and community-based services

Customize services with individualized, wraparound approach to service planning and delivery

Improve care management and coordination (especially for youth with most complex, costly problems)

Increase family-driven, youth-guided services

Increase cultural and linguistic competence of services

Increase use of evidence-informed practices

Increase training of children’s mental health workforce

SOCs Provide Positive Return on Investment (ROI)

Redeploy resources from higher cost restrictive services to lower cost home- and community-based services and supports

Increased utilization of home- and community-based treatment services and supports

Decreased admissions and lengths of stay in out-of-home treatment settings (e.g., psychiatric hospitals, residential treatment, juvenile justice, and out-of-school placements)

Cost data demonstrating impact on costs across systems (e.g., reduced out-of-home placements in child welfare and juvenile justice with substantial per capita savings)

New ROI document shows savings in short term and future

Stroul, Pires, Boyce, Krivelyova, & Walrath, 2014

ROI Examples: National CMHI EvaluationOutcome Cost Savings

Reduced Inpatient Use Average cost/child reduced by 42%$37 million saved when applied to all children in funded SOCs

Reduced ER Use Average cost/child reduced by 57%$15 million saved when applied to all children in funded SOCs

Reduced Arrests Average cost/child reduced by 39%$10.6 milling saved when applied to all children in funded SOC

Reduced School Dropout

Fewer school dropouts in SOCs (8.6%) than national population (20%)Potential $380 million saved when applied to all children in funded SOCs (Based on monetizing average annual earnings and earnings over lifetime)

Reduced Caregiver Missed Work

Estimated 39% reduction in average cost of lost productivity (Based on imputed average daily wage of caregivers)

ROI Examples

Outcome Cost Savings

Oklahoma 41% reduction in average total behavioral health charges vs. 17% reduction for control group60% reduction in average inpatient charges vs. 17% for control groupSavings of $357 per youth per month, projected $18 million savings if all youth in study participated in SOC

Wraparound Milwaukee

$3,200 average total all-inclusive cost per child per month vs. $6,083 group home, $8,821 correctional facility, $9,460 residential treatment, $39,100 inpatient

Massachusetts, Mental Health Services Program for Youth (MHSPY)

Total per child per month Medicaid claims expense less than half for SOC group vs. comparison group (both physical and behavioral health)Claims 31% lower for ER, 73% lower for inpatient

Align Incentives Across Partner Agencies

Child Welfare – Alternatives to out-of-home care with high costs and poor outcomes

Medicaid – Alternatives to inpatient and PRTFs Juvenile Justice – Alternatives to detention and

correction facilities with high costs and poor outcomes Education – Alternatives to out-of-school placements and

high special education costs Substance Use – Alternatives to out-of-home treatment,

improved outcomes for youth with co-occurring conditions

Pires, 2006

“Reach for the sky! There is a big blue sky waiting right behind the clouds.”Woody

Evidence-Based Practice ApproachIn Systems of Care

Team-based, collaborative process for implementing individualized, tailored care plans

Primary strategy for operationalizing the SOC approach at service delivery level

Typically for children with complex needs and their families, but can be applied for all levels of need

Evidence-based “process” that cuts across all clinical interventions and formal and informal supports

Resources from National Wraparound Initiative

Individualized, Wraparound Practice Approach

Wra

paro

un

d P

roce

ss

Child and Family Team – Family members (and youth as appropriate), involved providers, members of the family’s support network collaborate to create a customized care plan

Intensive Care Coordination – Dedicated wraparound facilitator/care coordinator organizes and manages process across systems (small ratio)

Individualized Service Plan – Includes and coordinates the entire array of needed services and supports require

Partnership with Families and Youth – experts in analyzing the issues in their lives and potential strategies to address them

Peer Support – Peer support for families with “family partners” with lived experience and increasingly youth peer support

Collaboration – All agencies and providers work together to reduce fragmentation and ensure coordination

Strengths Based – Incorporates strengths and assets to build on, enhances engagement and resiliency

Ecological Perspective – Addresses multiple life domains

Family/Surrogate

Family

MentalHealth

LivingArrangement

Educational/Vocational

Medical

Cultural/Linguistic

SpiritualLegal

Income

Social/Recreational

Crisis/Safety

Substance Use

Life Domains

Evidence Base for Wraparound: Meta Analysis Move to less restrictive environments Improved functioning based on CAFAS scores Improved school attendance and grades, fewer disciplinary

actions Fewer out-of-home placements and days in placements Fewer arrests, less detention, lower recidivism rates Improvement on standardized measures of behavioral and

emotional problems ROI, such as 29% reduction in Medicaid spending, 74% lower

inpatient costs, 32% lower ER costs, 29% lower residential treatment costs, expenditures half of comparison group

Bruns & Suter, 2010

“The things that make me different are the things

that make me me.”Winnie The Pooh

How?Strategies for Expanding

Systems of Care

SAMHSA’s Theory of ChangeInnovation to Widespread Adoption

SAMHSA SOC Expansion Planning and Implementation Grants

Purpose to expand the SOC approach statewide and throughout territories and tribes

Planning grantees develop strategic plans for expansion

Implementation grants provide up to $1million per year for 4 years to support implementation of the SOC approach statewide

Informed by a study of expansion strategies that identified five core strategy areas for SOC expansion (implications for widespread adoption of any innovation)

System of Care Expansion Planning and Implementation

Need

Inputs

Expansion Planning Activities

Expansion Implementation Activities Outcomes

Need for wide-scale adoption of SOCs:• SOCs are in selected communities but not yet implemented broadly

• Positive outcomes for SOCs documented

• More children, youth, and young adults and their families could benefit

• Create SOC Expansion Team

• Conduct self-assessment and determine areas to be addressed to expand SOCs

• Determine goals for expansion at state, tribal, and territorial system level and at community level

• Determine overall approach to expanding SOCs with two-level strategy

• Identify expansion strategies in core strategy areas of policy, services, financing, training, and strategic communications

• Complete a strategic plan that includes key elements

• Establish priority goals and strategies

• Develop a financing plan

Systemic changes in:• Policy and partnerships• Services and supports• Financing• Training and workforce

development• Generating support

through strategic communications

• Evaluation/CQI

SOC implementation:• Develop SOC

infrastructure• Develop treatment services

and supports based on SOC philosophy

• Provide services• Collaborate across child-

serving systems• Incorporate family-driven,

youth-guided approaches to systems and services

• Incorporate cultural and linguistic competence into systems and services and address disparities

State, Tribal, and Territorial LevelSystemic changes are implemented:• Changes in policy, requirements,

interagency partnerships, evaluation/CQI • Changes to develop/expand services and

supports based on the SOC philosophy• Changes in financing and resource

investment• Changes in training, TA, and workforce

development • Changes in support for SOC expansion

Community LevelSOC approach is implemented:• SOC values/principles are implemented• Home- and community-based services

and supports are implemented• SOC infrastructure is implemented• Resources are invested in home- and

community-based services and supports• Services and supports are provided to

increasing numbers of children with SOC approach

Child and Family LevelChildren and families benefit:• Children and families receive effective

home- and community-based services and supports with the SOC approach

• Children and families experience positive clinical and functional outcomes

• Children and families are satisfied with their service experience

State, tribal and territorial grantees identify and link with communities for focus of expansion efforts

Community grantees link with lead state agency for youth with mental health conditions for systemic changes to support SOC expansion efforts

Federal lnputs:

• SOC Expansion Grants for Two- Phase Process of Planning and Implementation

• Federal TA

• National Evaluation

Jurisdiction Inputs:

• Previously developed SOC expansion plans

• Previous community-level SOC grants

• Previous SOC expansion efforts

• Resources committed to SOC expansion

State-Community Partnerships

States, tribes, territories, and communities develop comprehensive strategic plans for SOC expansion including:

State, tribes, or territorial systems and community system(s) create partnerships

for two-level expansion strategy

including:

States, tribes, territories, and communities implement SOC expansion strategies at system and community levels including:

Outcomes are achieved at the state, tribal, and territorial system level, the community level, and the child and family level including:

Need and Inputs

Evaluation/CQI – Refine Expansion Strategies

Strategic Framework: Roadmap for System Change

Five Core Strategy Areas:

1. Implementing Policy, Regulatory and Partnership Changes

2. Developing or Expanding Services and Supports Based on the SOC Philosophy and Approach

3. Creating or Improving Financing Strategies

4. Providing Training, TA, and Coaching

5. Generating Support

Overlapping and Interrelated

Policy, Regulatory, and Partnership Changes

Organizational locus of accountability for SOCs (state and local)

Interagency structures, agreements, and partnerships for coordination and financing

Rules, regulations, guidelines, standards, and practice protocols SOC requirements in requests for proposals and contracts SOC approach in data systems and monitoring protocols for

outcome measurement and quality improvement Linking with and building on other system change initiatives

(e.g., health reform, reforms in other systems) Expanding family and youth involvement at policy level Improving cultural and linguistic competence at policy level

Expanding Services and Supports

Array of home- and community-based services and supports Individualized, wraparound practice approach to services Family-driven, youth-guided services Care coordination and care management Care management entities Provider network with new providers and retooled residential

providers Evidence-informed and promising practices and practice-based

evidence approaches Cultural and linguistic competence of services Reduce racial, ethnic, and geographic disparities in service

delivery Use of technology (e.g., electronic medical records, telemedicine,

videoconferencing, e-therapy)

Services in Joint CMS-SAMHSA Bulletin

Intensive care coordination, wraparound approach Intensive in-home services Mobile crisis response and stabilization Parent and youth peer support services Respite Flex funds Specific evidence-based practices

Financing Strategies

Medicaid Mental Health Block Grants Redeploying funds from higher cost to lower cost services Funds from partner child-serving systems Federal SOC grants and grants to create sustainable

financing Case rates or other risk-based financing State mental health and substance use funds Use of federal entitlements other than Medicaid New financing structures and funding streams

(e.g., health reform) Local funds

Training, Technical Assistance (TA), and Workforce Development

Training, TA, and coaching on the SOC approach Ongoing training and TA capacity, training and TA

institutes, centers or other structures and processes Training, TA, and coaching on evidence-informed and

promising practices and practice-based evidence approaches

Strategies to prepare future workforce to work within SOC framework

Generating Support Through Strategic Communications

Establishing strong family and youth organizations to support SOC expansion

Generating support among high-level policy makers and administrators at state and local levels

Using data on outcomes and return on investment to promote SOC expansion

Partnerships with providers, provider organizations, managed care organizations, and other key leaders

Social marketing and strategic communications directed at key audiences

Cultivating leaders and champions for the SOC approach

Infusing SOC Values into Expansion Planning

Family-driven, youth-guided approaches to services and systems

Cultural and linguistic competence in services and systems and addressing disparities

Cross-system collaboration in services and systems

Tested Models Offers tested models for many ACA provisions to address unique

needs of children with behavioral health challenges› Essential benefits for Medicaid and Health Insurance Exchanges› Medicaid and CHIP expansion› Health homes› 1915(i) state plan amendments› Money Follows the Person› ACOs

Health Homes Systems of care and their care management entities can be

health homes – Improve quality and manage costs for populations with serious disorders, provide intensive care management, individualize care, link to needed services and supports across systems

Wotring & Stroul; Pires et al – Center for Health Care Strategies

Intersect Between Health Reform and Systems of Care

“All it takes is faith and trust and a little bit of pixie dust…”Peter Pan and Tinkerbell

Useful Tools

Complete as a group exercise or leadership group

Invite multiple stakeholders to complete the self-assessment individually

Tabulate results across stakeholders

Not an evaluation, but a diagnostic tool

Assess areas of progress and areas that need attention in SOC work

Self-Assessment of SOC Expansion Strategies

Policy, Regulatory, Administrative Sample Items

4. Promulgating Rules, Regulations, Standards, Guidelines, and Practice Protocolsa) Promulgating rules and regulations that require elements of the system of care

philosophy and approach to support expansion of the system of care approachRating of Progress: 0=None 1=Some 2=Moderate 3=Significant 4=Extensive

Notes:   5. Incorporating the System of Care Approach in Requests for Proposals

(RFPs) and ContractsIncorporating requirements for elements of the system of care philosophy and approach in RFPs and contracts with providers and managed care organizations to support expansion of the system of care approachRating of Progress: 0=None 1=Some 2=Moderate 3=Significant 4=ExtensiveNotes:

Outcomes of SOC Expansion – How Will You Know?

SOC values and principles are implemented Services and supports consistent with SOC

approach are implemented SOC infrastructure is implemented Resources are invested in home- and

community-based services Services and supports are provided to

increasing numbers of children with SOC approach

Values and Principles

1. SOC values and principles are implemented

› Individualized, wraparound approach

› Family-driven approach

› Youth-guided approach

› Coordinated approach

› Culturally and linguistically competent approach

› Evidence-informed approach

› Least restrictive approach

› Broad array of home and community-based services

› Data-driven continuous quality improvement and accountability approaches

Services and Supports

2. Services and supports consistent with SOC approach are implemented› Availability of specific treatment services and supports

provided in SOCs (non-residential)› Availability of out-of-home treatment services for short-term

treatment goals that are linked to home- and community-based services and supports

Infrastructure3. SOC infrastructure is implemented

› Point of accountability structure for SOCs

› Financing strategies for SOC infrastructure and services

› Structure/process to manage care for high-need populations

› Interagency partnerships/agreements

› Structure/process for partnerships with family organizations/leaders

› Structure/process for partnerships with youth organizations/leaders

› Structure/process to advance culturally and linguistically competent services

and address disparities

› Defined access/entry points to care

› Provider network to deliver comprehensive service array

› Structure/process for training, TA, and workforce development

› Structure/process for measuring and monitoring quality, outcomes, and

costs and using data for continuous quality improvement

› Structure/process for strategic communications/social marketing

› Structure/process for strategic planning and resolving barriers

Resource Investment

4. Resources are invested in home- and community-based services› Increased utilization of home- and community-based services and

supports› Decreased admissions and lengths of stay in out-of-home treatment

settings (e.g., psychiatric hospitals, residential treatment centers, juvenile justice placements, out-of-school placements)

› Cost data demonstrating impact on costs across systems by utilizing home- and community-based services and supports

Children Served in SOCs

5. Services and supports are provided to increasing numbers of children with the SOC approach› Identification of areas within the jurisdiction that have high levels of

SOC implementation› Increased number and description of children with serious

mental/behavioral health challenges and their families served with the SOC approach within the jurisdiction

Rating Tool for SOC Development

Developed to assess progress in implementing the SOC approach

Provides “snapshot” of implementation of key elements of SOCs at a point in time

Method to derive an estimate of the “level” of implementation of the SOC approach

Identify areas of strength and areas needing improvement Use as progress assessment/evaluation across multiple communities/regions in a larger jurisdiction (state, tribe, territory, large geographic area)

Use at regular intervals to track progress (e.g.,annually)

Levels of SOCImplementation

Level 1 –No ImplementationLevel 2 – Some ImplementationLevel 3 – Moderate ImplementationLevel 4 – Substantial ImplementationLevel 5 – Extensive Implementation

Respondents

Designed for approximately 10+ respondents per community or region – scores are averaged

Can be customized to each community re number and type of respondent

› Local Community- or Regional-Level Director or Manager of Services for Children with Behavioral Health Challenges

› Lead Provider Agency Director or Manager› Family Organization Director or Family Leader› Youth Organization Director or Youth Leader› Local Community- or Regional-Level Director or

Manager of Services for Children with Behavioral Health Challenges from a Partner Agency

› Other Key Stakeholders Identified by Lead Contact Person for a Community or Region

TOTAL SCORE Score %

STRATEGIC PLAN SCORE (MAX = 4)    

PRINCIPLES SCORE (MAX = 152)    

SERVICES SCORE (MAX = 136)    

INFRASTRUCTURE SCORE (MAX = 48)    

COMMITMENT SCORE (MAX = 60)    

TOTAL SCORE (MAX = 400)    

LEVEL OF IMPLEMENTATION RATING Score %

LEVEL I NO IMPLEMENTATION (0) (0%)    

LEVEL II SOME IMPLEMENTATION (1 – 100) (1% – 25%)    

LEVEL III MODERATE IMPLEMENTATION (101 – 200) (26% – 50%)

   

LEVEL IV SUBSTANTIAL IMPLEMENTATION (201 – 300) (51% – 75%)

   

LEVEL V EXTENSIVE IMPLEMENTATION (301 – 400) (76% – 100%)

   

Overall Purpose of Systems of Care

To improve outcomes for children, youth, and young adults with serious mental health conditions and their families through systems of care

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