developing a broad service array and supports for system
TRANSCRIPT
Developing a Broad Service Array
and Supports for System of Care
Expansion
Exemplified by New Jersey and Massachusetts
By Jeff Guenzel and Joan Mikula
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Two States:
Similar Needs, Different Approaches
New Jersey Massachusetts
• Lawsuit: filed in 2001, settlement reached in 2003
• Priority strategies for state-wide system of care implementation:
▫ Overuse of Deep End Srv.
▫ Lack of Service Array
▫ Evidence-based Treatment
• Lawsuit: filed in 1999, verdict reached in 2006
• Priority strategies for state-wide System of Care implementation:
▫ Overuse of Deep End Srv.
▫ Lack of Service Array
▫ Evidence-based Treatment
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A Snapshot: New Jersey
Jeffrey Guenzel, M.A., L.P.C.
Division of Child Behavioral Health
Director
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Serve youth with emotional and/or behavioral needs and their families through
strength-based, individualized, and efficacious services guided by the core
values and principles of the NJ System of Care.
Mission
Key Components
Single portal for access to care
Intensive care management utilizing a wraparound model of care
serving youth with complex needs and their families
Linkage for youth with moderate needs, assist youth discharged
from CCISs, complete 14-day plans
Family-led support for CMO and UCM involved families, community
education, warm lines, advocacy
Crisis planning for youth with behavioral/emotional needs, available
24/7/365
CSA
CMO
YCM
FSO
MRSS
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Our in-community services are flexible therapy
services that are provided at the home or other in-
community sites.
In-Community Services
Intensive In-Community Services –
Psychotherapy services provided in the youth’s
home.
Behavioral Assistance – Under a plan
developed by an IIC therapist, the BA will work
to modify specific behaviors of the youth.
IIC
BA
Out-of-home Treatment• CCIS- Inpatient Treatment
• Intensive Residential Treatment
• Residential Treatment
• Specialty Beds
• Psychiatric Community Residences
• Group Homes
• Treatment Homes
• Detention Alternative Beds
• Emergency Diagnostic Residential Unit
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Additional NJ Components
• Evidence-based programs – FFT and MST
• Suicide Prevention/Traumatic Loss Coalition
• Partial Care/Hospital and Outpatient
• Therapeutic Nursery
• Children‟s Interagency Coordinating Councils in Each County
• Community Development Funding
• Youth Partnership and Youth Advisory Council
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What have we learned in the past 10 years?
The system of care model works!
• Less children/youth in institutional care
• Less children/youth accessing inpatient treatment
• Closure of state child psychiatric hospital and RTCs
• Very few youth in out-of-state facilities
• Children in out-of-home care have more intense needs than prior to the system of care development
• Wraparound works – youth being served at home, in their communities
• Less youth in detention centers – many reasons, not necessarily just because of the system of care
• More preventative
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Key New Jersey Data
• About 40,000 youth served last year
• Over 7,000 attendees at DCBHS trainings
• Only 9 youth in out-of-state residential treatment settings currently
• In 2002, 60% over 14; In 2010, 40% over 14
• High family satisfaction
• RTC length of stay decreased by 25%
• 96% of youth accessing Mobile Response stay at home
• NJ has 47th lowest youth suicide rate in the U.S.
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New Jersey’s Child Welfare Reform
• In 1999, Children’s Right’s filed a class action lawsuit against New Jersey to reform its child welfare system. A settlement agreement was reached in 2003. A court-enforceable Reform Plan was part of the settlement agreement.
• In October 2005, the Child Welfare Reform Panel monitoring the reforms found that the State was not making the anticipated progress toward meeting the mandated reforms. In mid-November, Children’s Rights sought to hold the state in contempt of court and requested that the system be taken over by a receiver.
• In July 2006, then New Jersey Governor Corzine created a separate Cabinet-level children’s agency, and appointed a Commissioner to the agency (Kevin Ryan). The court then approved a Modified Settlement Agreement that focuses the reform effort on caseloads, training, services, safety and adoptions.
• The Center for the Study of Social Policy was appointed (July 2006) by the Honorable Stanley R. Chesler of the United States District Court for the District of New Jersey as Federal Monitor of the class action lawsuit Charlie and Nadine H. v. Christie.
• On Wednesday, December 14, 2011, Commissioner Blake is scheduled to give her testimony before District Court Judge Stanley Chesler in relation to the release of Period X Monitoring Report of the Modified Settlement Agreement (MSA). New Jersey is now viewed as substantially meeting the requirements set forth in the MSA.
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Overuse of Deep-End Services
Out
of
Home
Intensive In-
Community
Wraparound – CMO
Behavioral Assistance
Intensive In-Community
Lower Intensity Services
Outpatient
Partial Care
After School Programs
Therapeutic Nursery
Low
Intensity
Services
Out of Home
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Before After
Lack of Services and Service
Capacity
• Change focus on use of emergency/crisis
• Placement vs. treatment
• Values and principles▫ Supporting community-based care
• Linkage with child-serving systems▫ Juvenile justice, child protection, schools
• Role of families and family support
• Balance consistency and local customization
• Uniform assessment
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Evidence-Based Treatment
• Specific “big” programs statewide▫ MST, FFT
• Support “small” programs locally▫ TF-CBT, parenting programs, individual and
group therapy approaches, suicide prevention
• Integrating evidence-based and best practice concepts in system of care▫ Talking the same language▫ Assessments and recommendations
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A Snapshot: MassachusettsJoan Mikula
Assistant Commissioner
Massachusetts Department of Mental Health
Rosie D. vs. Patrick
6 MCE’s administering remedy services
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Community
Service
Agencies
(“CSAs”)
Pediatric
Behavioral
Health
Screenings
Mobile
Crisis
Intervention
Therapeutic
Mentoring
In Home
Behavioral
Services
In Home
Therapy
Each CSA has within its structure Intensive Care
Coordination (ICC), Family Partners (FP), and a
System of Care CommitteeBehavior Management
MonitoringBehavior Management Therapy
Class action lawsuit filed on behalf of MassHealth-enrolled children under the
age of 21 with serious emotional disturbance (SED) regarding EPSDT access.
Children’s Behavioral Health Initiative
(CBHI)• “CBHI” covers all remedy services as well as all other
public payor funded, child and adolescent focused, behavioral health services currently and prospectively provided by state agencies
• Oversight Structure:
▫ CBHI Executive Team Comprised of agency heads and two family members, meets
biweekly
▫ CBHI Advisory Council Meets monthly, in legislation
▫ CBHI Interagency Implementation Team Co-chaired by State Mental Health Children‟s Director and
CBHI head
Interagency Development Resulting
from CBHI Structure
• Protocol Development▫ Interagency and agency specific development and implementation of interface
between EOHHS agency and CSA
▫ Led to creation of DMH System Integration Specialists that actively work with CSA staff
• Joint Procurement▫ DMH and DCF, utilizing Building Bridges Framework, procuring $250M
of residential service together, using joint: Standards Program models Rates Management and training structure
▫ DMH and DCF, as part of development, solicited family and youth input: Family Forums, attended by approximately 350 families
Youth developed and administered surveys to youth currently placed in residential services across the Commonwealth
Interagency Development Resulting
from CBHI Structure, continued
• Capstone▫ DMH and DYS (Juvenile Justice agency) interface
• Resource Sharing▫ Multiple Interagency Service Agreements, transferring funds for specific enrichments,
as well as cross agency staff accessibility to enrich local understanding of behavioral health needs.
• Chapter 321▫ Legislation passed in 2008, with four key tenets:
EARLY IDENTIFICATION: This bill takes the "screening" portion of the Rosie D settlement and extends it to other places in the community.
MOST APPROPRIATE SETTING: Creates a performance standard for hospitals and charges them when they don't meet it. This helps move “stuck youth” out of hospital beds.
INSURANCE COMPANIES: Increases accountability and consumer protection through the Division of Insurance.
STATE SERVICES: Establishes the Department of Mental Health as the State Mental Health Authority, and establishes a Children's Behavioral Health Research Center.
Lack of Service/Service Capacity• Court order results in infusion of home- and community-based
services and supports with care coordination as the hub and with Family Partners as cornerstone stone
• Development of strategic plan by all child agency leadership along with plan dissemination
• Expand provider network to assure racial/ethnic/linguistic access
• Elevate workforce development
• Capitalize on re-procurement opportunities to align standards/specifications across public purchasers
Lack of Service/Service Capacity, continued
• Utilize commitment and energy of families and youth in advocacy
• Include private insurers at every opportunity
• Elevate behavioral health into policy discussions re: medical homes and Accountable Care Organization's
• Capitalize on public adverse events to advance case for services by using various forms of media
• Engage foundations in dialogue with public agencies to advance development of and commitment to service expansion---use foundations as leverage
• Develop ways to bring federal initiatives to state planning, including State Mental Health Planning Councils
Overuse of Deep End Services
• Retool and align community and residential providers
• Placement vs treatment
• Formalize family/youth feedback and input into design plans----elevate and underscore message
• Invite leaders from SAMHSA/other federal agencies/foundations to lay groundwork oor planning, ie Building Bridges/Medicaid Innovations Center/ Institutes---Ongoing high level challenge to improve
• Capitalize on procurement opportunities to align standards/specifications/quality management/outcome expectations to create common approach and reduce fragmentation across and within payers
• Bring research to the planning table re efficacy of current/traditional approach to residential treatment
• Focus on restraint/seclusion prevention with ultimate goal of elimination
Evidence-informed Practice
• Support „wraparound' through remedy services---permeates beyond intensive care coordination
• Expanded role for Family Partner
• Support 'small' programs locally, i.e., PBIS, TF-CBT, parent education − with a 'large' oversight body to assess opportunities for broader adoption
• Retool workforce
• 'Incubate' peer leader approaches
• Capitalize on Federally funded projects to educate policymakers and leadership re service elements to incorporate into ongoing procurements
• Utilize foundation support to 'jump start' internal adoption of practices
Contact Information
• NJ Department of Children and Families
www.nj.gov/dcf
• Jeff Guenzel
609-888-7200
• Mass Department of Mental Health
www.mass.gov/eohhs/gov/departments/dmh/
• Joan Mikula
617-626-8086