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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