A Systematic Approach to Meeting the Ongoing Needs of Children with Complex and Enduring Behavioral and

Emotional Disorders and their Families

A framework for a comprehensive approach to addressing the needs of a critical care population

Based on a review of research indicating the practices most likely to be associated with effectiveness

Not a single service, but a systematic approach to integrating the arc of care across multiple environments and multiple interventions

Despite important strides in service development, we have children who are placed repeatedly in high-level group homes and remain in placement for long periods of time

This subset of children have highly disrupted family relationships that have been generated in a variety of ways and exhibit complicated behavior patterns

Clinically, children and youth who experience multiple and extended high-end group home placement are distinguished by their complexity and heterogeneity

“Children manifest complex psychopathology, characterized by attachment difficulties, relationship insecurity, sexual behavior, trauma-related anxiety, conduct problems, defiance, inattention/hyperactivity, and less common problems such as self-injury and food maintenance behaviors.”

Tarren-Sweeney (2008) The Mental Health of Children in Out of Home Care. Current Opinion in Psychiatry, v. 21, pages 345–349.

The subset of children and youth with repeated and extended group home placement also put a great deal of pressure on the demand for psychiatric hospitalization

Examined from the other perspective, the children and youth who experience repeated psychiatric hospitalization also are more likely to be in group care:

A recent study found that three factors are highly related to rehospitalization:◦ living in a residential treatment facility, ◦ a diagnosis of oppositional/defiant or conduct disorder,◦ prior history of hospitalization

Rehospitalized youth were also less likely to have family involvement

Chung, W., et. al. (2008) Psychiatric Rehospitalization of Children and Adolescents: Implications for Social Work Intervention, Journal of Child and Adolescent Social Work, v.25, pages 483–496

Beyond the diagnostic criteria there are two practical characteristics of most of the children and youth in this subset:

“We don’t know what else to do” Behavior-based placement disruptions

◦ James (2008) Entry Into Restrictive Care Settings: Placements of Last Resort? Families in Society, Vol. 89, No. 3, p. 348

◦ McCurdy (2004) ‘And What About Residential…?’ Re-conceptualizing Residential Treatment As A Stopgap Service For Youth With Emotional And Behavioral Disorders. Behavioral Interventions, vol. 19, pages 137-158.

First, match the right services with the right kids and families

Most of the time, intensive in-home, day treatment or treatment foster care will be the best alternative for children with severe emotional disorders and their families

However, for the subset for whom those options are not effective, we should use short term group care as an integral component of a comprehensive response

Short-term, highly intensive group care that is multi-modal, ecological and holistic

Continuous and extensive family involvement Parallel services with the family and community

to prepare for reconnection while the child is in group care

Ongoing post-group care services to address continuing to reinforce and continue to strengthen the connection with primary caregivers, to build family resilience and protective capacity, and to address the child’s ongoing mental and behavioral health needs.◦ Hair (2006) Outcomes for Children and Adolescents

After Residential Treatment: A Review of Research from 1993 to 2003. Journal of Child and Family Studies, Vol. 14, No. 4, pp. 551–575

Make group care a part of a Re-Connection Engine

Learn to see group care settings not as places to live, but as components of an integrated, multi-environmental, multi-modal intervention designed to help children and their families achieve and maintain positive and productive permanency, despite the impact of their emotional and behavioral handicaps as well as any limitations of their primary caregivers.

Instead of raising other people’s children, find ways to help those people learn how to, and feel confident and competent in raising their children themselves.

Step One: Convene a statewide stakeholder’s group to examine the current status of high level group care in California

Step Two: Develop a framework for transforming the nature of group home services

Step Three: Gather legislative support for this transformationStep Four: Obtain financial support for the transformation effortStep Five: Select four demonstration sites who are committed to

carrying out the transformationStep Six: Assist each site in developing a community-specific

approach to accomplishing these changesStep Seven: Work with state entities to help them adjust the fiscal

and regulatory constraints that impede transformationStep Eight: Test out initial alternative program and funding modelsStep Nine: Adjust models to improve effectivenessStep Ten: Based on these results propose a statewide model

Target population Arc of Care Service Innovations:

◦ Environmental interventions

◦ Intensive treatment◦ Parallel services◦ Post-placement services

Role of the placing agency

Child and Family Involvement

Evaluation:◦ Permanency, safety, well-

being◦ Average length of stay◦ Re-entry◦ Family Connection◦ Client satisfaction◦ Utilization by county

agencies◦ Operation by the private

agency◦ Actual costs◦ Payments◦ Impact on state-county

AFDC-FC budgets◦ Impact on county MH

payments

Bay Area Consortium (San Francisco, San Mateo, Santa Clara, Contra Costa and Solano Counties) (about 100 children)◦ Children 6-12 years of age who are already in or referred to a

level 12 or 14 group home using a regional approach Sacramento County (about 24 children to start with)

◦ Children 12-16 who are in a level 12 or 14 home and are likely to continue in care indefinitely using an integrated care model

Los Angeles County (about 80 children to start with)◦ Any child who is currently in level 12 or 14 who cannot be

returned home using SB 163 wraparound alone using res-wrap San Bernardino County (about 35 children to start

with)◦ Children 14-17 who have multiple psychiatric hospitalizations

and are currently in a level 14 group home or placed out of state, using a trauma-focused, CBT model with the team following the child

AB 1453 requires each site to prepare three documents for review by CDSS prior to implementation:◦ Voluntary Agreement that describes the new care

system in detail◦ Alternative Funding Model that explains how the

new system will be funded◦ Waiver Requests to make it possible to operate

the new system

After input from a stakeholders’ group, CDSS is charged with reviewing the VAs, AFMs, and WRs to see if they meet the statutory requirements

Then CDSS has to determine if the requested waivers can and should be granted

Upon approval of the VA and AFM and granting of the waivers, a state-county MOU is created

Counties can then make arrangements with providers to begin offering RBS enrollment as an option

Sites are able to present drafts for sections of their deliverables to CDSS and the Steering Committee for iterative feedback

CDSS and its partners are working internally to prepare for the formal review process

Demonstration sites are working through local implementation teams and subcommittees to lay the ground work for implementation

Consultants prepare templates and other tools to help the demonstration sites and the state manage the design and implementation process

Everything takes longer than you would expect At this point, we are hoping to begin serving

children by July, if not sooner in some places Transformation is much more complicated than

we imagined when we started◦ Lack of easily replicated models◦ Fiscal constraints◦ Regulatory restraints◦ Newton’s first law of motion (organizational inertia)◦ Inter-system constraints

Despite this and the enormous pressure of the fiscal crisis, the local teams are plugging along with dedication and inspiration

The statute only briefly addressed the mental health component of RBS

EPSDT is a separately regulated resource, so it’s operation isn’t affected by AB 1453

This means the RBS providers will continue to use coordinated but distinct planning for the MH aspect of each child or youth’s care, based on individual needs, and in line with their local MH contracts

The target populations are already using high levels of mental health services

Utilization tends to decrease as these youth achieve permanency

RBS is available as a resource to county MH agencies

Demonstration sites must explicitly address both AFDC-FC and EPSDT funded activities in their VAs and AFMs.

The point of service integration in a multi-modal system is to use synergy and efficiency to obtain better outcomes for the same or lower costs across the board

Three agencies in each county use high end group home placements (MH, JJ, CW)

But group homes are regulated by CW Each agency accesses group homes differently Funding can be different depending on which

agency makes the placement Each county also funds group homes differently Each group home has a different way of billing

for the services it offers Each placing agency has different expectations

for the help that will be provided through placement, and in the way that it manages ongoing service delivery

If we do nothing, more than half of the children in our target populations will eventually emancipate from care, run away, enter the criminal just system or graduate to the streets

We know that as the fiscal crisis deepens the pressure for more placements will increase

We have a narrow opportunity to make a real difference in the lives of the children and families in our community who have the greatest level of need

Ultimately we want to design a resource that can be accessed quickly, consistently and reliably from multiple systems

So that we can rapidly and effectively interrupt the negative care trajectory of multiple and extended group home placements

And replace it with a positive and sustainable arc of care that anchors children with their families, and families with their communities.

Satisfaction: Youth, family, referring

agency

Youth/Family Outcomes: Safety, permanency, well-being;

Developmental progress;Improved condition/behaviors

Residentially-Based Services (RBS)

Youth/Family referred for intervention

3. Match Youth/Family Need with Program Capability:“Which RBS program can best meet child/family needs?”

Family-Based Support & Services (At Home)

Family-Based Services (Out-of-Home)

Residentially-Based Services

Locked Detention

1. Select Intervention:“What intervention best meets the needs of this child/family?”

2. Select Intervention Setting:“Where can this child/family be most successful in getting their needs met?”

Mission

Service Quality

Assess youth/family strengths & needs

Case planningduring RBS

post discharge

Service intervention goals

Projected discharge date & timeline

Team decision-making

Service evaluation

Service delivery

Prog

ram

qua

lity

Eval

uate

d by

Acc

redi

ting

Body

Management:Accountability, collaboration, communication, supervision

Staffing: Hire, train, supervise,

coach, evaluate, retain & advance quality staff

Quality improvement

Respect Child-centered

Family participation Permanent connections

Developmental focus Positive care

environment Strength-based

Reconnect youth with community ASAP

RBS

Youth at home, in school, out of

trouble

Title XXII Regs

Faci

lity

qual

ityEv

alua

ted

by C

omm

unity

Ca

re L

icen

sing

Quality Assurance:Evidence-based, promising/best

practices; program evaluation; program improvement

Values

Administration:Fiscal, program, personnel, community responsiveness

Youth enters RBS

Youth leaves

residence

After-care

services & support

Utilization Effectiveness

Cost Effectiveness

Com

preh

ensi

ve A

sses

smen

t

Program and Facility Quality

Cost