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Evaluating the Impact of an Interconnected Systems Framework
Kelly L. Perales, LCSW
© 2014 Community Care Behavioral Health Organization
About Community Care
• Behavioral health managed care company founded in 1996; part of UPMC and headquartered in Pittsburgh
• Federally tax exempt non-profit 501(c)(3)
• Major focus is publicly-funded behavioral health care services; currently doing business in PA and NY
• Licensed as a Risk-Assuming PPO in PA; NCQA- Accredited Quality and Disease Management Programs
• Serving over 750,000 individuals receiving Medical Assistance in 39 counties through a statewide network of over 1,800 providers
2© 2014 Community Care Behavioral Health Organization
HealthChoices Regions Served
3© 2014 Community Care Behavioral Health Organization
Southwest Region
Lehigh-Capital Region
Southeast Region
Northeast Region
North Central Region: County
North Central Region: State
North Central Region: County
North Central Region: County
North Central Region: County
Community Care Office
Pike
Erie
Crawford
Mercer
Venango
ButlerArmstrong
Indiana
Westmoreland
Allegheny
Greene
FayetteSomerset
CambriaBlair
Delaware
Clarion
Forest
Warren McKean Potter
CameronElk
Jefferson
Clearfield
Bedford
Centre
Clinton
Fulton Franklin
Adams
Cumberland
Perry
MifflinSnyder
Union
Lycoming
Tioga Bradford
ColumbiaMontour
Northumberland
Dauphin
York
Lancaster
Chester
Berks Lebanon
Schuylkill
Montgomery
Philadelphia
Juniata
Sullivan
HuntingdonBucks
LehighNorthampton
Carbon
Monroe
Pike
Luzerne
WyomingLackawanna
Susquehanna
Wayne
Lawrence
Beaver
Washington
CSBBH
• Community and School Based Behavioral Health (CSBBH)– Families– Advocates– Providers– Schools– Other Child Serving Systems– Counties– Office of Mental Health and Substance
Abuse Services (OMHSAS)
4© 2014 Community Care Behavioral Health Organization
CSBBH
• 35 teams from 12 provider organizations
• 58 school buildings in 21 school districts
• 12 counties
• 1000+ youth and families
5© 2014 Community Care Behavioral Health Organization
Stakeholder-Reported Outcomes
• Gathering and reporting can improve care– Evaluation activities integrated into care
• Desire for connection among families, schools, and community-based services & resources to aid youth
• Routine tracking of progress can improve outcomes– Stakeholder-reported outcomes to improve care– Clinicians can make more informed
adjustments to treatment plans– When discussed with stakeholders, engages
& empowers
6© 2014 Community Care Behavioral Health Organization
Consumer-Reported Outcomes
• Gathering and reporting can improve care
• Challenges exist:– Burden to collection, scoring, and
having information available to discuss in sessions
• Community Care as a resource to support providers and schools in developing brief process to gather and use outcomes
7© 2014 Community Care Behavioral Health Organization
Collaboration with Multiple Sources
8
• School administrators, staff, teachers
• Providers
• Parents/caregivers
• Youth
© 2014 Community Care Behavioral Health Organization
Functional and Behavioral Outcomes• Collaborative process with provider, teacher, and
family input• Goal to measure progress in treatment and
enhance therapy– Useful across children with multiple diagnoses
and different ages– Brief enough to be completed and scored by
busy clinicians and families– Sensitive to change, allowing scores to
document improvement as child improves during treatment course
– Strength based where possible– Can be used to facilitate conversations
between families and clinicians
9© 2014 Community Care Behavioral Health Organization
Collection of Outcomes
• Purpose to gather feedback from caregivers about how they feel treatment is going
• Graph of results are available immediately via the secure Web portal:– http://secure.ccbh.com
• Results of the survey are discussed with caregivers
• Clinicians use feedback to help establish strength-based, appropriate treatment goals
10© 2014 Community Care Behavioral Health Organization
Children Served by CSBBH
• 2009-present – 1,801 students–Majority are boys (71.4%)– 15.7% are Hispanic – 69.6% white, 14.2% black or African
American, 0.2% Asian, and 15.6% other– Ages range from 4 to 19 years old, with
a mean age of 9.5 years
11© 2014 Community Care Behavioral Health Organization
SDQ
• The Strengths and Difficulties Questionnaire (SDQ) measures caregiver, teacher, and youth report of child behavior (Goodman 1997)
• The SDQ contains four sub-scales for difficulties: 1) emotional symptoms, 2) hyperactivity, 3) peer problems, and 4) conduct problems
• A summation of the four difficulties scales is made to compute Total Difficulties Score
• One strength-based sub-scale – pro-social behaviors
• The SDQ is completed every three months; the SDQY is completed by youth ages 14 and older
12© 2014 Community Care Behavioral Health Organization
SDQ-Parent
13© 2014 Community Care Behavioral Health Organization
• For SDQ information, 4 subscales are totaled for a Total Difficulties score. This score is graphed against an indicator for the 10th Percentile score (green line). Children with Total Difficulties scores 25 or higher are reporting substantially higher problem behaviors than other children
SDQ
14
• There was significant improvement in parent (p<.0001) and teacher (p<.0001) reported total difficulties scores over time
• Parents have significantly higher (p<0.05) average ratings of difficulties and pro-social behaviors compared to teachers’ ratings
© 2014 Community Care Behavioral Health Organization
Child Outcomes Survey
• Family functioning– Shared decision making, supporting each other
• Child functioning– Success in getting along with family, friends,
doing well at school, completing household tasks– Overall wellness
• Caregiver perception of therapeutic relationship– Feeling respected, working on important goals,
well-suited approach, caregiver confidence
15© 2014 Community Care Behavioral Health Organization
Is the COS being used?
• How much is the Child Outcomes Survey (COS) being discussed in sessions?
– Asked parents on a 1-10 scale how much the Child Outcomes Survey results were discussed with clinician?
– Examined what factors are associated with use of the COS results in sessions
16© 2014 Community Care Behavioral Health Organization
Discussion of COS
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0
10
20
30
40
50
60
70
80
Low Functioning Score Medium Functioning Score High Functioning Score
% R
epor
ting
Disc
ussi
on in
Ses
sion
Low Level of Discussion Moderate Level of Discussion High Level of Discussion
• Most discussion with families of children who are doing better in treatment
• Least discussion with families of children who are doing least well in treatment
© 2014 Community Care Behavioral Health Organization
COS: Child and Family Functioning
• There was a significant increase in family functioning over time (p<.0001)
• There was a significant increase in child functioning over time (p<.0001)
18© 2014 Community Care Behavioral Health Organization
COS: Therapeutic Relationship
• There was an overall significant improvement in therapeutic relationship over time (p=0.002)
19© 2014 Community Care Behavioral Health Organization
Monitoring Care: BH Service Utilization
20© 2014 Community Care Behavioral Health Organization
• This chart represents the service utilization for 726 children who used mental health services Pre-CSBBH (red bars) and During (blue bars) and the 475 children who did not use any services Pre-CSBBH (green bars)
Monitoring Care: Pharmacy Data
21© 2014 Community Care Behavioral Health Organization
Diagnoses Medications
Feedback from School Personnel
Subscale Mean SD Min. Max.Competency 7.24 1.97 1.00 10.00Impact 7.25 1.92 1.33 10.00Satisfaction 7.23 2.17 1.00 10.00Collaboration
7.32 1.98 1.67 10.00
22© 2014 Community Care Behavioral Health Organization
• Average ratings 7.2-7.3 on scale of 1-10
Standardized Assessment of Academic Performance
23
Math
# Scored in Math
% Advanced in Math
% Proficient in Math
% Basic in Math
% Below Basic in
MathCCH Students
151 27.2 23.8 24.5 24.5
All Students 15102 41.3 31.0 15.5 10.6
Reading
# Scored in
Reading
% Advanced Reading
% Proficient Reading
% Basic Reading
% Below Basic
ReadingCCH Students
144 10.4 29.9 13.2 46.5
All Students 15063 29.6 36.8 16.0 15.9
© 2014 Community Care Behavioral Health Organization
Use of Outcomes is Promising
• Clinicians appear to be able to administer outcome measures and use information in therapy sessions
• Discussion of information from COS associated with better therapeutic relationships and improves child and family functioning
• Standardized assessments aid in understanding functioning and performance
• Continued efforts to facilitate sustainable inclusion of outcomes and quality improvement
24© 2014 Community Care Behavioral Health Organization
Scranton, PAHistory and Time Line
• District and Community Leadership Team – established in 2009-10 school year
• Transformation of mental health services for children/youth and families
• Utilized PBIS Implementer’s Blueprint and Stages of Implementation (Fixen)
• Began in two schools, after reviewing data indicating positive outcomes, then expansion
Scranton, PA“Current Conditions”
• Eleven Elementary Schools (K-5)– 2 implementing ISF at all three tiers– 4 implementing PBIS at tier one and have SMH – 4 implementing PBIS at tier one– 1 will be trained/kick off PBIS this year
• Three Intermediate Schools (grades 6-8)– 3 implementing PBIS at tier one and has SMH– 3 beginning tier two
• Two High Schools (grades 9-12)– 1 with SMH and previously implementing PBIS– 1 implementing PBIS at tier one and has SMH
2013-14 School Year
• 22 licensed mental health professionals• 44 bachelor’s level behavioral health workers• Closure of center-based partial
hospitalization program• Closure of five school-based partial
hospitalization programs• ROI – less restrictive educational
placements, return to home schools, less restrictive mental health placements, cost savings
• Increased collaboration, communication – improved outcomes
Child Outcomes Survey (COS) Family Child Outcomes Survey (COS) Family Functioning:Functioning:
Child Outcomes Survey (COS) Child Child Outcomes Survey (COS) Child Functioning:Functioning:
Child Outcomes Survey (COS) Child Outcomes Survey (COS) Therapeutic Alliance:Therapeutic Alliance:
Strengths and Difficulties Questionnaire Strengths and Difficulties Questionnaire Parent Parent (SDQ-P) and Teacher (SDQ-T) Total (SDQ-P) and Teacher (SDQ-T) Total Difficulties:Difficulties:
ISF Comparison
• Significant improvement over time for child and family functioning
• For PBIS schools, higher report of family functioning than non PBIS schools
• Therapeutic Alliance ratings were higher in the PBIS schools.
32© 2014 Community Care Behavioral Health Organization
Family Functioning
33© 2014 Community Care Behavioral Health Organization
Child Functioning
34© 2014 Community Care Behavioral Health Organization
Therapeutic Alliance
35© 2014 Community Care Behavioral Health Organization