IN Program Structure Indiana has 92 counties and 25 Certified Community Mental Health Centers • (CMHCs) that serve as the safety net for the state The populations served are: • – Serious Mentally Ill /Serious Emotionally Disturbed – Chronically Addicted – Dually Diagnosed The current array of mental health and addiction services are supported by • MH Block Grant, SA Block Grant, Medicaid and other third party payers Program implementation of new services will be supported through the Office • of Medicaid and the Division of Mental Health and Addiction Indiana has a 1915(i) SPA for Child Mental Health/High Fidelity Wraparound •
IN Program Structure (continued) Mental health and substance abuse issues are prevalent and relevant concerns • across all child serving agencies E.g. One of child welfare’s greatest concerns is access to care and qualified professional to deliver – services; juvenile justice is managed at the county level and access to care is of concern; concern for Bureau of Development Disabilities is very few facilities accept children who are dually diagnosed. CMHCs provide the array of services across the continuum with the exception of • mobile response stabilization and support services The Department of Child Services utilize contractual agreements with CMHCs and • other providers to ensure youth involved with child welfare receive mental health services Youth with behavioral health issues who are involved with Juvenile Justice access • services through DCS, services that are court ordered or receive alternative community supports
IN Program Components • Indiana currently does not have MRSS in the array of services being offered. – Many years ago mobile crisis services were offered for the SMI/SED population but it was not sustainable and was dropped from the service array. • CMHCs offer 24 hour crisis services by phone and access site • Mobile crisis services are offered on a smaller scale in different parts of the state – funded through grants or agency (CMHC) support
IN Barriers/Challenges • Indiana is at the beginning stages of information gathering for upcoming procurement process. • Potential barriers that may impede success are: – Workforce issues – Financial structural – Cross agency implementation
IN Objectives • Obtain information regarding program and payment structure including blending and braiding of funds • Gain knowledge about: – “Lessons learned” – Implementation elements of a cross state agency collaborative model
KANSAS
Kansas Participant Name Title/Role Organization (if applicable) Kansas Dept. for Aging & Disability Kelsee Torrez SOC Project Director Services (KDADS) Children’s Behavioral Health Kansas Dept. for Aging & Disability Gary Henault Program Manager Services (KDADS) Therapist/Intensive Outpatient Parent, Adolescent & Child Nicole Stafford Program Manager/SOC Project Empowerment Services (PACES) Coordinator Vicki Broz Program Director Compass Behavioral Health
KS Program Structure • There are 26 community mental health centers (CMHCs) in Kansas • CMHC staff are available 24/7 for crisis calls and to assess for hospitalization • CMHCs serve anyone in their catchment area; SOC youth are ages birth-21, with SED, mostly school aged, residing within 16 counties. • Some CMHCs are under the county’s jurisdiction, others are independently operated with a Board of Directors. • CMHCs are locally (county, state) and federally (Medicaid, Block Grant, etc.) funded
KS Program Components Urban: • Parent, Adolescent & Child Empowerment Services (PACES): emergency shelter to youth and families; co-responder who works with the Unified School District (USD) and local police department; goal is to reduce police contacts & reduce suspensions; and has identified one therapist to serve as a crisis responder for the USD. Rural/Frontier: • Compass Behavioral Health: 4 therapists are available 24/7 for youth and families; can utilize tele-video conferencing for assessments (Medicaid reimbursable); and offers crisis housing for youth.
KS Barriers/Challenges • Creating a unified plan for Kansas. – Each catchment area has unique needs (urban, rural, frontier). • Our team would like to improve local partnerships with child welfare and juvenile justice. – Requires proactive planning and improved communication among partners, which can be a challenge with a strained workforce. • We are interested in a non-crisis mobile response strategy. – This would require policy change, workforce development, and culture change.
KS Objectives Top 3 objectives for this meeting: 1. To learn how to plan, integrate, expand and sustain a statewide crisis and non-crisis mobile stabilization service. 2. How to implement care coordination and peer support within this approach. 3. The process and structure of other states’ response strategy: dispatcher, response team, leadership roles, etc. • This is an added objective from the initial application
SOUTH CAROLINA
South Carolina Participant Name Title/Role Organization (if applicable) Vanesha Perrin Program Manager/Team South Carolina Department Leader for Quality Assurance of Health and Human Services, Division of Behavioral Health Lynelle Reavis Program Manager, Policy South Carolina Department Management Team Leader of Health and Human Services, Division of Behavioral Health
SC Program Structure Community Crisis Response and Intervention (CCRI): • Currently 100% State funding – Anticipate county funding once local outcomes are demonstrated • South Carolina has a robust state agency network including DSS, DJJ and DMH – Funded through contract with DMH – will join the monthly multi-agency stakeholder meetings regarding continuity of care • Statewide, with a focus on customizing services to meet the needs of the area served.
SC Program Components CCRI will provide: A 24/7 warm line staffed with individuals who have mental health and • crisis experience to field the calls to the designated local DMH clinicians Clinical screening in order to de-escalate the crisis and provide linkage to • ongoing treatment and other resources. Services will be rendered in the following modalities – In person at the location of the crisis – In person at a CMHC Clinic – Telephonically Statewide clinical and administrative supervision via a centralized office • Staff to build relationships and resources with community partners •
SC Barriers/Challenges • Finding an experienced workforce for the supervisory positions. • Gaining support of all necessary community partners, specifically hospitals and probate courts. • Completing a service design for areas that lack adequate resources has also been a barrier.
SC Objectives To learn: • Best practices to inform future policy decisions • About quality and outcome measurements/indicators • About financing strategies (beyond Medicaid) to fund CCRI
TENNESSEE
State of Tennessee Participant Name Title/Role Organization (if applicable) Heather Taylor Dept. of Mental Health & Substance Director, Office of Children & Youth Abuse Services Mental Health Morenike Murphy Dept. of Mental Health & Substance Director, Office of Crisis Services and Abuse Services Suicide Prevention Keri Virgo Department of Mental Health and Project Director, System of Care Substance Abuse Services Across Tennessee Dr. Lisa Pellegrin Department of Children’s Services Psychology Director Crystal Parker TennCare Director, Children’s Programs Ellyn Wilbur Tennessee Association of Mental Executive Director Health Organizations Melissa McGee Tennessee Commission on Children Director, Council on Children’s and Youth Mental Health Rikki Harris Tennessee Voices for Children CEO
TN Program Structure Statewide Youth Mobile Crisis Services • Provides statewide crisis services for children and youth under the age of eighteen (18) years • Emergency counselors (triage specialists) handle calls 24/7 through regional hotlines or the statewide crisis line and determine an appropriate response • Statewide Services are provided by 4 contracted agencies 1. Youth Villages 3. Frontier Health 2. Mental Health Cooperative 4. Helen Ross McNabb • State Funded (DMHSAS and TennCare)
TN Program Components • 24/7 Hotline Triage Counselors • Face to Face Assessments • Telehealth Assessments (when appropriate) • Community Referrals • Follow-Up
TN Barriers/Challenges • Diverting youth from the ED and helping ensure access to available community services • Different payor sources • Geography • Transportation
TN Objectives • To walk away with an implementable, multi-agency plan to expand crisis stabilization options for children and families in Tennessee • To observe and connect with other states on their high-impact, low cost crisis stabilization programming • To learn how existing children services in Tennessee can coordinate with youth mobile crisis
MILWAUKEE MOBILE CRISIS RESPONSE AND STABILIZATION SERVICES: FORCES AND PARTNERSHIPS DRIVING EVOLUTION Bruce Kamradt Administrator Emeritus, Wraparound Milwaukee Christopher Morano Founding Director Emeritus, MUTT
Background and History • Mobile Response Services in Milwaukee were developed 22 years ago as an integral component of Wraparound Milwaukee • Wraparound Milwaukee (WM) is a coordinated, single system of care serving Milwaukee County youth with serious emotional and mental health needs and their families across child serving systems
Background and History (cont.) • WM is operated under the auspices of the Milwaukee County Mental Health Board as a unique Care Management Entity(CME) with a capitated contract under WI Medicaid to plan for, provide, pay for and manage care for youth with SED and their families. • 1670 families served in 2016 • Average daily enrollment of 1213 families
Key Service Components of WM • Care Coordination – utilizing a high fidelity wraparound approach • Mobile Urgent Treatment Team(MUTT) – 24/7 crisis response and planning • Comprehensive Service Array – Availability of clinical and support services delivered through provider network • Family Support and Advocacy Organization
Evolution of MUTT Team • MUTT began in 1995, during Year 2 of the CMHS grant that initiated WM, as a service to children enrolled in Wraparound with the primary goals to: – keep youth and families together, – support care coordinators in crisis/ safety planning and management, – reduce ER use and – prevent need for unnecessary inpatient psychiatric care
Evolution of MUTT(cont.) • A change in state law in 1996 required all WI counties to plan for and provide mental health crisis services (HFS34) for adults and youth • HFS34 created new fee-for-service funding under WI State Medicaid program for provision of mobile crisis response and optional stabilization services. The state made MRSS a more comprehensive service • MUTT evolved to be the designated crisis system for all children in Milwaukee county but also retained it’s “gatekeeper” functions for WM youth.
Evolution of MUTT(cont.) • 2002 - Crisis stabilization services including crisis group home and crisis 1:1 stabilizers added to service array. • 2005 - Contract with child welfare for creation of a dedicated foster care crisis team due to excessive placement disruptions and response to federal lawsuit. • 2006 - Contract with Milwaukee Public Schools for specialized crisis team, grades 6-12, to respond to school aggression, suspensions, etc. (ended in 2010 due to loss of state funds). • 2015 - MUTT/Milwaukee Police Dept. trauma team developed based on Yale Child Studies model of police, mental health partnership.
The Need for Mobile Response Services 1. Create a single point of access for children/families experiencing a mental health crisis 2. Reduce over utilization of emergency room and psychiatric inpatient care 3. Clinical triage/assessment for entry in WM 4. Reduce "secondary" placements from hospital into residential treatment centers
Components of MUTT Service • Telephone Service: qualified and trained staff, 24/7, providing callers with information, support, counseling, intervention, emergency service coordination and referral. This is provided directly by MUTT staff from a central office and dedicated crisis line. • Mobile Response Service (Mobile Urgent Treatment Team): provides onsite, in-person intervention for persons experiencing a mental health crisis; available to make home visits and other locations in the community; staff must be qualified under state HFS34 requirements. This is provided directly by MUTT staff.
Components of MUTT (cont.) • Walk-in Service: face to face support at an identified location; MUTT uses psychiatric crisis service in emergency room of county psychiatric facility • Short-term Hospitalization: MUTT maintains agreement with the county’s child and adolescent inpatient service • Linkage and Follow-up: connects child and family to ongoing services (i.e. Wraparound Milwaukee) • Stabilization Services
Crisis Stabilization Services • Stabilization services are designed to: – reduce or eliminate symptoms of mental illness to prevent need for inpatient hospitalization or – assist in the transition of a child to a less restrictive placement or living arrangement when the crisis has passed. An array of crisis stabilization services have been developed by WM to be used in conjunction with and under the direction of the MUTT
MUTT Crisis Stabilization Services • Crisis/Respite Beds in Community Group Homes – Placement up to 14 days to divert from hospitalization • Crisis Beds in Residential Treatment Facilities (RTF) – Crisis beds designated in a RTF for short-term placement up to 14 days (rate negotiated with RTF) • Crisis Beds in Treatment Foster Homes – Purchased on a case by case basis • Peer to Peer Support – Some done by Families United of Milwaukee via WM
MUTT Stabilization Services (cont.) • Crisis 1:1 Stabilizers: – Short-term service provided in the home, school and community to evaluate, manage, monitor, stabilize and support youth’s well-being and appropriate behavior consistent with their crisis plan, and to prevent another crisis from occurring • 1:1 Crisis Stabilizers: – Have BA/BS degree or H.S. diploma – Over 250 stabilizers (part & full-time) – Work under crisis/safety plan mostly with WM enrolled youth
Composition of Mobile Urgent Treatment Team (MUTT) • 20 MSW social workers, 3 PhD psychologists, consulting psychiatry services as needed • 24/7 availability (pager from 11pm – 7am) • Two-person teams • Preferred provider arrangement with Milwaukee County inpatient psychiatric unit • Two MSWs co-located with police – directly housed in a police station (Trauma Team)
Required Staffing for MUTT • Program Administrator and Clinical Director – can be the same person • Professional staff licensed by state – If under 3000 hours of supervised clinical experience must have one hour of supervision for every 30 clock hours of face to face time. – If over 3000 hours, one hour of peer clinical consultation for every 120 hours of face to face time is required. • New staff have 40 hour orientation training – 20 hours with over 6 months emergency work experience
MUTT Data • 3000 calls to MUTT in 2016 – 916 initial cases • 1850 face to face • 45% of families seen in the home, 24% in schools, 10% Emergency Rooms • 50% of referrals came in on first shift, 45% on 2 nd shift and less than 5% from 11pm to 8am • Average response time = 20 minutes – 241 sq. mile service area
Funding Strategies to Support MUTT Medicaid covers 60% of costs for mobile crisis response and • stabilization services based on performing provider hourly rates under (HFS34); Counties are expected to cover remaining costs. WM covers remaining costs of MUTT through through pooling funds • received from Medicaid capitation contract($1892 pmpm); case rate from CW of $114 per day (230 youth) and case rate from JJ of $80 per day (400 youth) $750,000 additional contract with CW for dedicated crisis service to • foster homes City of Milwaukee provides $90,000 contract for new MUTT/Police • Trauma Unit Monies saved from reduced use of psychiatric hospitalization and RTFs • are re-invested into expanding community-based services
Medicaid Coverage for Crisis Intervention in Wisconsin • Medicaid can only pay County human service agencies or agencies with whom they contract to provide crisis intervention services. • Agencies must be certified under HFS34. • Recipients being discharged from a hospital or RTF are eligible for crisis services if they are likely to experience another crisis if these services are not provided. • Recipients in a hospital or RTF are eligible to receive crisis services if needed to develop a crisis plan or to facilitate transition back to their home or community.
Current WI Medicaid Fee Schedule for Crisis Service • Psychiatrist and Advanced Practice RN – $148.16 per hour (state reimburses federal share at 60% or $85.15 per hour) • PhD Psychologist – $110.23 per hour (state reimburses $63.35) • Master degree or BA/BS – $88.90 (state reimburses $51.09) • Paraprofessional – $44.00 per hour = $27.50 • Per diem for Group home/RTF – $139.54 per day (Medicaid reimburses at $80.19 per day)
Information Technology • Access to good data system is critical for a mobile response team • MUTT uses Synthesis , an electronic health record and data system developed and used by WM • MUTT enters data into the system for all contacts and work with families; includes assessments, crisis plans, authorized services and providers, progress notes, etc.
Information Technology (cont.) • Synthesis converts progress notes into billing documents that go to Medicaid electronically • MUTT and WM use a single release of information allowing case data to be shared and viewed on-line – MUTT can see care plans and crisis safety plans, care coordination notes, provider notes, etc. MUTT plans and progress notes can than be viewed by WM care coordinators. Juvenile justice also uses system. • Internet-based IT system is needed so you are not “flying blind” into crisis situations
Outcomes Supporting MUTT Sustainability Over 20 Years Reduction in utilization of inpatient psychiatric hospitalization • – There was a reduction in inpatient psychiatric bed days for youth with SED from 5000 days in 1995 to under 500 days by end of 1997 WM average utilization per child per month for inpatient care over the past 20 • years has ranged from 1.5% to 3.5% of total expenditures – That equates today to pmpm of about $78 or less than one day of psychiatric hospital care (1216 current enrolled youth with SED). Child welfare has seen significant reduction in “failed foster placements” since • initiation of dedicated MUTT services. – Nearly 90% of youth seen by MUTT have been stabilized in their current foster care placement. Reduction in child and adolescent bed capacity in Milwaukee County •
Outcomes Supporting MUTT Sustainability Over 20 Years (cont.) • Average length of stay in psychiatric inpatient care for youth managed through MUTT = 2.4 days – versus average stays of nearly 70 days before MUTT assumed gate- keeper duties. • Average response time on calls going into the community for MUTT = 20 minutes. • MUTT has received high consumer satisfaction per survey. • Provides Crisis Prevention Institute (CPI) training to all Milwaukee police officers.
THE MILWAUKEE MODEL: LESSONS LEARNED
Lessons Learned From a System of Care (SOC) Perspective • Mobile response was the first component developed in our SOC because it could have the most immediate impact on reduction of inpatient hospital and other institutional care, allowing redirection of saved monies (“Gatekeeper Function”). • Mobile Response, care coordination and stabilization services should be integrated into SOC because they often need to function together in concert with and as part of the Child and Family Team
Lessons Learned From SOC Perspective (cont.) • It has been more advantageous to coordinate and link the children’s mobile response service with CW, JJ and schools than adult crisis service • Critical to have an array of crisis stabilization services (i.e. in-home stabilizers, crisis stabilization beds, etc.) available to care coordinators to support crisis plans and alternatives to out of home care. • Need formal agreements with inpatient providers to avoid longer term hospital stays
MOBILE RESPONSE AND STABILIZATION IN NEW JERSEY Elizabeth Manley Assistant Commissioner New Jersey Children’s System of Care
New Jersey System New Jersey Department of Children and Families Commissioner Division of Division of Children’s System of Family Child Protection & Office of Division on Women Care & Community Permanency Adolescent Services (formerly DCBHS) Partnerships (formerly DYFS) (formerly DPCP)
Summary of Children’s Initiative Concept Paper The Children’s Initiative concept operates on the following abiding principles: The system for delivering care to children must be restructured and • expanded. There should be a single point of entry and a common screening tool • for all troubled children. Greater emphasis must be placed on providing services to children in • the most natural setting, at home or in their communities, if possible. Families must play a more active role in planning for their children. • Non-risk-based care and utilization management methodologies must • be used to coordinate financing and delivery of services.
Children’s System of Care Objectives To Help Youth Succeed… At Home Successfully living with their families and reducing the need for out-of-home treatment settings. In School Successfully attending the least restrictive and most appropriate school setting close to home. In the Community Successfully participating In the community and becoming independent, productive and law-abiding citizens.
System of Care Values and Principles Youth-Guided and Family-Driven Community Based Culturally/Linguistically Competent Strength Based Family Involvement Individualized Unconditional Care Collaborative Home, School & Community Based Cost Effective Promoting Team Based Independence Comprehensive
Children’s System of Care History July 2012 July 2015 2006 Intellectual/developmental NJ wins a The Department of disability (I/DD) services for Federal Children and Families youth and young adults 1999 July 2013 SAMHSA (DCF) becomes the first under age 21 is NJ wins a federal system Substance use treatment Grant cabinet-level transitioned from the services for youth under of care grant that allowed System of department exclusively Department of Human age 18 is transitioned from us to develop a system of Care - dedicated to children Services (DHS) Division of DHS, Division of Mental Expansion and care. and families. Developmental Disabilities Health and Addiction Sustainability to the DCF Children’s Services, to DCF/CSOC. System of Care (CSOC). May 2013 December Unification of care 2014 2000 - 2001 2007 – 2012 management, under Integration of NJ restructures the funding The number of youth in CMO, Physical and system that serves children. out-of-state behavioral is completed Behavioral Health is Through Medicaid and the health care goes from statewide. piloted in Bergen contracted system more than 300 to and Mercer County administrator, children no three.* with expected longer need to enter the child *How did we do this? Careful individualized planning and the development of Statewide rollout welfare system to receive in-state options (based on research about what kids need) using resources that behavioral health care were previously going out of state. services.
Overuse of Deep-End Services Out of Low Home Intensity Services Intensive In-Community • Wraparound – CMO • Behavioral Assistance • Intensive In-Community Lower Intensity Services Out of Home • Outpatient • Partial Care • After School Programs • Therapeutic Nursery
Language Is Important Client Case Placement
Language Is Important Language of CSOC Not the Language of CSOC • Children, youth, young • Clients, Case, adult Consumer • Parents, caregivers • Mom and Dad • Treatment • Placement • Engagement • Not Motivated • Transition • Close, Terminate • Missing • Runaway • Family Time • Home visits
Key System Components • PerformCare is the single portal for access to care Contracted System Administrator available 24/7/365 • Utilizes a wraparound model to serve youth and Care Management Organization families with complex needs Mobile Response & • Crisis response and planning available 24/7/365 Stabilization Services • Family-led support and advocacy for Family Support Organization parents/caregivers and youth
Key System Components • Flexible, multi-purpose, in-home/community clinical support for parents/caregivers and youth with behavioral and emotional Intensive In-Community disturbances who are receiving care management, MRSS or out-of- home services Out of Home • Full continuum of treatment services based on clinical need • Supports, services, resources and other assistance designed to DD-IIH and Family maintain and enhance the quality of life of a young person with Support Services intellectual/developmental disability and his or her family, including respite services and assistive technology Substance Use • Outpatient, out of home, detox treatment services (limited), Treatment Services co-occurring services • Partial Care, Partial Hospitalization, Inpatient and Traditional Services Outpatient services
Case Management Census 89
Out of Home Census 90
Case Management Organization In Home/Out of Home 91
NJ Building In-State Capacity and Increasing Community Based Services 92
Mobile Response and Stabilization Services 9/1/2016 through 9/30/2016 ( n = 1,064 ) Did not stay in Current Living Situation 6% Stayed in Current Living Situation 94%
CSOC is Proportionally Serving More Youth Age 13 and Under
Integrating Services
NJ MRSS Mission and Goal Mobile Response and Stabilization Services help children/ youth and their families who are experiencing an emotional or behavioral stressor by interrupting immediate crisis and ensuring youth and their families are safe. MRSS provides the support and skills necessary to return youth and families to typical functioning.
NJ MRSS Program Elements • Youth and young adults under 18 • Young Adults involved with DCF under 21 • Parent/Caregiver consent • Escalating emotional or behavioral needs • Family defined crisis
What Is a Crisis? A crisis occurs when: • One’s sense of balance is disrupted • Coping and problem solving skills that worked in the past are not working • Life functioning is disrupted • Crisis is defined by the person/ family experiencing it!
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