System of Care for Severely Emotionally Disturbed Youth Strategic Plan FY2010 2014 Department of Behavioral Health And Developmental Disabilities System of Care for Severely Emotionally Disturbed Youth Strategic Plan FY2010 - 2014 Executive Summary: There is a sense of urgency that exists in Georgia today. The urgency is in fully addressing the concerns of Georgia citizens in an eroding economy, rising need, and vastly changing resources. These pressures are even more apparent for our youth and family who already struggle with challenges that not all family's experience. These are the families that battle with the effects of parenting at risk youth, and the children that are risk for removal from their home, family and community. As a stakeholder for severely emotionally disturbed (SED) youth, the call goes out to you. Whether you are the parent of a challenged child in Glynn county, or the professional reviewing available resources in Clayton; perhaps you are the legislator from District 12, or the overwhelmed school teacher in rural Georgia who questions how to teach a child with SED; maybe you are the unconcerned citizen who sees a 12 year old child, smoking at the crossroads, or the state agency personnel who gets the call in the middle of the night about a crisis. You are among us. The call to support the families in our Georgia communities goes out to you. You alone can make the difference in building a more supportive system of care based on relationships, but you cannot do this by yourself. We all play a part in Georgia's transformation to healthier communities with healthier families. It is at this time we must consider a shared vision for these Georgia families; a vision which is driven by the needs and voices of our families; a vision which is shared by all stakeholders who have accountability for decision making and support for our families and communities; a vision which allows for greater communication, increased accountability, and inter-agency collaboration and transparency. A vision which must transform our communities and lead Georgians in the development and mastery of a community-based system of care that will ensure safety to children and families, and that will support families to develop healthy relationships and lead meaningful lives. It is at this time that all stakeholders in a system of care must endeavor to provide and advocate for the least-restrictive, culturally supportive, community-based care that is the most conducive for family effectiveness and positive change; a system of care which supports families in a time of difficulty and challenge, when it is imperative they feel heard, understood, and sustained; a system which begins with relationship, and maintains the values of compassion and caring throughout each contact between stakeholders and families. In 1986, the system of care definition for children with emotional disturbances was becoming widely known: A comprehensive spectrum of mental health and other necessary services which are organized into a coordinated network to meet the multiple and changing needs of children and their families. At a federal level, the Child and Adolescent Service System Program (CASSP) philosophy has long been recognized as defining best practice and preferred systems of care for children and their families, especially those with severe emotional disorders (SED). The CASSP principles clearly state that services for children and families should be child-centered, family-focused, community-based, multi-system, culturally competent, and least restrictive. There is currently not a sufficient level of research base at this time that determines what works best clinically with youth and their families, however this is starting to be addressed by both the Federal and various State governments, and supported through grants that help to establish infrastructure and training on evidenced-based practices. To implement a system of care which fully supports families, there are several operational characteristics that successful systems of care possess. Without these distinctions, a system of care has little chance of reaching sustainability. Over the next five years, Department of Behavioral Health and Developmental Disabilities, in concert with the Department of Education, Department of Juvenile Justice, Division of Family and Children Services, as well as additional collaborative stakeholders who are engaged in system of care development will focus on how to develop and operationalize the following: System of Care: Specific, Defined Approach to Customizing Care for Children With Emotional/Behavioral Disorders and Their Families Operational Characteristics Collaboration across agencies Partnership with families Cultural & linguistically competent Blended, braided, or coordinated financing Shared governance across systems &with families Shared outcomes across systems Organized pathway to services & supports Interagency/family services planning teams Interagency/family services monitoring teams. Cross agency care coordination Individualized service/supports "wrapped around" child and family Home & community-based alternatives Broad, flexible array of services Integration of clinical treatment services & natural supports Linkage to community resources Integration of evidence-based treatment approaches Cross Agency MIS One accountable care manager Stroul, B., & Friedman, R. (1986). A system of care for children and youth with severe emotional disturbances (Rev.ed.) Washington, DC: Georgetown University Child Development Center, National Technical Assistance Center for Children's Mental Health. System of care is not a prescriptive set of services that must be delivered, nor is it a fragmented system of service funding and delivery. System of care is an integrative process that incorporates a philosophical, conceptual approach to a new way of interfacing with families and communities; a way that supports families in whatever manner the family determines is best, through an infrastructure of services and supports that are both formal and informal, and are known to be effective. System of care is an organic approach to collaboration; it is more creative than prescriptive; more proactive than reactive; more multidisciplinary than categorical; more expansive than limited; more open and transparent than guarded and defensive; and more focused on serving and sustaining than on helping and fixing. It is not about what a provider, stakeholder, or professional can do for a family, but what a family can do for themselves. The State of Georgia Mental Health Gap Analysis, requested by the Georgia Mental Health Planning and Advisory Council, recognized the following elements as constituting a "good" system of care for children and adolescents: System-wide commitment to tearing down system barriers to allow state and private child serving agencies to openly and fully coordinate access to and delivery of their direct services Methods and supports for empowering children and their families and front-line staff to provide them. Children and their families do best when they participate fully in treatment planning and service choice Children and their families need to have one and only one integrated assessment and treatment plan and should be able to access all needed and chosen services from wherever they present in the system. This unified access and treatment planning approach should also assure continuity of treatment and supports as well as facilitate access to a variety of services across agency lines Best practice principles should be implemented consistently on a statewide basis. These include provisions of needed services in the child's community and in the child's home in the least restrictive, most normalized manner with a comprehensive array of service. Leadership committed to managing and delivering services in new, creative, and flexible fashion The sagacity that has guided the system of care development in Georgia has originated from a collaborative effort that incorporates families, communities, agencies, and other stakeholders in driving Georgia toward a new vision for children and families. In October 2004, Georgia was awarded a Child and Adolescent State Infrastructure Grant (CASIG) from Substance Abuse and Mental Health Service Administration (SAMHSA). The goal of this grant was to help expand the state's infrastructure for developing comprehensive systems of care to meet the needs of youth with SED, substance abuse, and co-occurring disorders and their families. This grant focuses on building systems of care through workforce development; expansion of the youth and family voice in service design and delivery; development of financing strategies; and development of interagency mechanisms to support system of care integration. Georgia was also awarded a Substance Abuse Coordination (SAC) grant from the Center for Substance Abuse Services in October 2005. Georgia is one of three states to have received both grant awards and was approved by SAMHSA to integrate the activities and administration of the two grants. A State Level Children's Behavioral Health Service Collaborative was initially formed to oversee the implementation of the goals and objectives of the CASIG/SAC. Following are the stated vision, mission and values of Georgia's system of care initiative: Vision: Mission: Values: Youth and families thriving in an effective, collaborative, accountable system of care Georgia's system reform for severely emotionally disturbed (SED) children promotes a system of care to enhance behavioral health services and supports by developing infrastructure and removing barriers through partnerships with families, communities, and child-serving agencies so youth and families thrive. Family Matters Every family has strength, knowledge and experience. Therefore, Georgia's system of care for SED children will: Ensure our work is driven by the family and youth Drive programs to build family and youth resiliency Community Matters Children achieve better outcomes when services are provided within their own community and with family. Therefore, Georgia's system of care for SED children will: Develop a community-based infrastructure for accessible, affordable service provision Support individualized, strength-based, culturally and linguistically competent services Promote early identification and intervention Partners Matter Children and families achieve better outcomes when partners work together. Therefore, Georgia's system of care for SED children will: Facilitate broad, informed participation of families, government and community Establish common ground and mechanisms for open communication Articulate goals that are relevant for all stakeholders Accountability Matters We are accountable to: Our families and children for the quality of services Our funding sources for best use of resources Each other as partners Paramount to implementing system of care principles is the development of staff competencies and a core belief system which will govern and direct all community-based services. This will require community backing in an effort to innovate natural supports for families when families are ready to transition from formal to informal supports. Capacity building of community development and social services has become a critical element in today's economy. There has been increasing reliance by both federal and state governments on community-based initiatives to provide a number of social services, particularly among low-to-moderate income groups across the country. Relationships among local leaders, community members, consumers and parents of consumers will be helpful in providing the community support that will enhance the innovative skill and credentialed structure offered through Georgia's various child serving agencies. In this way, communities have a stake in strengthening families in a way that fosters a family's resiliency, independence and self-sufficiency. Historically in Georgia, state agencies funding distribution for severely emotionally disturbed (SED) children has primarily purchased more restrictive levels of care. In fiscal year 2005-06, Georgia agencies which include Division of Family and Children Services (DFCS), Division of Mental Health, Developmental Disabilities, Addictive Disease (MHDDDAD), Department of Juvenile Justice (DJJ), and Department of Community Health (DCH), spent $560 million on over 300,000 youth. DFCS and DJJ represented 64% of theses expenditures largely through Level of Care spending, with 55% of the expenditures supporting the most restrictive levels of care (psychiatric hospitalization, residential treatment and group care). 1. Emerging research has demonstrated that residential treatment, that is, treatment in a group residential setting outside the home, and group homes for children and adolescents have consistently been shown to be ineffective in creating long-term gains for youth with behavioral health needs.2 Additionally, any benefits from residential treatment seem to be short-lived and return to the residential setting becomes once again necessary following discharge.3 Since 2007, Georgia child serving agencies have been struggling with the establishment of system of care on a foundation of shifting sand. Care for SED children is now delivered through a complex system of payor sources, eligibility requirements and provider networks. When Department of Community Health (DCH) instituted a managed care initiative for parental custody children in 2006, Georgia's Division of Mental Health, Developmental Disabilities, Addictive Disease (DMHDDAD now referred to as Department of Behavioral Health and Developmental Disabilities, DBHDD) transferred funding to DCH for 23,000 children now being served in Care Management Organizations (CMO's). In 2007, the Commission for a New Georgia further directed that behavioral health care for children be delivered in a fee-for-service system which leveled the playing field for child and adolescent providers. In July 2007, the federal Medicaid authority, CMS, ordered the "unbundling" of services which thoroughly dismantled Georgia's Level of Care (LOC) system. The LOC system historically provided for the residential and treatment funding for children in custody of the Division of Family and Children Service (DFCS) and the Department of Juvenile Justice (DJJ). Although there are some positive changes that have resulted from these actions, such as the expanding availability of home and community-based behavioral health services for youth and their families, several issues remain unresolved. There currently exists multiple eligibility categories for children based on poverty, custody, un-insurability or disability. Children often move from one eligibility category to another, based on changing family circumstances, which further fragments the ability to provide support and often creates major disruption in their behavioral health care. In addition, providers must manage several contracts, authorization procedures, eligibility systems, payment structures, utilization criteria and billing procedures for essentially the same or a similar population of youth. This current structure further maintains the "silo" funding that has plagued Georgia for decades and creates resource intensive inefficiencies that build barriers for Georgia families. Further, it establishes fragmented delivery systems that do not require all providers to engage in the collaborative process of family-centered practice and planning that child and youth serving State agencies are committed to; and leaves a segment of SED youth and their families with providers who do not ascribe to the philosophies and principles of a collaborative system of care. This critical issue underscores the vital need for support of this proposed five year, system of care development plan. Goals and Objectives for System of Care Development A Five Year Plan Build a comprehensive system of care to meet the needs of children with severe emotional disturbance (SED), substance abuse disorders, and co-occurring disorders. Establish a State Level Children's Behavioral Health Services Collaborative Develop a statewide vision for behavioral health services across all child-serving agencies Develop a strategic plan for building capacity to provide behavioral health services including provider and network development Expand family and youth partnerships throughout the state Infuse family driven service in to the system of care through family involvement Develop funding strategies to continue to build on and improve the SED service system Identify fiscal resources needed to provide behavioral health services Conduct financial mapping across the major child-serving systems of the dollars currently being used to finance behavioral health services for children and adolescents, and what services are being financed and for which populations of children and adolescents Identify funding mechanisms and flexible funding strategies to support services development Maximize use of all funding streams across child-serving agencies Develop a trained workforce with specialty knowledge of working with youth with SED, substance use disorders, and co-occurring disorders Develop a cross-system workforce development and training strategy to improve delivery of behavioral health services. Establish core competencies for clinical staff and develop a credentialing process Provide training for front-line and supervisory staff on provision of culturally competent services Provide specialty training on treatment of youth with co-occurring disorders Provide training on evidenced-based practice interventions within systems of care Develop policy and practice guidelines to support service system improvements Provide guidelines for accessing all behavioral health services including Medicaid Rehab Option services Develop state level interagency agreements for provision of behavioral health services Develop a mechanism for statewide information dissemination on resources available to serve youth in need of behavioral health services Develop a statewide web-based information resource that includes access to all child-serving agency information Develop a MIS infrastructure to share data across child-serving agencies Innovative Financing Strategies One of the key elements of sustaining Georgia's system of care is the development of financing strategies which support the shift to a community-based system, and reduces the reliance on more resource intensive residential treatment options. Georgia's system of care must be supported by new and creative financing strategies that provide for the expanded, innovative collaboration in caring for Georgia's children and families. The State of Georgia needs to affirm the need for providers to develop truly cooperative agreements aimed at expanding flexibility in its network of formal supports, as well as supporting the development of informal supports at the community level. Families will be the beneficiaries of these further incentives for system of care development which draw on collaborative, synergistic relationships that enhance the flexibility of community-based supports and care. Georgia's innovation currently centers around the development of Care Coordination. The goal is to develop and utilize this service to increase the supports for children who need moderate to high intensity level services, and to serve them in their communities. This service provides for the intensive planning and care coordination around a family-centered practiced model, with the desired result of implementing an individual care plan, integrating the formal and informal supports necessary to achieve the goals of the plan, and to monitor the changing needs and supports identified for the family and the provision of those services. Medicaid Targeted Case Management will be pursued to assist in financing Care Management Entities, who are being established to provide administrative and service based support around innovative practices and family-centered models of care. Further financing strategies will be developed upon the review of the Financial Mapping project that is being completed by Sheila Pires, from the Human Service Collaborative, Washington, D.C. This work is expected to be completed in March 2010. Maintaining the mission and focus of Georgia's system of care will rely on broad based support from families, community, stakeholders and state agency leadership. There are extensive challenges which will be faced while "institutionalizing" the system of care approach in Georgia, meaning that the intended result is that system of care principles will be so integrated in the supports that are provided for SED children and their families that it becomes "business as usual." However, there is much work to do before Georgia achieves that level of system of care integration. Some of the key challenges in Georgia's system of care development will be: Categorical funding streams that lead to fragmentation of service delivery Inability to finance intensive care coordination Limited supports for financing family and youth involvement at all levels Cross-agency training needs which exceed training budgets Limited investment in evaluation and quality assurance to assess and improve quality Competing mandates and specialized language across child serving agencies Fee-for-service provider rates which challenge behavioral health providers' capacity to implement evidence-based treatments and practices Georgia's children and families depend on our ability to "stay the course" and maintain a passionate commitment to the ongoing evolution of Georgia's system of care. Georgia is not alone in this endeavor. Following are some examples of what other states have accomplished in their own pledge to better serve children and families. Innovative Trends Implemented in Other States with System of Care Reform Initiatives: Every state in our nation faces issues caring for children whose families are currently challenged. Many states have integrated all SED children in to one successful program that provides a comprehensive, creative approach built on system of care principles. The State of Wisconsin applied for a 1915(b) waiver program to transition from a Medicaid feefor-service to a managed care pilot program. This program is designed to integrate and oversees the social, behavioral, and physical health care needs of children placed in out of home care in Milwaukee County. This waiver allows Wisconsin to implement a pilot program to develop a comprehensive Wrap-Around program aimed at reducing the over-utilization of residential treatment specifically with a population previously labeled as severely emotionally disturbed. This pilot program additionally pooled funds from child welfare, juvenile justice, the Medicaid capitated program from the 1915(b) waiver, and mental health. The Milwaukee Wrap-Around System has reduced residential expenditures from $18.4 million in 1996 to $8 million in 2006. In Delaware, integrated physical/behavioral health managed care organizations (similar to Georgia's CMO's) are responsible for managing only acute care behavioral health benefit for all Medicaid eligibility categories of children as well as the SCHIP population. Children needing more than acute, short-term services (as well as non-Medicaid and non-SCHIP children) are managed by the State Division of Child Mental Health Services acting as a public managed care organization financed by Medicaid, SCHIP, general revenue and block grant dollars. 4 Arizona's system is unique in its ability to include non-traditional agencies that focus on more informal supports such as respite and family peer support. Arizona's system is a complete behavioral health carve out that includes all eligibility categories of children previously served by Division of Mental Health Developmental Disabilities and Addictive Disease ( now DBHDD) in Georgia. It utilizes funds from Medicaid, SCHIP, general revenue, block grant dollars to develop a broad service array of formal and informal supports. New Jersey's non risk-based behavioral carve-out includes all child populations and uses a statewide Administrative Service Organization and locally based Care Management Entities to manage care for children with serious, complex issues who are involved with multiple systems. New Jersey's system also includes locally based Family Support Organizations (family run organizations) in its design to partner with the care coordination entities. Collaboration is a process that can only happen within the context of relationship where each person/agency feels equally responsible for the success of their joint project or process. It requires commitment, communication and transparency for all stakeholders involved. For the system of care to fully support the needs of Georgia families and youth, we must come together to create authentic visions and initiatives for addressing the shared concerns of Georgia's citizens. In order for Georgia communities to realize their full potential, each person/agency must look outside themselves and develop collaborative relationships, not only with each other, but with those for whom support is needed. This transformation will require competent, moral leadership capable of implementing a system which will ensure safe, family-centered, quality services that provide a desired outcome, and is fiscally responsible; leadership that instills the values of compassion and awareness of the needs of the individuals and families we serve, while staying centered on the families need for self-determination. It is in this spirit that the implementation of, and commitment to, Georgia's system of care proceeds. References: 1. Pires, S., Report on Behavioral Health Spending for Children and Adolescents in Georgia Across Child Serving Systems, Summer 2007. 2. Burns, B.J., Hoagwood, K. & Maultsby, L.T., Improving Outcomes for Children and Adolescents with Serious Emotional and Behavioral Disorders: Current and Future Directions. ("A dominant observation is that the least evidence of effectiveness exists for residential services, where the vast majority of dollars are spent."); Chamberlain, P. , Treatment Foster Care, US Department of Justice, Office of Juvenile Justice and Delinquency Prevention, Juvenile Justice Bulletin, December, 1998. 3. Brown, E.C. & Greenbaum, P.E., Reinstitutionalization After Discharge from Residential Mental Health Facilities: Competing Risks Survival Analysis. 4. Supra note 1.